- The more deprived the area that a person lives in, the less likely they are to report a positive experience of accessing general practice and a good overall experience of general practice.
- Older patients tend to report better access to general practice – they are more satisfied with their experiences making appointments and find it easier to get through to their practice by phone. However, they are less likely to have used online services.
- Asian patients report poorer experiences making appointments and more difficulty getting through to their GP practice by phone. Black patients are the least likely to have used any online services.
- Differences in experience of and access to general practice observed between demographic groups have been consistent over the past 3 years of survey data (changes in survey method mean that we can’t look any further back).
Access to health care is a limited but important marker of quality of care. How readily patients can access general practice tells us little about the quality of the care they receive during a consultation, but ‘access’ to services remains important to patients, and to politicians vying for votes. Lack of access to health care can contribute to poor health, and equity of access to health care – ensuring that patients are able to access services in proportion with their health needs – is key to reducing health inequalities.
Despite the NHS mandate to offer equal access for equal need, inequalities in access to NHS services are well recognised. Asylum seekers and refugees, Gypsy, Roma and Traveller communities and LGBTQI individuals all report particular barriers to accessing NHS services, or experiences of discrimination when receiving them. Recent Health Foundation analysis found that general practice in areas of high deprivation is under-funded and under-doctored relative to need.
Policymakers have long seen increasing the number of GPs as a vital step to improving access to general practice. Doing so has proved difficult. In 2015, then Secretary of State Jeremy Hunt promised 5,000 more GPs by 2020, and while the number of GP trainees has risen, the number of full-time equivalent, fully qualified GPs has fallen. Other government pledges on access – such as giving all patients access to routine ‘extended hours’ appointments – have been implemented, but have added pressure to an already over-stretched workforce, with potentially negative impacts on GP recruitment and retention.
While the government’s plan to increase GP numbers remains (this government has committed to an additional 6,000 GPs by 2024), expanding the skills mix in primary care (by bringing in allied health professionals such as physios and paramedics) is increasingly seen as a route to better access for patients. The 2020 GP contract provides funding to add 26,000 allied health professionals to primary care by 2024. The same contract also requires all GP practices in England to offer a ‘core digital service’ to patients, including online appointment booking. This reflects a concurrent policy objective of increasing and improving access through digital technologies and through remote and asynchronous consulting.
These are national pledges and plans, intended to apply across England. But it is possible that different population groups have different experiences of accessing general practice. Understanding whether this is the case is crucial because it helps us to know whether national ‘blanket’ policies on access are appropriate, or whether more targeted intervention is needed.
In this short analysis we use data from the GP patient survey, an annual independent survey run by Ipsos MORI on behalf of NHS England, to explore who gets good access to general practice, unpicking how patient satisfaction with the service they receive varies by deprivation, age and ethnicity. The 2020 GP patient survey data were mostly collected before the COVID-19 pandemic, therefore this analysis doesn’t reflect patient experiences or service changes during the pandemic.
We explored the differences by deprivation, age and ethnicity in overall experience of and access to general practice using results from the 2020, 2019 and 2018 GP patient survey. We analysed weighted data, accounting for differences between all patients at a practice and the patients who completed the questionnaire. We included data from 2018 and 2019 to determine whether the differences we see in 2020 varied over time. Data prior to 2018 are not comparable due to changes to the questionnaire.
To explore differences by deprivation, we used results at the practice level because data on deprivation are not available at the individual respondent level. We attributed responses to neighbourhoods (Lower Layer Super Output Areas) based on the proportions of patients served by each practice in each neighbourhood. We then aggregated neighbourhood responses into their respective Index of Multiple Deprivation (IMD) quintile. Ethnic group and age were reported by respondents in the survey and therefore we drew ethnicity and age comparisons on an individual level, rather than practice level.
We focused on patients’ overall experience of their GP practices and three areas of access: making appointments, telephone access, and online services. We classified ‘very good’ or ‘fairly good’ responses as a ‘good’ overall experience, and patients who said getting through by telephone was ‘easy’ or ‘fairly easy’ as finding the process ‘easy’.
We used the chi-squared test to determine whether there were any significant differences by age, ethnicity or deprivation. We compared each age, ethnicity and deprivation group to all other groups to determine which were significantly different from each other. Performing multiple significance tests increases the likelihood of finding a significant difference by chance. To account for this, we used a more stringent threshold of significance. We set our significance level at 0.0016 which is 0.05 divided by 32, the number of comparisons we made. For use of online services, we compared the use of any online service between groups, rather than for each service individually. All differences presented are statistically significant, unless otherwise stated.
Patients in the most deprived areas had poorer experiences of their GP practices, compared with patients in less deprived areas (Figure 1). At GP practices in the most deprived areas, 78% of patients reported a very or fairly good experience, compared with 83% in the least deprived areas.
Younger and Asian patients reported the poorest experience. 76% of younger patients and 74% of Asian patients had a good overall experience of general practice compared with 90% of patients aged 85 and over, 83% of white patients and 84% of black patients.
Patient satisfaction with overall experience of general practice remains high, but has decreased since 2018. The patterns we describe across deprivation, ethnicity and age have remained persistent with no signs of gaps narrowing.
Figure 1.1: All ethnicity comparisons were statistically significant except other vs mixed; all age group comparisons were significant except 16-24 vs 25-34 and 75-84 vs 85; all IMD comparisons were significant.
Around two-thirds of patients report a good experience making appointments. Patients at GP practices in less deprived areas had better experiences making appointments: 65% of patients in the least deprived areas report a good experience compared with 59% of patients in the most deprived areas. Good experiences increased with age, with 63% working age adults (16–64 years) reporting a good experience making appointments, increasing to 77% of patients aged 85 and over. With making appointments, black patients report the most good experiences (69%) and Asian patients report the least (58%). These patterns are consistent over time.
Across all groups, fewer patients report a good experience with making appointments than an overall good experience. Similar patterns for deprivation and age (higher satisfaction for less deprived and older patients) are seen for patients’ satisfaction with the type of appointments offered and appointment times available to them.
Figure 2.1: All ethnicity comparisons were statistically significant except other vs white; all age group comparisons were significant except 16-24 vs 45-54, 1624 vs 85 and over and 34-44 vs 65-74; all IMD comparisons were significant.
Only 56% of patients in the most deprived areas find it easy to get through to their GP practice by phone, compared with 64% of patients in the least deprived areas. Asian patients and patients younger than 65 find it hardest to get through to their GP practice by phone.
Figure 3.1: All ethnicity comparisons were statistically significant except mixed vs black, mixed vs white and mixed vs other; all age group comparisons were significant except 25-34 vs 75-84 vs 85; all IMD comparisons were significant.
Across all groups, most patients had not tried to book appointments, order repeat prescriptions or access their medical records online in the past 12 months. Patients in more deprived areas had used online services less than patients in the least deprived areas, but this gap has narrowed since 2018. Patients in the most deprived areas are also less likely to have used their GP practice website and those that had found it more difficult, compared with patients in the least deprived areas.
Patients aged 55 to 74 were most likely to have used one of the online services, with 34% of patients having used at least one of the services. Only 15% of patients aged 85 and older had used any of the online services. For patients aged 45 and older, ordering repeat prescriptions was the online service used the most. For patients aged 16 to 44, booking appointments online was the online service used most (by 17–21% of patients).
Only 23% of black patients used any online services in the past 12 months, compared with 30% of patients with a mixed ethnicity and 29% of white patients. Patients with mixed ethnicity are the most likely to book appointments online, whereas white patients are the most likely to order repeat prescriptions online.
Figure 4.1: all ethnicity comparisons were statistically significant except Asian vs white, mixed vs other and other vs black; all age group comparisons were significant except 55-64 vs 65-74; all IMD comparisons were significant.
Analysis of the past 3 years of data from the GP patient survey suggests that general practice in England works better for some demographic groups than for others. People living in richer areas report better overall experience of and access to general practice than people living in poorer areas. Older people are more satisfied on these metrics than younger people, and Asian people are the least likely of all ethnic groups to have good experiences of accessing and using general practice.
Different demographic groups may have differing levels of need, or different expectations of care, and this analysis does not seek to explain the results observed. We also note that descriptions based on a single demographic characteristic mask complexities where characteristics overlap (for example white British people are less likely to live in a very deprived area of England than black and minority ethnic people). As the 2020 GP patient survey data were mostly collected before the COVID-19 pandemic, this analysis doesn’t reflect the large changes to service provision made by general practice as part of the pandemic response.
Our analysis suggests that experience of and access to general practice varies across England in a way that is patterned by demographic features. These findings are consistent with previous analysis of access to GP services by demographic groups. If patient experience and access are to be improved, then further work is urgently needed to understand the reasons underlying these trends. This is particularly important in light of the COVID-19 pandemic, which has necessitated a rapid shift in how patients are able to access general practice, with increased reliance on remote consultations and online access. There are legitimate concerns that ‘remote by default’ consulting – which relies on patients being able to access and use mobile phones or online platforms – may lead to digital exclusion, and further marginalisation of disadvantaged people.
It is concerning that some of the groups reporting the worst access to and experience of care from general practice are those where we expect there to be the greatest health need. General practice in England is under-funded and under-doctored in areas of high deprivation, and there is a risk that policies intended to apply equally across the population (such as promises to extend opening hours or increase GP numbers) may inadvertently widen health inequalities.
To prevent a paradoxical widening of health inequalities from policies intended to improve access to general practice, policymakers must seek to understand why experiences of access differ between demographic groups. Targeted interventions may be required to ensure that general practice is meeting the needs of all demographic groups.
Health Foundation @HealthFdn
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