General practice is a critical part of the NHS. Offering ‘cradle to grave’ continuous care, GPs and their teams are responsible for managing acute illness and long-term conditions, and providing preventative care. GPs also have a key role in coordinating patient care and ensuring appropriate referrals to urgent and routine hospital care. Poor access to general practice has a range of negative impacts, including unmet care needs, avoidable harm (for example via delayed diagnoses or referrals) and inappropriate use of other NHS services.

For all its importance, general practice in England has an access problem. Or – more accurately – access problems. In recent years, patient satisfaction with access to general practice has plummeted. Dissatisfaction covers multiple domains, including the experience of making an appointment, waiting times for appointments and the type of appointment offered (eg whether it is in-person or telephone). Meanwhile, pressures in general practice are high. Despite government promises to recruit more GPs, the number of fully qualified, permanent full-time equivalent (FTE) GPs has fallen since 2015. But patient demand is rising fast, and appointment numbers are at record highs, putting further strain on remaining GPs. 

Improving access to general practice is a priority for all political parties, and policy ‘ideas’ are emerging. The Labour party, for example, suggests expanding self-referral schemes for some conditions and creating new ways to access primary care via ‘neighbourhood health centres’. The current government has tried to improve access via a mix of routes, including:

• increasing the number and range of health professionals working in general practice (giving patients access to professionals with different skillsets)
• requiring practices to work together to extend their opening times
• supporting practices to improve their telephony and triage systems.

But access is still a problem, and initiatives to improve it are unlikely to work unless they fully understand the problem they are trying to solve.

A major challenge is that access to general practice is traditionally seen through the lens of ‘supply’ – things like how many GPs there are, and the number of GP appointments available. These things are critical, of course: access to general practice can’t happen if there’s no capacity. They are also things the NHS routinely measures.

Yet thinking about access in this way can obscure broader factors that influence people’s access to care – things like how people decide what to do about symptoms, their knowledge of health services and the barriers they may face in reaching services. Thinking too narrowly about access also risks undermining different dimensions of access that matter to patients beyond simply getting a GP appointment – including its speed, convenience, whether it’s online or in-person, and more. The ‘candidacy framework’ – first developed by Mary Dixon-Woods and colleagues – is a broader way of understanding access to health care services. 

This long read is the first in a series of outputs from a collaboration between the Health Foundation and researchers at The Healthcare Improvement Studies Institute (THIS Institute). We draw on the candidacy framework to build a more holistic understanding of general practice access issues. We first summarise headline data on access to general practice, introduce the candidacy framework, then analyse previous approaches to improving access, to inform future policy efforts.

We have also created an 'options list' (see Appendix 1), a resource that catalogues and categorises attempts to improve access to general practice with a view to informing future improvement efforts. The list includes interventions that have already been tried, are ongoing or have been proposed, and categorises them according to how they are intended to improve access to general practice. 

Available data paint a partial and sometimes contradictory picture of access to general practice. Viewed through some metrics, access to general practice is improving. General practice is delivering record numbers of appointments. The recruitment of an additional 34,000 health professionals, mainly via the Additional Roles Reimbursement Scheme, has broadened the range of staff and services for patients in their local GP surgeries. Around 40% of appointments occur on the day they are booked. 

But survey data paint a uniform picture of falling public satisfaction with access (Figure 1). The 2023 GP patient survey – an annual survey sent to more than 2 million adults across England – finds that just over half (54.4%) reported a good overall experience of making an appointment, the lowest level in the 6 years the question has been asked. The percentage of people who got an appointment at a time they wanted (49.8%) is falling, as is the percentage who found it easy to get through to their practice by phone (49.8%).

Although the percentage of people who say they wanted their most recent appointment to be ‘same-day’ matches the percentage of same-day appointments recorded in national general practice activity data (both around 40%), waiting times for GP appointments remain a significant source of public dissatisfaction. Public perceptions data show that 65% of people think access to GP services has worsened in the past 12 months, and making it easier to get a GP appointment is one of the top three public priorities for the NHS. 

Some demographic groups have worse access than others. Health needs and consultation rates are higher in more socioeconomically deprived areas, but general practice in these areas is underfunded and under-doctored relative to need. Disabled people, carers, people from Bangladeshi and Pakistani ethnicities, people from socioeconomically deprived areas and people who identify as LGBTQI+ all report worse overall experience of accessing general practice. Patients in deprived areas tend to spend less time in GP consultations, and have seen a bigger increase in remote appointments (and decrease in face-to-face appointments).

More generally, the way that people book appointments, and the type of appointments they get, is changing. Although most people still make appointments over the phone, the proportion booking online or through an app is slowly increasing. In line with national guidance, many practices have implemented triage systems, often using online tools – these capture all requests for care and direct them to a clinician who decides the timing and type of appointment to be offered. And the rapid expansion of professional roles working in general practice (now often including paramedics, pharmacists, physios, link workers and physician associates) means that the proportion of appointments specifically with a GP is decreasing. 

Changes to the type of appointment offered – and public perceptions of these changes – are complex. The percentage of in-person appointments with GPs decreased significantly at the start of the COVID-19 pandemic, and around 40% of GP appointments are now by phone. Data about public perceptions of the shift to remote access give mixed messages. Analysis of practices using online triage systems suggests that most patients prefer a telephone appointment, but making it easier to get in-person appointments is a popular choice when people are asked about priorities for the NHS. GPs have also faced sustained media criticism about how hard it can be to get in-person appointments.

Other direct patient care staff in general practice, such as nurses and health care assistants, are more likely than GPs to have in-person appointments – probably reflecting the physical nature of the tasks they undertake (eg taking bloods and changing dressings). But there are also concerns that the addition of new roles into general practice is contributing to declining patient satisfaction. Patients are sometimes unsure what type of health care professional they have seen, and say they prefer to see a GP. 

Data about access to general practice also have limitations. National appointments datasets cover limited domains and are only as accurate as the information contained in general practice IT systems. Survey data have other limitations (changes to question wording, or mixing questions about hospital and GP waiting times, make it hard to understand what is really happening). Public perceptions data are also shaped by researchers' views on what is interesting, relevant and worthy of asking – so how broadly we think about access to general practice affects the data available. 

Especially lacking is the kind of data that could help us understand how recent changes in the general practice workforce have affected access. For example, access to ‘general practice’ is no longer the same as ‘access to ‘GPs’, but survey questions rarely distinguish the two. Overall, the full range of influences on access isn’t always visible when thinking about why problems occur and, relatedly, what might be done about them. 

One way of thinking about access in a more rounded way is by considering how patients, professionals, the systems they work in and broader structural factors interact to shape people’s access to care. The candidacy framework was developed to provide a holistic perspective on access to health care by analysing how people identify themselves as ‘candidates’ for health care. The framework is characterised by seven features: identification of candidacy, navigation, permeability of services, appearances at health services, adjudications, offers and resistance, and operating conditions. 

Although the framework was originally developed to understand access to health care by vulnerable groups, it offers a helpful way of thinking about some major influences on people’s access to general practice too – as well as how ease of access can vary between patient groups and GP practices. For example, people need to identify themselves as candidates for care in the first place, and people have varying perceptions of what warrants medical attention in general practice, versus managed at home or elsewhere – see, for instance, Wasting the doctor’s time (Llanwarne et al, 2017), The iceberg of illness and trivial consultations (Hannay D, 1980), and Illness identity as an important component of candidacy (Macdonald et al, 2016). 

Table 1 summarises features of candidacy, giving examples of how each might apply to general practice.

The candidacy framework draws attention to how access to general practice is not simply a matter of supply or speed of appointments. Access is also a function of how people perceive their symptoms, identify GP services as being able to meet them, have the resources (cognitive, physical, and others) to find their way to them, and can present their needs in a way that can be adjudicated upon and subsequently processed, all in complex and resource-constrained environments.

Although GP services are free at the point of care in the UK, many barriers to access exist – additional to those outlined above – and these may be especially consequential for some groups. Narrow interpretations of access risk obscuring important barriers, and how access might differ between and across patient groups. In contrast, candidacy frames access as a highly dynamic process.

Viewing access through the wider lens offered by candidacy could help policymakers think more broadly about where improvements to access are most needed, understand why many existing attempts have failed and identify alternative solutions. It may also help avoid ‘zombie’ solutions – repeating efforts that have often been tried before, in different guises.

Policymakers considering ways to improve access to general practice can also learn from a back catalogue of previous attempts. Appendix 1 sets out a comprehensive list of more than 400 ideas and efforts to improve access to general practice in the UK in the last 40 years. The list is arranged into six categories (see Table 2) and includes attempts ranging from national level improvement projects right down to local practice quality improvement projects. For more information and examples on each approach, click on the links in the first column.

Coalition, Labour and Conservative governments have all tried measures such as extending the opening hours of GP surgeries, expanding the range of places to access GP services (eg via walk-in or urgent care centres) and offering patients greater choice over where and how they access general. Other approaches to improving access characterise specific political eras.

Between 1997 and 2010, Labour’s approach to improving the NHS involved widespread introduction of centrally managed targets. In 2000, this included a target that patients should be able to see a primary care professional within 24 hours, and a GP within 48 hours. Coalition and Conservative governments focused more on growing the primary care workforce, initially (and unsuccessfully) by boosting GP numbers, and latterly by recruiting additional ‘direct patient care’ staff (who are not GPs) to work in primary care. 

The success of these policies has been mixed. In 2013, the Prime Minister’s Challenge Fund (which incentivised participating practices to pilot new ways to improve access, with relatively modest investment of £50m) helped show what can work and how strategies can be tailored to local needs. More recently, recruitment of direct patient care staff to work in general practice (via the additional roles reimbursement scheme) exceeded initial targets, enabling 50 million extra appointments per year in general practice. Some approaches have had mixed effects. Extending practice opening hours can increase appointment availability, but these appointments may be underutilised. Anticipated benefits (such as reducing use of emergency departments) may not be realised, and new services (such as walk-in centres) may generate supply-induced demand and be poor value for money. 

Labour’s 24/48 hour access target – in place from 2000 to 2010 – is arguably a textbook example of unintended policy consequences. Flaws with methodology meant that data collection was unreliable, and – as some practices limited advance appointment slots to better meet targets – patients experienced problems booking appointments more than 3 days ahead. People’s ability to see their preferred GP declined, and – despite politicians claiming that targets had been met – overall satisfaction with GP opening hours fell between 1998 and 2004. 

Efforts to improve access to general practice have focused on some domains of candidacy more than others. A range of policies have attempted to boost access by making services easier to navigate, or more permeable. But there have been fewer attempts to improve access by focusing on aspects of patient experience – for example, how people identify themselves as candidates for care, or how staff decide on care pathways.

Policies to improve access to general practice may also involve trade-offs between different components of access. Access to the same GP over time – often referred to as relational continuity – is associated with a range of positive outcomes, including lower mortality, unplanned hospitalisations and use of emergency services. But evidence (eg from Nuffield Trust and others) suggests that policy initiatives to improve quick access to general practice may have weakened relational continuity. 

Similarly, broadening the range of health professionals working in general practice might increase appointment capacity, but could also reduce continuity of care with GPs for patients who need it, erode people’s ability to assess which symptoms warrant medical attention and which do not, or make navigation harder for some people. Increasing digital routes to access may help some patients but risk excluding others, reducing the permeability of services. 

Problems with access to general practice are longstanding and complex. Rising GP workload, and the corresponding decline in permanent FTE GPs, is a fundamental problem. Improving access will be difficult unless the overall resourcing of general practice – including funding, as well as the total number and range of staff – matches patient need. 

In the context of ongoing GP shortages, recent increases in the different types of patient-facing staff have contributed to increased supply of appointments in general practice. But ongoing declines in public satisfaction and heated debate about the acceptability, scope and regulation of some new roles suggest that boosting supply in this way is not solving all access challenges. 

Improving access to general practice depends on having a good understanding of what needs to be fixed. Policies that take a narrow approach are likely to make things worse. Viewing access through a wider lens (for example, using the candidacy framework) can help policymakers think more broadly about what might be blocking improvement, consider trade-offs between ‘domains’ of access and reduce the chances of unintended consequences. 

Drawing on the candidacy framework, the IMPRESS project – a collaboration between the Health Foundation and researchers at THIS Institute – aims to build a more nuanced and holistic understanding of general practice access issues. We’re working together to develop ‘CandidacyGP+’, a new framework tailored specifically for general practice. This will give more nuanced insight into access challenges, in turn helping inform better ways to improve access to general practice – which we know is a priority for patients, practitioners and policymakers alike.