General Practice Access Short Life Working Group: access principles

4. General Practice Access Short Life Working Group and Workshop

The General Practice Access Group met remotely for the first time on Thursday 17^th November 2022. The meeting agreed the terms of reference for the group (Appendix 1), including the scope of the group and the process for developing Access Principles to capture the voice of General Practice teams, clinicians, Health Boards, HSCPs, professional bodies, other key stakeholders, and people.

To gather the breadth of input required, a workshop (on Microsoft® Teams) was held to explore what the Access Principles should be for General Practice from the practice teams’ and clinicians’ perspective.

The workshop began by setting out the purpose of the workshop and confirmed what was in and out with scope. These are outlined below:

Within Scope:

• All General Practices across Scotland
• All people, citizens

Out-with Scope:

• The needs of particular groups of patients
• Finding answers/ solutions to access
• Fixing demand and capacity issues in General Practice

Areas are out of scope, not because these issues are not important, but to maintain focus on what was going to be a complex issue.

Chris Corkish, a representative of the RCGP Scottish Patient Forum and patient representative on the group, shared some personal reflections on access from a number of people’s perspectives. It was noted that there would be separate work to ensure the people's voice would be heard and included in the principles (see 5. People Engagement).

The workshop was then split into three parts.

• An initial whole group discussion to define access and explore what ‘bad access’ looks like.
• Eight break-out rooms with 8-12 people in each to review access across a 5-step person journey.
• Summarising this together from the practice and person perspective considering the challenges, successes and ideas relating to steps in the access process.

We used Microsoft® Teams and a Miro® interactive white board to capture the contributions.

4.1 Defining access

In terms of General Practices, provided the following feedback.

By more common terms, ‘access’ as a noun is defined by the Cambridge Dictionary as:

“the method or possibility of getting near to a place or person” or “the right or opportunity to use or look at something.”

As a verb: “to be able to get to or get inside a place.”

The main themes to define access in terms of General Practice included:

• Access is a journey of multiple routes
• Access is a way for people to get the help/care they need when they need it
• Care and how it is accessed should be appropriate (although who and how do we define what is appropriate?)
• Access should be easy, clear, transparent and people should understand how to access the care they need, so they can effectively use services
• Care should be accessed at a mutually agreeable time (for both the service and service user)
• Access should be “Fair for all”
• There should be a single point of contact for people
• Information on services should be easily available
• “I am taken seriously and listened to”
• A person’s expectations for care are met (good clinical outcomes)
• Timeliness of availability should be suitable

From these themes and taking into account the feedback of the group, Access for the purposes of this work is defined as:

“the method by which people can get to the appropriate clinical care that they need, when they need it.”

4.2 What does bad Access look like?

Thinking of the worst possible process can help directly identify the solutions for each step of a problem. This is known as a TRIZ (Theory of Inventive Problem Solving^[25]) process. It encourages reflective abstract thinking.

In this case, we considered access from the practice and the person’s perspective. Although it is meant to be purely theoretical, it is there to encourage courageous thinking and how we would challenge or confront the worst processes we could imagine. Like the definition process, all participants did this as a single group.

The scenario discussed was ‘Stephanie has IBS [irritable bowel syndrome]. Her symptoms have been worse of late. She calls the practice on Monday.’

The questions asked:

1. ‘What would the worst access to care from practice perspective look like?‘; and

2. ‘What would the worst access to care for Stephanie look like?’

The main themes of worst access included:

• People don’t know or understand the system and how to use it
• People are unable to get through on the telephone (for a variety of reasons)
• The Practice tells people what it cannot do rather than what it can
• People’s perceptions of need/ capacity discourage them from accessing care
• Uncaring and negative response from practice staff
• General Practice does not understand or respond to a person’s needs
• People are not aware of other forms of accessing help such as NHS Inform

4.3 The Five Steps

In 2013, the International Journey for Equity in Health published Patient-centred access to health care: conceptualising access at the interface of health systems and populations^[26] Levesque proposed a framework of person-centred access to health-care. From Levesque’s model, the group considered access and access improvement in five steps from two different perspectives – that of the person (service user was Levesque’s term) and that of the General Practice. In each step the group looked at the challenges, ideas, and successes we have experienced.

Question 1

Practice side: What does good approachable care look like?

Service User: How do I put better support around me to improve my health?

Question 2

Practice side: What does acceptable access look like?

Service User: How I seek and access the care I need?

Question 3

Practice side: What does availability of access to care look like?

Service User: I successfully reach the care I need.

Question 4

Practice side: What does inappropriate deliverable care look like?

Service User: What Personal 'cost' can there be for me to access healthcare?

Question 5

Practice side: What does inappropriate access to care look like?

Service User: How do I put better support around me to improve my health?

A summary of the main themes from the discussions on each question is available in Appendix 2.

From reviewing the responses to the five questions above, we identified the following common areas as key themes to be considered in the development of access principles:

• Ease of access (convenient, timely, flexible)
• Maximise the use of technology/digital, multiple channels to single point of access
• Care navigation and role of the receptionist
• Understanding the role of the MDT and it is not just the GP
• Equity and ‘Fair for all’
• People’s understanding of the system, availability of information (health literacy, digital exclusion)
• Urgent care versus routine care
• Want versus need
• Demand versus capacity
• Preventative and proactive versus reactive
• Variation versus standardisation