What are the systemic reasons affecting GP access?

Practices have been criticised for providing poor access, but the data reveals that the level provided depends very much on system issues, finds Jaimie Kaffash

It has been tempting for policymakers and the media to hold up examples of good practice when it comes to GP access, and bash practices that they say are not offering good levels of access. Indeed, health secretary Wes Streeting caused anger among GPs with his comment in January 2025 that some GPs were ‘coasting’. He repeated this trick last month, with comments that GPs who are unhappy about contractual requirements around access are ‘laggards’.  

But an analysis by Cogora, the publishers of Pulse, has looked into the practices that are struggling with access. It reveals what many GPs already know – that these struggles are almost entirely systemic, based on patient demographics, deprivation, funding and workforce, among other factors.

For this analysis, practices in England were ranked across a variety of factors around access based on their list size, including around their appointments per patient (total appointments, face to face, with a GP, within a day and routine waiting times). This data was combined this with various patient survey metrics, including: patients seeing their preferred healthcare professional on their last visit; how long they waited on the phone; their recollection of waiting times; and whether they felt waiting times were appropriate, among other factors (see methodology, below).

This methodology is fairly crude and has a number of flaws, but however it was tweaked, it showed the same trends – practices that receive less funding offer worse access.

Age, funding, disease prevalence and workforce

Practices with older populations and higher disease prevalence provide better access. Under the Carr-Hill formula, these practices are provided with more funding per patients. This isn’t necessarily a bad thing – these populations do have more need for GP access. And it should come as no surprise that these practices have fewer patients per GP and staff member.

Professor Azeem Majeed, head of the department of primary care and public health at Imperial College London, says of the link between high performance and age of patients, funding and workforce: ‘This makes intuitive sense and is also supported by the evidence. Practices serving older populations, or those with higher levels of deprivation and disease burden, inevitably need more capacity to meet demand. If funding and workforce provision do not adequately adjust for these factors, then patients in these communities will experience poorer access and lower satisfaction. The implication is that equitable access depends on aligning resources to patient need, not just to crude headcounts. This is one of the major challenges facing general practice and the wider NHS.’

Size of practice

There is also a link between the size of a practice and the levels of access provided, with smaller practices more likely to score higher. This shouldn’t be a major surprise to anyone who has studied general practice. It is well known that, despite successive governments’ attempts to encourage practices to work in larger groupings, smaller practices tend to do better in patient satisfaction scores.

The Institute for Government’s report into access made similar conclusions. It said: ‘Practices with larger patient list sizes are less satisfied than those in smaller practices. The effect is significant but not large: for every additional 1,000 weighted patients, our central estimate is that satisfaction declines by approximately 1.6 percentage points.’

It did make the point that access was only one part of good GP care, and that there is evidence that larger practices can work more efficiently, and were less likely to require admission to hospital.

Dr Steve Taylor, GP spokesperson for Doctors Association UK, says a lot of the benefits of smaller practices come from continuity of care: ‘Smaller practices have been shown to increase patient outcomes and satisfaction. It is likely that this is due to greater knowledge of individual patients, continuity being key, but even low-level continuity with previous knowledge of patients can be extremely helpful in managing patient care. This is much more likely in smaller practices, where patients are more likely to have greater continuity of care. It’s also more likely that smaller practices have linked knowledge of patients across the whole team, with conversations between admin, reception and clinical staff being more likely to occur.’

Professor Majeed adds: ‘There is longstanding evidence that continuity of care and personal relationships with GPs and their teams are stronger in smaller practices. Patients value being able to see the same clinician, and staff in smaller teams may have greater familiarity with their patient population. This tends to translate into higher reported satisfaction, even if the absolute volume of appointments is lower than in larger practices. Smaller practices may also be more flexible in how they offer appointments, though this can vary widely.’

Deprivation

When we look at the deprivation levels in a practice population, the picture becomes murkier. Deprived practices tend to offer similar numbers of appointments as those in less deprived areas. But patient satisfaction scores reveal a much bigger divide between deprived practices and those in more affluent areas.

Practices in deprived areas tend to have younger populations, which would affect the funding they receive. There are moves to rectify this, but as it stands, their funding is reduced, despite the many health problems associated with deprivation.

The Deep End Project is a group covering the 100 most deprived practices in Scotland. Dr Stewart Mercer, who is part of the group, says the combination of normal levels of appointments and low patient satisfaction makes sense. He says: ‘That’s probably due to capacity issues in deprived practices – unmet need is high but the ability of GPs to deliver more consultations to meet this need is limited due to the inverse care law [which states that good care is more readibly available to those in least disadvantaged groups]. It may also be that, due to poor access and the 8am phone fiasco, many patients in deprived areas have simply given up trying to get a GP appointment.’

According to GP and practice managers in deprived practices, there are numerous additional challenges involved in improving access. Lothian GP Dr Peter Cairns says: ‘I work in a deprived setting – the evidence would suggest our priorities should be implementing interventions known to improve long term outcomes and population health, especially for those patients who are disengaged from services, rather than endlessly facilitating “access” for those who demand it.

‘Much of the demand for “access” is being driven by circumstances outwith primary care’s control: sick lines, housing pressures, waiting lists in secondary care, etc. There is no meaningful plan to deal with this in England or Scotland that I can see.’

Patient ethnicity

The ethnicity of a patient population seems to have an even greater effect on access. Again, practices with a high number of non-white patients tend to have younger populations.

One potential explanation for lower appointment rates for practices with high numbers of non-white patients can be found in the concept of candidacy developed by Professor Mary Dixon-Woods of The Healthcare Improvement Studies Institute (THIS Institute), University of Cambridge, which is around ‘how people’s eligibility for healthcare is determined between themselves and health services.’ It finds that people might have different thresholds for seeking care – for example, smokers or people with obesity-related health issues, which is more common in deprived areas, may fear being judged by staff; or a lack of health literacy may make them less confident in navigating their way around the systems.

Dr Carey Lunan, a GP at the Deep End Project based at the University of Glasgow, says it is ‘important to disentangle about the difference between demand, and need, in driving appointment numbers’. She says: ‘Ideally it should be needs-led, but that’s not the way the system works.

‘ [Former lead of Deep End] Professor Graham Watt speaks about the importance of GPs in more socio-economically deprived areas needing to be the doctor for the “unworried unwell”; consumption of healthcare can also be driven by higher health literacy, higher levels of agency and “candidacy” and trust, better navigation of systems, higher digital inclusion, better self-advocacy…often meaning that those who don’t benefit from these things are less able to proactively seek care and have their needs met, and health inequalities worsen.’

At the other end of the scale, patients from more affluent communities can – as one practice puts it – ‘a magnified sense of entitlement, stating that they have been taxpayers all their lives and that the NHS is a disgrace’.

It might just be that GPs aren’t ‘coasting’, or ‘laggards’, but there are very real systemic reasons why some practices aren’t able to offer the level of care they would like.

You can find all the data and the methodology in the full report. Click here to download the full report. GPs can download it for free.

Commercial partner of this white paper: General Practice Solutions