ccess to general practice appointments and sustainable change: a focused ethnographic case study.

BACKGROUND: Access to an appointment with a GP is important to patients, but hard to achieve in modern general practice, with general practice delivering more consultations than ever before. Research has focused on discrete systems for managing access in general practice, for example, telephone prioritisation, and these have been demonstrated to be variably successful in managing demand. AIM: To examine the sustainability of previous attempts to improve access to GP appointments to understand if access systems previously deployed have been adapted, abandoned, or sustained. DESIGN AND SETTING: This was a focused ethnographic comparative case study in eight English general practices. METHOD: Qualitative observation, semi-structured interviews, and documentary analysis were undertaken. The study included 74 patient and 70 staff interviews. RESULTS: Approaches to managing access are heavily focused on management of demand, and general practices constantly change access systems to try to achieve this. In all the case-study practices, access solutions previously deployed were adapted, rather than abandoned or adopted, usually via ongoing changes or 'persistent tinkering'. The complexity introduced by these adaptations can be confusing for patients and fuels dissatisfaction, stress, and hostility. Persistent change to access systems creates unintended consequences and significant work for all involved. CONCLUSION: Persistent tinkering is a necessary and reasonable response to the challenges of access in general practice. In part this is because the problem is framed as one of managing demand. An alternative approach might investigate what patients want or need and consider how best this could be delivered.