Experiences of access to general practice in England: qualitative study and implications for the NHS 10 year plan.

OBJECTIVE: To report experiences and views of patients, carers, and staff on access to general practice in England in the context of major government plans to reform NHS services. DESIGN: Qualitative interview study. SETTING: Patients and carers in Devon, Medway, Blackpool, Luton, and Lancashire, and NHS general practices in the east of England. PARTICIPANTS: 70 interviews with 41 patients and carers and 29 general practice staff, including general practitioners (GPs), nurses and allied health professionals, practice managers, and administrators. Analysis was based on the constant comparative method, with themes mapped to the three shifts-to digital, to community, and to prevention-proposed in the 10 year plan for England. RESULTS: Patient participants represented 12 ethnic groups and diverse personal and medical characteristics. The three shifts offered some benefits to participants but also introduced new risks and disadvantages. The shift to greater digitisation in general practice (mainly in the form of online appointment booking systems and access to medical information) offered more convenience for some patients and improved efficiencies. The shift did little to resolve the fundamental scarcity of appointments with a GP, however, and it introduced new forms of disadvantage and exclusion while failing to address what patients were often seeking: human connection and empathy with a GP they knew. The shift from hospital to community based services, with GPs working over greater geographical scale in new neighbourhood based models, was perceived by participants to offer greater capacity for appointments but faced constraints including practical challenges to coordination and organisation. New services encompassing larger areas risked patients feeling unrecognised and unknown at their practice and undermining the long term relationships with GPs that patients valued. Prevention efforts, while accepted as important, were seen as challenged by their tendency to fragment care, oversimplified models focused on single diseases, and consuming capacity that could otherwise be used for contacts initiated by patients. Concern about increased workload for staff at general practices was consistently expressed. CONCLUSIONS: Although improving access to general practice is a stated priority in government plans to reform NHS services, the three proposed shifts may not be what patients are seeking or what practices want in order to support their work. The proposals will require careful design, implementation, and evaluation in collaboration with key stakeholders, to ensure they do not undermine continuity of care nor fragment existing services.