Title: Whatever happened to all those attempts to change access to General Practice? Revisiting case studies to learn about innovation, impact and SUStainable change. (GP SUS)
Funder: Department of Health and Social Care

Abstract: For decades there have been attempts to devise new systems for timely access to appointments at the general practice. For example, these systems could include offering online consultations, or requirements for pre-consultation telephone calls or completion of an online form. Several of these systems have been tested in research studies. At the end of the studies the researchers leave, the study is written up and the practices involved in the study are left to decide whether they want to continue using the system, or adapt it, or abandon it, over time. But very little is known about what they chose to do and what happens next. We believe that there is much to learn from the experiences of these study practices and patients. We have formed a research study to understand these experiences. _x000D_ _x000D_ Our study will also be informed by dramatic changes to GP appointments that have taken place over the 2020/21 pandemic. During this time many practices changed the way that patients consult with GPs and other practice staff, using remote telephone and video consultations rather than face-to-face appointments. While some patients and staff were very pleased to see these changes, others are concerned that (some) patients may have been deterred from seeking help. Both patients and doctors may feel that a diagnosis may be more difficult if the patient is not in the same room. There is also a question whether doctors are more likely to prescribe more readily ‘to be on the safe side’._x000D_ _x000D_ At the heart of this proposal are the questions: what happens after practices introduced changes to patient access? Did they find their systems worked or did they have to make further adjustments? Were there safety concerns? Did they change again in the pandemic? What might be learned from them about how to develop changes to better serve patients in general practice in the long term? We have discussed this study widely and know that these questions really matter to patients as well as practice staff and policy makers. Indeed, a public reviewer commented that access to appointments is THE most pressing issue facing general practice._x000D_ _x000D_ The aim of the study is to support long lasting improvements that work for everyone. We will start by looking at all the different models of access that have been used, looking at all the published research and talking to doctors, patients, researchers and policymakers. We will then work with eight different general practices in England to learn as much as we can about the different systems they use, how and why they have been adapted locally and what they learnt about their system during the pandemic. Our ‘case study’ methods will involve spending several weeks with the practices, attending meetings, reading documents and having formal and informal conversations with at least 6 members of staff and 15 patients registered with each of the eight practices. We will compare these cases with a practice in Copenhagen who have used a “same day” appointment system successfully for several years, without increasing overall demand, to see what we might learn for the UK from their experience._x000D_ _x000D_ We will put together everything that we learn during this research and work with patients, the public and other stakeholders, providing feedback to practices and for policy-makers, and holding three workshops to create resources to support changes that lead to a truly patient centred general practice.

Lay abstract: Background: _x000D_ There is a crisis in General Practice that pre-dates the pandemic. Access to appointments has been described by our PPI advisors as the single most important issue for patients. Several innovative systems and approaches intended to improve access have been studied in England but results have been inconclusive and contradictory. Post pandemic General Practice will need to reconfigure access. We see untapped potential to learn from what happened in practices that participated in earlier evaluations of different access systems and which subsequently continued, adapted or abandoned the approach. The experiences of these practices and the patients they serve could provide rich insights into the sustainability of access models, in different GP contexts, before and during the pandemic. _x000D_ _x000D_ Aim: _x000D_ To work with General Practices that have in the past tried interventions designed to improve access for patients, to learn whether and how these innovations were abandoned, adapted or sustained, and to use this learning to support long term improvements in access to general practice._x000D_ _x000D_ Objectives:_x000D_ 1. To create a typology of different organisational approaches and digital technologies used to enable patient access to general practice appointments (with a GP or other primary care clinician, via to face to face, phone or online consultations)._x000D_ _x000D_ 2. To describe and compare the longer-term impacts of different approaches to patient access to General Practice (including the rapid changes introduced during the 2020-21 Covid-19 pandemic) to understand whether the various approaches worked as anticipated, were adapted or abandoned, and whether practices were able to sustain any improvements over time._x000D_ _x000D_ 3. To distil and develop deep, transferable learning about sustainable approaches that support and improve access to General Practice._x000D_ _x000D_ Methods: _x000D_ Three work packages include a scoping review, case studies and an integration and implementation phase. We propose focused ethnographic case studies in 8 English practices that were part of a variety of access intervention studies that completed at least 18 months before March 2020. As a comparator our Danish collaborators will use the same methods for a case study of the NF33 practice in Copenhagen which has several years’ experience of successfully implementing a same day appointments model which has reduced demand while increasing responsiveness. Drawing on key contemporary theories about implementation, adaptation and abandonment our focused ethnographies (8 English sites, 1 Danish) will include observations in practices, interviews with a purposive sample patients (up to 15 in each practice) and with staff of all types (6- 8 in each practice). Analysis will use thematic approaches and cross case comparisons with a particular focus on what supports long lasting improvements that work for everyone._x000D_ _x000D_ Anticipated impact and dissemination: _x000D_ By drawing on experiences at least three years after the practice participated in evaluation studies of access interventions we will maximise learning about real world implementation using timely and cost effective focused ethnographic case studies. We will feedback to participating practices and prepare policy briefing papers during the study, with steering group contributions from policy and professional stakeholders, and embedded PPI throughout. Three workshops will create resources to support future and sustained change.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE