A paradox of access problems in general practice: a qualitative participatory case study

Background: Despite longstanding problems of access to general practice, efforts to understand and address issues do not adequately include perspectives of people providing or using care, nor do they utilise established theories of access to understand complexity. Aim: To understand problems of access to general practice from the multiple perspectives of both services users and staff using an applied theory of access. Design and Setting: A qualitative participatory case study in an area of Northwest England. Method: A community-based participatory approach and qualitative interviews, focus groups, and observation were combined to understand perspectives. Inductive and abductive analysis, informed by the applied theory, allowed the team to identify complexities and relationships between interrelated problems. Results: A paradox of access problems is presented, in which the demand on general practice both creates and hides unmet need in the population. Data show how reactive rules to control demand have undermined important aspects of care, like continuity. The layers of rules and decreased continuity create extra work for practice staff, clinicians, and patients. Complicated rules, combined with a lack of capacity to reach out or be flexible, leave many people, including those which complex and/or unrecognised health needs, unable to navigate the system to access care. This paradoxical relationship between demand and unmet need exacerbates existing health inequities. Conclusion: Understanding the paradox of access problems allows for different targets for change and different solutions to free up capacity in general practice to address the unmet need in the population.