Sarah Burns is a GP in Hampshire and a Senior Teaching Fellow at the University of Southampton
Noor* speaks little English. Last month she found a breast lump. She hopes it will go away once her period comes. But it doesn’t. Noor calls her GP surgery. There is a new telephone system – her call is answered quickly by the automated system, but there is a long, recorded message Noor doesn’t understand, and she is placed in a virtual queue. Over the next 20 minutes, Noor watches the credit on her pay-as-you-go mobile disappear. When the call is finally answered the receptionist speaks fast, and all Noor can understand is that she isn’t allowed to call to make a GP appointment anymore. She hangs up. Her mobile credit for the month almost completely gone, and no further forward.
Over the next 20 minutes, Noor watches the credit on her pay-as-you-go mobile disappear.
A week later, Noor goes into the surgery and speaks to another receptionist. Again she can’t really understand what she is being told. But the receptionist won’t book her an appointment and keeps showing her the surgery webpage and pointing to something on there. Noor doesn’t have a smart phone or access to the internet.
Noor’s husband died 3 years ago. She lives with extended family and her two young children. She doesn’t have anyone she feels comfortable sharing this intimate health problem with. Noor notices the breast lump has grown. She is worried. Her Mum died of breast cancer back in Pakistan. But she doesn’t know how to get to see the GP.
Two months’ later one of the regular volunteers at the food bank, who speaks some Urdu and has got to know Noor over the last 3 years, notices that Noor looks stressed and unwell. Noor breaks down in tears and opens-up about her health worries. Together they sit down and look at the GP website. The volunteer fills in an e-consult on Noor’s behalf.
The next day, Noor gets a text asking her to attend for a GP appointment that afternoon. The GP has organised a telephone interpreter, and Noor is able to fully explain her worries. The GP examines her. Finding a craggy, hard lump, she explains to Noor that she is concerned she might have breast cancer and needs an urgent referral. It is almost three months since Noor first tried to make a GP appointment.
These systems are often promoted as improving patient choice, whilst the reality is that they have been designed with the provider in mind.
Access in Primary Care is a hot topic. To cope with increasing demand and diminishing resources, many practices are turning to digital systems to manage patient access. This is understandable given the level of stress on the system and burnout amongst practitioners.
These systems are often promoted as improving patient choice, whilst the reality is that they have been designed with the provider in mind. A recent systematic scoping review identified that very few studies have looked at the impact of protected characteristics on access.1 Studies have shown that the use of online consultations disadvantages digitally excluded patients,2 particularly those in more deprived and vulnerable communities where there may also be language barriers.3
Whilst, as practitioners, utilising digital approaches to manage access can give us a sense of control in a strained system, does it really serve us or our patients? Capacity will still be reached, but are we seeing a shift in the patients we see? How many of us are frustrated by the literate, self-empowered patients, with ready IT access, who make digital contact repeatedly for minor, self-limiting problems? If practices now utilising digital access systems looked at the demographics of those making contact, I suspect it would show a narrowing of diversity when compared with the practice population they serve.
However tough the landscape is in Primary Care, we must not lose sight of the populations we serve. Initiatives to improve access need to be flexible, accommodate the needs of both those delivering and receiving care and avoid worsening the health and social inequalities we all already encounter in our daily work. Worsening health inequality as an unintended consequence of trying to improve access must not be ignored.
*Author’s note: Noor is a fictional patient based on the author’s clinical experience and not a specific patient
References
- Eccles A, Bryce C, Driessen A, Pope C, MacLellan J, Gronlund T, Nicholson B, Ziebland S, Atherton H. Access systems in general practice: a systematic scoping review. BJGP [Internet]. 2024 [cited 2025 Feb 18]; 74(747):e674-e682. Available from: https://doi.org/10.3399/BJGP.2023.0149
- Turner A, Morris R, Rakhra D, Stevenson F, McDonagh L, Hamilton F, Atherton H, et al. Unintended consequences of online consultations: a qualitative study in UK primary care. BJGP [internet]. 2022 [cited 2025 Feb 18]; 72(715): e128-e137. Available from: https://doi.org/10.3399/BJGP.2021.0426
- Paddison C, McGill I. Digital primary care: improving access for all [Internet]. Nuffield Trust; 2022 [cited 2025 Feb 18]. Page 10. Available from: https://www.nuffieldtrust.org.uk/research/digital-primary-care-improving-access-for-all-rapid-evidence-review
Featured photo by Cherry Laithang on Unsplash
Such an important article!