Helen Salisbury: Improved access is meaningless without increased capacity
BMJ 2025; 389 doi: https://doi.org/10.1136/bmj.r641 (Published 01 April 2025) Cite this as: BMJ 2025;389:r641
- Helen Salisbury, GP
- helen.salisbury{at}phc.ox.ac.uk
Follow Helen on Bluesky @helensalisbury.bsky.social
We have a capacity problem in general practice. There are too few GPs, either as partners or employed, for the number of patients who need looking after. This is despite there being GPs unable to find work and practices that would like to employ them but lack the money or space.1
Unsurprisingly, capacity and access are a priority for the government—perhaps because nothing says that the system is broken quite as effectively as an 8 am queue for appointments snaking around the block. Last year’s primary care network contract included extra payments related to this, with a number of boxes that needed to be ticked to earn them.2 Unfortunately, the focus was entirely on ease of access (how the patient makes contact with the surgery through new telephone systems and online triage) rather than on increasing capacity (the number of GP appointments available). This doesn’t help patients or doctors, and it often just exacerbates the mismatch between supply and demand.
In this year’s contract there’s a requirement, although delayed until October, that all practices have online systems open during core hours (8 30 am to 6 30 pm, Monday to Friday), through which patients can submit non-urgent clinical or administrative queries.3 When online access started some practices left their submission portal open continuously, but they rapidly moved to limit these hours after arriving on Monday mornings to hundreds of patient queries and finding it impossible to respond to them all.
In our practice we have, until now, turned our system off at 4 30 pm so that there’s time for submissions to be read on the same day and actioned if necessary. This is because, despite the system advising patients that submissions may not be seen immediately, we’re concerned that they may send clinical queries that do need an urgent response and that they could come to harm if their question about chest pain or breathlessness isn’t seen until the next day. Some online systems (although not all) don’t allow submissions if they contain certain trigger phrases. This is meant to prevent patients from using online access for queries that need an urgent response, but such safeguards are unlikely to be foolproof.
Limited benefit
However, there’s a more fundamental problem: making access easier increases demand. Patients message us with questions they would never have booked an appointment to discuss, but we must now read and respond to them. The huge amount of work this creates is of only limited benefit and eats into time we should be using to see patients.
Clinical queries also raise important questions about responsibility and liability. If an anxious student submits a query about a bad headache that started that morning, they probably need to take some paracetamol and go back to bed. Once we’ve read it, however, we’re obliged to ask about the headache’s severity and check for red flag symptoms just to make sure we’re not missing meningitis or a subarachnoid haemorrhage.
Clearly, we need to make it simple for patients to seek medical care when they need it. But online access is no panacea. It’s a mode of access that excludes many patients and may worsen the capacity problem.4 It reminds me of the town where I grew up, where a failed road redevelopment scheme became famous for funnelling traffic very quickly from one bottleneck to an even bigger one on the other side of town. Making access to GPs easier without taking concrete steps to increase capacity feels like much the same failure of planning.
Footnotes
Competing interests: See www.bmj.com/about-bmj/freelance-contributors
Provenance and peer review: Commissioned; not externally peer reviewed.