Everyone agrees that access needs improving, and as we have seen, not much is working. But practices are finding some successes by being given the freedom they need. Jaimie Kaffash reports
Successive governments have focused on the ‘8am rush’ to secure an appointment by phoning the practice. Of course, the availability of appointments is crucial here, but the logistics behind the ease of access – how easy it is to actually get through to the practice – have been equally pressing.
NHS England’s ‘Delivery plan for recovering access to primary care’ sought to address this through ‘Modern General Practice Access’. This is a model encouraged by NHS England, and is based on the following principles:
- Optimised contact channels – offering patient choice of telephone, online and in person through easy-to-use websites, online consultation tools and improved telephony systems
- Structured information gathered when the patient contacts the practice, to understand what is being requested
- Use of a single ‘care navigation’ across each channel to prioritise patients safely and fairly, and moving away from ‘first come, first served’.
It also refers to making ‘full use’ of the primary care team and ‘self-access’ options, as well as improved use of data. GP practices have implemented this through a mandatory move to cloud telephony and through triage systems. As we will see in this chapter, these changes have proved fairly successful in England, according to GP practices, who have implemented them in their own way. They might even have contributed to the uptick in satisfaction scores on the GP Patient Survey this year.
Total triage
According to NHS England, total triage is where ‘every patient that contacts the practice is first triaged before an appointment is arranged. All patient requests are screened and signposted by the practice to the next step of their care journey. Practices use a combination of both digital and traditional pathways to achieve this.’
Surveys carried out for Cogora’s Access All Areas White Paper revealed that many practices felt total triage had come a long way since the pandemic. Around half say they have introduced total triage in a bid to improve access, and almost 90% of those who did say it has been successful.
Interestingly, many respondents to the survey – which went out in July 2025 – said they had either very recently introduced total triage, or were in the process of introducing it. One GP in Manchester said: ‘We are moving to total triage from the end of September this year. All the other practices in our PCN have already done this. It seems to be the only way to control the relentless demand for GP appointments.’
Another GP in Essex, writing in August, said: ‘Since completing the survey, we have switched to a total triage model.’
A GP in Nottingham said: ‘We introduced total triage this week. I am optimistic about it but the triage has to save a minimum of 30 appointments a day for it to work (as we lose 30 appointments a day for the triage to be able to triage). On two occasions we phoned separate patients within 20 minutes of their triage request and were able to offer them an appointment within 30 minutes but they both decided to go to A&E instead!’
Some who said they had begun setting up total triage in recent months said they were doing so in anticipation of contractual changes in October. Under the new patient charter, patients can expect to hear what the next stage of their care will be within 24 hours of contacting their practice via telephone, online submission or walk-in.
Heather Wilson, a practice manager in Blackpool, said: ‘After the announcement about online consultations needing to be available during opening hours from October, our partners and I both decided to implement the total triage model.’
The contract changes loom large for some, however. One practice manager in Essex says: ‘Triage works for us while we have a safe working capacity on it but after October this will be unsafe and will not be able to deliver the same level as we are. We will not have the capacity for appointments.’
GP triage
In most cases, the process involves the GPs in the practice taking on all the triage. Dr Eithne Macrae, a GP in St Helens, says total triage has worked well since implementation in July 2023. She says: ‘With GPs and not admin triaging, we can arrange appropriate investigations, request further history etc, so the patient is seen with the results (if clinically appropriate and can wait) – thus getting the most out of each GP appointment.
‘GP triage appropriately diverts patients to the right place first time, so we are physically seeing fewer patients but we are seeing those who need to see a GP sooner than before. We are managing a much greater number of patients than pre-total triage.’ One GP in Berkshire says his practice dedicates four GP sessions a day to triage, but this has ultimately proved efficient.
Such a GP-led process isn’t used across the board. One practice manager in Bristol says: ‘We use trained health navigators rather than clinicians or a machine in order to free up GPs to see the right patients at the right time.’
Controlling demand
Some practices are using total triage to try to control demand. The Manchester GP whose practice is currently implementing total triage says: ‘All requests will now be submitted online or via the receptionists helping the patient to fill out the form. We will be providing no additional appointments but hopefully we can deflect some of the patients who don’t need a GP appointment.
‘We are planning to offer all appointments as face to face once they have been triaged, 15 minutes duration with the option for telephone at the patient request. We will see how it goes – having to have online access open until 6:30pm from October will be a significant challenge. My GP day is now 11 hours long often with no break for lunch – it’s not sustainable to do that for years on end.’
Dr Sarah Dixon, a GP in Hertfordshire and West Essex, says online access has made it easier for patients to contact the practice with what are often self-limiting issues. She adds: ‘We do need to base access on needs rather than the wants and demands of a patient.’ Some patients might be unhappy with this, she says, but it does ensure patients get the appropriate care.
Workload
Some practices have, however, reported workload issues as a result of triage. Putting GPs on triage means they are taken away from patients. One GP in Gloucestershire, whose practice has GPs triaging all request, says: ‘The problem with this is that it is GP intensive and also we struggle to cope with the number of requests in a day. It means the triaging GP is necessarily not doing other things/providing appointments to see people.’
It isn’t always the most satisfying role either, says the GP in Essex who has recently implemented triage. ‘As clinicians we are all struggling with sitting in a hub for 12 hours reading these forms and would all rather see patients and do the job we trained for.’
Patient feedback – health and digital literacy
There have been concerns around how patients will react to total triage, especially with regard to health and digital literacy.
The Essex GP says the number of phone calls has dropped since the introduction of total triage ‘so I presume the “I’ve been waiting on the phone and look at my phone I have called 300 times has changed”.’ However, the GP adds: ‘The abuse continues with patients refusing to complete the form, complaining to receptionists it is a stupid form/system etc. We have found the receptionists have been completing forms for patients of all ages 20-80, the latter older group at face value managing far better than the younger counterparts.
In general, patient feedback has been mixed. Lisa Fall, a practice manager in Dorset, says: ‘With regards to online consults we have patients who love completing the forms, as it means the information can be sent, reviewed and an appointment sent back within 24 hours (for us anyway), versus those who absolutely refuse to fill a form in as they want to phone and get an appointment with a GP.’
However, Heather Wilson, a practice manager in Blackpool, reports that feedback has been ‘angry’. ‘Patients don’t want to fill in online forms, they want to call the surgery. The main view was that this would mean elderly and vulnerable patients would not be able to use the form and therefore be unable to contact us. When patients do fill in this form, we are finding the information they are giving is much more detailed than what they are giving the receptionist if they use the telephone to call us instead.’
The main takeaway for many general practice staff is summed up by the GP in Essex: ‘I think the problem with the one size fits all is it just doesn’t. Practices are different, people are different, and their needs are very different, forcing practices to one way of working just doesn’t work.’
Telephony services
Also as part of Modern General Practice Access, NHS England is mandating the improvement of telephone systems. In the 2023 imposed GP contract, NHS England announced that – from the end of 2025 – all analogue telephone systems would be banned from GP practices. They would need to move to digital telephony, which would allow:
- Routing of calls
- Call-back and call-queuing functionality
- Support for remote working and business continuity
- Enhanced reporting capability to support capacity/demand service planning, including call volumes, time in a queue, calls abandoned and average call length, among other metrics.
To support this move, NHS England made £240m available for practices using older systems as part of its delivery plan. This hasn’t been without controversy. Practices have warned of spiralling costs in the use of these new systems, with some claiming increased bills of £10,000 a year, with the BMA calling for the project to stop as a result. Meanwhile, there have been fears that the enhanced reporting could be used to performance manage practices.
These issues with contacting the practice can also be seen in attitudes towards reaching a practice by phone, which remains the most popular way of doing so – 62% said in 2015 that they had contacted their practice by phone on their last attempt, compared with 14% for both walk-in and online. Yet satisfaction with phone contact has dramatically decreased in the years since 2018, from 80% to just over 50% in 2025. There has been a slight uptick in the past year, however – only the second year to arrest the sharp decline over 13 years, with the only other being during Covid. Meanwhile, new monthly data from the Office for National Statistics shows that the percentage of patients reporting difficulty in contacting their practice is decreasing.
Practices report that digital telephony has been helping. One practice manager in Blackpool says: ‘I was annoyed and reluctant to move to a new-fangled phone system when we were already on the same system as our local hospital and everything worked really well, and the system was partially compliant. We moved to our new system about a year ago and I have to say I’m impressed. We fully use the system and I didn’t have any complaints from patients, or staff, regarding the switch. It’s obviously busy at 8am but routine calls about prescriptions/results etc are moved to a quieter time in the day.’
Staffing flexibility
But this still needs staff. Susan Lowe, a practice manager in Cheshire and Merseyside, says getting through to the practice has been a ‘longstanding problem’ that has been eased by triage. But this has involved a change in staffing: ‘We now have all the staff who are in the practice from 8am on the phones – no matter what non-clinical role they have. This simple thing has made a huge difference. We now have the call queue down to zero within 30 minutes most days. We flex staff onto the phones once the queue goes into double figures and this has a real positive impact. We have the phone activity visible in the triage hub and in the call handlers’ office.’
It is a similar case for Jane Dalgleish, a practice manager in Stockton, who says her practice has made many improvements to GP access. She adds: ‘The biggest improvement though has been access to the surgery via the telephone. We have an average wait on the phone of around 4.1 minutes and this includes busy Monday mornings. The change we made that has had the most impact on this is to have a “spare” member of staff who is able to jump on the call queue if it is starting to rise. Sometimes this is only for a few minutes to bring the calls down to manageable levels.’
These changes are helping practices to offer improved access, when given flexibility. But, as the last part of this series shows, greater improvements will need changes in attitudes from policymakers.
You can find all the data and the methodology in the full report, which can be downloaded here.
Commercial partner of this white paper: General Practice Solutions
