Access to GP Practices in Wales Older people’s experiences (HTML)

The Older People’s Commissioner for Wales

The Older People’s Commissioner for Wales is an independent voice and champion for older
people throughout Wales.

The Commissioner is taking action to protect older people’s rights, end ageism and age
discrimination, stop the abuse of older people and enable everyone to age well.

The Commissioner is working for a Wales where older people are valued, rights are
upheld and no-one is left behind.

How to contact the Commissioner:

The Older People’s Commissioner for Wales
Cambrian Buildings
Mount Stuart Square
Cardiff
CF10 5FL

Phone: 03442 640 670
Email: ask@olderpeople.wales
Twitter: @talkolderpeople
Website: www.olderpeople.wales

Accessible formats

If you would like this publication in an alternative format and/or language, please contact us.

Mae’r ddogfen hon ar gael yn Gymraeg // This document is available in Welsh

Foreword

As we get older, accessing GP and other health services often becomes a more prominent aspect of our lives. These services play a crucial role in supporting many older people to stay healthy, independent and safe, manage long-term conditions and minimise pain, which, in turn, enable older people to stay in work, volunteer, support or care for others, take part in family and
community life, and age well.

My team and I regularly travel throughout Wales to meet and speak with older people, and access to GP practices is an issue that is consistently raised. This was also reflected in the experiences of Black, Asian and Minority Ethnic older people shared as part of an engagement project about people’s lived experiences.

In recent years, we’ve also seen significant changes to the way that services are being provided, with a rapid shift towards delivering online services – significantly accelerated by the pandemic – which risks leaving behind older people who are digitally excluded.

Understanding the barriers older people face when trying to access GP practices is crucial to
prevent people, often in the most vulnerable situations, from being discouraged or excluded from accessing vital health services. Tackling the kinds of issues that make it difficult to access GP practices is also important in the longer-term to help make an age-friendly Wales a reality.
That is why I invited older people to share their recent experiences of accessing GP practices in Wales, to provide an insight into the kinds of issues people are facing, the impact these are having on people’s day-to-day lives, and the action older people want to see that would improve their experiences.

The survey I distributed to older people covered a wide range of matters – including making and
attending appointments, relationships and interactions with doctors and surgery staff, continuity
of care and clinician, and the surgery environment itself – and provided an opportunity for
people to raise other issues that affect their access to GP practices.

There was a significant response from older people throughout Wales, with over 900 completed
surveys received in total, and I would like to thank everyone who got in touch to share their
experiences and make the publication of this report possible.

I would also like to thank the older people’s groups who provided feedback on my survey questions, and the voluntary and statutory organisations that helped my office to develop and
distribute my questionnaire, including Age Cymru and Llais.

Furthermore, I would like to thank other key health bodies and organisations, including the NHS
Wales Strategic Programme for Primary Care, Royal College of General Practitioners, Royal
College of Nursing, Institute of General Practice Management, British Medical Association,
General Medical Council and others who engaged in very helpful discussions relating to the
policy and operational context throughout this work.

My findings highlight that older people often find practice staff to be friendly, helpful, kind and
apologetic when there are issues, and there was general recognition that services and staff are
under pressure, doing their best under the circumstances. But the experiences shared reveal that many older people also face difficulties and challenges that leave them feeling frustrated, let down and left behind. Also of great concern is the fact that a number of people described themselves as suffering, getting worse, being worried and anxious, or simply ‘giving up’ trying to access their GP practice as a result.

Based on these kinds of experiences, my findings suggest that the older people who responded to my survey are yet to experience the full extent of the service improvements being reported to the Welsh Government.

Many of the issues identified within this report can be tackled at little or no cost with practical
steps by GP practices to improve older people’s experiences. Some of the action older people want and need to see, however – relating to service redesign and modernisation of systems and
infrastructure, for example – will require longer-term investment and support from the Welsh
Government, health boards and local authorities. While I recognise the pressures currently being faced by public services, including financial pressures, without sufficient funding and resources to improve access to services, many older people may find themselves unable to get the treatment they need.

The action I am calling for will help to enable relationships of trust between patients, doctors and practice staff that often add so much value to interactions and are so highly valued by older people. In addition, delivering this will help to ensure that people can access the health services
they need, when they need them, in a way that suits them, which will make a positive difference
to the lives of many thousands of older people throughout Wales.

Heléna Herklots CBE
Older People’s Commissioner for Wales

Executive Summary

Background

Access to GP surgeries is a longstanding issue in Wales, and is often raised by older people
with the Commissioner at engagement events and via the Commissioner’s Advice and Assistance Service.

The Commissioner previously examined these kinds of issues in 2017, publishing her ‘GP Services in Wales: The perspective of older people’ report, together with formal Guidance for GP practices and health boards.

In the years since, health services – including GP services – have faced significant pressures
due to the impact of the pandemic and the impact of inflation on public spending.

Research undertaken on behalf of the Commissioner in 2023 indicated that these pressures are
having an impact on older people’s access to services: over 40% of people aged 60+ said they were less likely to try to get a GP appointment, access an out of hours GP service or request a home visit due to reported NHS pressures. This research also found that 89% of older people felt ‘anxious’ about the state of the NHS, the top issue of concern amongst a wider list.

Other research in 2023 reflected these findings, such as Age Cymru’s ‘What Matters to You’
survey, which found that 72% of older people had a negative experience of GP surgeries. Due to continued evidence of older people facing difficulties accessing GP practices, and concerns raised by Black, Asian and Minority Ethnic older people during engagement throughout 2022/23, the Commissioner wanted to examine older people’s experiences in more detail.

The Commissioner conducted a survey during autumn 2023, which covered various aspects of accessing GP practices, including making an appointment, communications with and from practices, joined-up care and services, patient satisfaction and challenging poor service or practice.

Over 900 older people responded to the Commissioner’s survey, and the information and
evidence shared forms the basis of this report.

Alongside this, information was gathered through wider engagement with older people and
organisations and through drawing upon research previously undertaken by the Commissioner,
including Accessing Health Services in Wales: Transport Issues and Barriers, Access Denied:
Older People’s Experiences of Digital Exclusion in Wales and findings from the Commissioner’s
work to explore the lived experiences of Black, Asian and Minority Ethnic older people throughout Wales.

Current Policy

As part of her thematic analysis of older people’s experiences, and in shaping her recommendations, the Commissioner considered the role and impact of standards and frameworks designed to help improve access to GP services, as well as wider health policy and regulations, and the extent to which these are reflected in the reality of older people’s experiences.

These include:

• Access to In-Hours GMS Services Standards
• NHS Wales Performance Framework 2023-2024
• Guidance for the GMS Contract Access Commitment 2023/24
• National Patient Experience Survey
• Older people and people living with frailty: integrated quality statement

Commissioner’s Findings

Around two-thirds of the older people who responded to the Commissioner’s survey said they
found it difficult make suitable appointments, while around two-thirds also said they faced issues
when trying to contact or communicate with their GP practice, whether by telephone or online.

Many older people reported difficulties getting through to their GP practice on the phone,
particularly at certain times of the day, and often found navigating complicated telephony
systems a frustrating experience that them unable to access the service they needed or find the information they were looking for. Digital exclusion can also act as a significant barrier when
trying to access GP practices as more and more services move online.

Older people told the Commissioner that appointments offered to them often feel unsuitable,
either due to the type of appointment itself (preferred face-to-face appointments are often
limited) or due to their concerns about experience of some clinicians, with examples shared of
delays or missed symptoms as a result of this.

In some particularly concerning cases, older people said they would withhold information about
their health or symptoms with certain clinicians, preferring to discuss some matters with their
doctor only, something that presents a significant risk to people’s health.

Many older people reported that services did not feel ‘joined-up’ or communicate with each other effectively, and shared examples where patient information had gone missing or had to be
provided several times, prescriptions were delayed and people were left being sent ‘from pillar
to post’ to try and resolve issues.

There was also little awareness amongst older people about alternative services that might enable someone to access treatment more quickly, which suggests cross-promotion of health services is currently relatively limited.

Wider issues, such as access to public transport, or difficulties accessing services in an individual’s language of choice, also create barriers that mean older people often feel that their needs have not been considered when services are being planned or delivered due to a lack of coordination and partnership working across different agencies.

On a more positive note, much evidence was provided by older people that suggests that, generally, people do feel that they are treated kindly and with respect by doctors and practice
staff, who were often ‘doing their best under difficult circumstances’.

Some older people, however, reported far less positive experiences, such as rude behaviour from some individuals or their concerns being dismissed. The processes in place within GP practices – such as having no information about callback times, or having to provide personal information in reception – were also criticised.

Older people also highlighted issues with the GP practice environment, saying practices were ‘shabby’ and ‘unclean’. Other issues, such as unsuitable waiting room seating, ‘sensory overload’ from information screens and having to shout/being unable to hear were also shared.

Where people were unable to access their GP practices, they were often left suffering in pain,
self-medicating or, in some cases, would simply give up seeking treatment from their GP.

Around a third of the older people who responded to the Commissioner’s survey had raised
a compliment, concern or complaint about GP services with their practice or health board.
However, amongst these individuals, around two-thirds reported being unsatisfied with the
outcome they had received. Amongst the Black, Asian and Minority Ethnic older people who told
the Commissioner they had raised a compliment, concern or complaint, no-one was satisfied
with the outcome.

Furthermore, Black, Asian and Minority Ethnic older people face significant barriers in terms of language, often do not feel listened to or that concerns are easily dismissed and, in some cases, face discrimination based not only on race, but also on age.

Other examples of age discrimination shared were often along the lines of ‘what do you expect at your age?’, indicating that stereotypes and assumptions about older people may be having an
influence on people’s access to services, including the support available to ensure people can
access what they need and follow clinical advice.

The Commissioner’s findings demonstrate that the difficulties and challenges faced by many
older people often leave them feeling frustrated, let down and left behind. In addition, and of great concern, is the fact that a number of people reported they were suffering, that their conditions had deteriorated or that they were left feeling worried and anxious.

The Commissioner’s findings also suggest that the older people who responded to her survey are yet to experience the full extent of the service improvements being reported to the Welsh
Government.

The Commissioner’s recommendations, summarised below, recognise the pressures on public
services, including financial pressures, but many of the issues identified within this report can
be tackled at little or no cost with practical steps by GP practices to improve older people’s
experiences. Some of the action required, however will require longer-term investment and
support from the Welsh Government, health boards and local authorities.

A key part of the action the Commissioner is calling for aims to enable and build relationships of
trust between patients, doctors and practice staff. These kinds of relationships often add a great
deal of value to interactions and are highly valued by many older people.

The Commissioner will also play her part by taking forward action to influence policy and
practice, as set out below.

Summary of Commissioner’s Recommendations

A summary of the key areas covered by the Commissioner’s recommendations is set out below,
together with details of the organisations that will need to take forward the specific actions included within the full report.

• Build relationships of trust with older people: GP practices / health boards
• Remove practical barriers to older people’s access and improve communication with older people: GP Practices / health boards
• Support older people to attend GP practices and follow clinical advice: Primary Care Clusters / local authorities (with support from the third sector)
• Ensure older people are not digitally excluded from accessing GP practices: GP Practices / health boards / Welsh Government / UK Government
• Ensure sufficient resources are made available to modernise GP practice systems and ensure that older people’s experiences match access and quality standards: Welsh Government / NHS Wales Executive / Digital Health and Care Wales (in conjunction with GP practices)
• Improve public transport to GP practices: Welsh Government / health boards / Pan
  Cluster Planning Groups / GP practices
• Wider infrastructure (inc. planning system): planning authorities / local authorities

Action from the Commissioner

The Commissioner’s findings and the powerful quotes from older people provide a strong
evidence base that will be invaluable in helping the Welsh Government and other public bodies
to understand older people’s experiences of accessing GP practices, and will support the
Commissioner’s ongoing work to influence policy and practice within health services, and more
widely.

The Commissioner will continue to encourage and support health services, GP practices, and
other key organisations to reach out to and engage with older people throughout Wales in a
meaningful way so that the voices of patients of all ages help to shape policy and practice.

The Commissioner also wants to empower older people by helping them to better understand
what they can expect in terms of access to GP practices and where people can find help and
support if they experience issues or barriers. Alongside this, the Commissioner will continue
to provide information and support directly to older people through her Advice and Assistance
Service.

The specific action the Commissioner will take is outlined below:

• Ensure that the experiences of older people and the recommendations in the report are heard and understood by the Welsh Government and other organisations that can
  implement change, and that action is taken.
• Publish a guide to accessing GP practices for older people in spring 2024, explaining
• what people can expect from practices and what to do if they are having difficulty with
  access.
• Work closely with the Royal College of General Practitioners (RCGP) and the Institute of
  General Practice Management to help make improvements in access a reality for older
  people.
• Publicise the report widely, discussing the findings with groups of older people across
  Wales.

The Commissioner will monitor progress against the action she is calling for within this report
and will produce an update on initial progress in summer 2024.

Background

Older people’s perspectives of accessing GP practices

Older people’s access to GP services is a longstanding issue, which the Commissioner previously examined in 2017. The Commissioner’s report, ‘GP Services in Wales: The Perspective of Older People’ identified a number of challenges faced by older people, including making an appointment, continuity of care, accessibility of buildings, communications, length of
appointments, access to Welsh language services, feedback and complaints, and availability of
alternatives to GPs.1

The report included guidance for health boards and GP practices issued under Section 12 of the
Commissioner for Older People (Wales) Act 2006 on expected outcomes for older people.

Impact of the Covid-19 pandemic

The Covid-19 pandemic made access to GPs more difficult for older people, especially for people living with dementia and those who were isolated with no-one nearby who could help. The shift to online and telephone-based services was also accelerated by the pandemic, and while this was helpful for some older people, it created significant barriers for others, especially those who are not online. For example, older people told the Commissioner they had been unable to take part in online or video call appointments with their GP and had been unable to book a face-to-face appointment.

Between November 2020 and August 2022, Community Health Councils carried out local
engagement projects to seek the views of the public on their experiences of accessing their
GP practice.2 The results showed that some patients were experiencing very poor access, and that most people who tried to access GP practices were finding it challenging, particularly first thing in the morning and when making routine appointments. Remote appointments were more convenient for some, but did not meet everyone’s needs, especially those of people with sensory impairments, while some people wanted video consultations which were not available at their practice.

Evidence of older people’s access to GP practices in 2023

Since the pandemic, the NHS in Wales has faced significant, ongoing pressures that seem to have had a further impact on older people’s access to health services. Research undertaken on behalf of the Commissioner in March 2023 showed, for example, that reported NHS pressures made older people less likely to request a GP Home Visit (53% less likely), try to get a GP appointment (45% less likely) and contact an out of hours GP service (41% less likely). In addition, this research found that 89% of older people felt ‘anxious’ about the state of the NHS, the top issue of concern amongst a wider list.

These findings were reflected in Age Cymru’s fourth annual What Matters to You survey, carried out in spring 2023, which found that 72% of older people had a negative experience of accessing GP surgeries.3

Commissioner’s Survey of older people’s experiences of access to general practice

As a result of the continuing evidence of older people’s difficulties in accessing GP practices,
including particular concerns raised by Black, Asian and Minority Ethnic older people during
engagement throughout 2022/23, the Commissioner was keen to explore older people’s current
experiences of accessing GP practices and the issues encountered in more detail.

A survey was conducted in autumn 2023 asking older people about their experiences of accessing GP practices over the preceding months. The survey ran from 27 September to 30 November, and over 900 responses were received. The responses covered the whole of Wales, with patients from GP practices in every health board, and from both rural and urban areas.

A thematic analysis of responses was conducted, the results of which are presented below.
Discussion of the results includes additional information gathered through other research and
engagement with older people undertaken by the Commissioner, including Accessing Health
Services in Wales: Transport Issues and Barriers,4 Access Denied: Older People’s Experiences of Digital Exclusion in Wales5 and findings from the Commissioner’s work to explore the lived
experiences of Black, Asian and Minority Ethnic older people throughout Wales.

Current policy

A number of new standards and frameworks have been introduced by the Welsh Government in recent years, which include commitments in the contract between the Welsh Government and GPs to improve access to GP services. As part of her analysis and in shaping her recommendations, the Commissioner considered how far these kinds of policies, as well as wider health policy and regulations, are reflected in older people’s experiences of accessing GP practices, and what else needs to be done to make the policies and the improvements they should bring, a reality for older people.

Phase 1 Access Standards

In 2019, the Welsh Government published new Access to In-Hours GMS Services Standards,6
setting clear minimum expectations relating to access, including maximising the use of email and online appointment booking systems. The Commissioner welcomed the new standards as an important step forward in improving older people’s access to GP services, particularly on making appointments and communicating and interacting with GP services. However, wider issues around access still needed to be addressed, including transport, physical access to GP
practices and the practice environment.

These Phase 1 access standards became part of the General Medical Services Contract in
2022.

Other Welsh Government Initiatives

In June 2023, the Welsh Government’s NHS Wales Performance Framework 2023-2024,7
listed Access to Primary Care Services as the first of six Ministerial priorities.

In the same month, the Welsh Government published Guidance for the GMS Contract
Access Commitment 2023/24,8 requiring practices to make improvements to access based on
patient experience and use care navigation to take a forward-looking and planned approach
to appointments. Embedding and maintaining this second set of standards is continuing throughout 2023-24 and is subject to evaluation. These Phase 2 access standards are expected to become part of the General Medical Services contract at a future point. As part of the ongoing work to embed the Access Commitment, the Welsh Government expects GP practices in Wales
to collect patient feedback proactively and to respond with Access Improvement Plans, to ensure they are meeting the needs of their patients.

In 2023 the Welsh Government also asked GP practices to ask their registered patients to
complete a National Patient Experience Survey9 to give feedback on their experiences of NHS
services, such as an appointment with a doctor or health visitor, a hospital stay, an outpatient
visit or something else.

In January 2024, the Welsh Government published Older people and people living with frailty:
integrated quality statement10 to set the direction for whole system service transformation,
taking a whole system focus on older people and those living with frailty. As most NHS patient
contacts are in primary care, and as older people use the NHS more than any other group, the
Commissioner expects the integrated quality statement to be a major driver for improvement in
older people’s experience of GP practices.

Experiences of older people: survey results

This section provides an in-depth analysis of the data and information captured from responses to the Commissioner’s survey, and sets out key issues and concerns shared by older people which
affect access to GP surgeries. Illustrative quotes from older people are included throughout, which highlight people’s experiences in their own words, and provide a useful insight into the ways that
difficulties accessing GP surgeries can impact upon people’s lives.

Q14. Is there anything else you would like to share with us about your experiences with your GP practice?

This section of the survey allowed people to provide further information and many of the
responses to this question related to earlier answers. In some cases, the answers echoed ideas
from the previous question about what could improve experiences of GP surgeries.

Among issues raised were:

• Accessibility of practice websites.
• Friendliness of staff (positive).
• The size of practice premises. One older person said that their practice premises were not big enough for a second GP, and that the Health Board was not engaging with the issue.
• Transport.
• Concerns about the impact of housing developments adding to local populations and
  overwhelming GP practices.
• Concerns about the impact of practice mergers on ‘already overstretched’ services.
• The complaints process.
• Difficulty with changing practices.
• A concern about perceived numbers of preventable deaths and serious illness caused by
  a breakdown of NHS services.
• Calls for more resources for the NHS, targeted at areas of deprivation.
• A call for NHS reform, including for a single Health Board for the whole of Wales

Discussion and analysis

This section explores the evidence shared by older people in more detail, including the ways this relates to current policy and practice in Wales and, importantly, what this tells us about the kinds of action needed to deliver the change older people want and need to see.

This has helped to shape the Commissioner’s recommendations, which recognise areas that older people are keen to see prioritised, as well as the kinds of action needed to deliver change during the longer-term.

Main themes

Older people told the Commissioner that, in general, they place a high value on their local GP
practice. Many people gave very positive feedback about their practice. Older people recognise
that the NHS is under pressure, and many acknowledge that clinicians and staff are doing their
best in difficult circumstances.

However, older people also told the Commissioner that they have seen their relationship with their GP change during their lifetimes. This has shifted from a long-term relationship of trust with
a known doctor who was part of the community and sometimes, as one person said, almost part
of the family, to a series of transactions, not necessarily well co-ordinated or explained, with a
variety of doctors, nurses, other clinicians and non-clinical staff, many of whom older people did
not know and whose professional competence they do not always well understand.

The drivers of the shift from a relational to a more transactional experience of primary care, and less continuity of clinician, are understandable and include demographic change, the ever-expanding range of available treatments and the associated workforce challenges. However, such a significant cultural change requires the involvement of older people, explanation and support. Without relationships of trust with practice staff, opportunities are lost, for example, to identify carers or spot the signs of abuse. It is also concerning that some older people said they were adapting to this culture shift in ways which were potentially harmful, e.g. withholding information.

On top of this fundamental cultural change, older people report a range of practical difficulties
in accessing practices, making appointments and receiving health care, which can combine to produce a frustrating and sometimes distressing experience. Some older people say that accessing their GP practice is so daunting that they are giving up on approaching the practice at all when they are ill. People also described themselves as suffering, getting worse, and being worried and anxious as a result. This is very extremely concerning.

Relationships of trust

It is clear from many responses to the survey that, as in any relationship, older people want to be seen, known, respected and cared for as individuals, by professionals whom they know, respect and trust. A relationship of trust is essential to create a safe space in which people can openly discuss sensitive issues of physical or mental ill health. If people perceive the space as less safe, this can lead to a less open discussion with the clinician, potentially less effective treatment and worse outcomes.

Factors that undermine relationships

The Welsh Government’s Older people and people living with frailty: integrated quality statement,11 published in January 2024, recognises that the opportunity to build meaningful
relationships is important. Responses to the survey revealed several factors which can undermine older people’s trust in their relationship with their GP practice for some older people.

Factors include:

• Not knowing the clinician. Some people said that they do not disclose everything to a
  doctor whom they do not know, because they feel uncomfortable talking to a stranger;
• Not understanding a clinician’s expertise. Some people said that they did not think that a nurse or other non-medical member of staff was qualified to diagnose and treat them.
  These doubts had occasionally been borne out by experience; several older people reported being given the wrong advice and suffering as a result (although this can also
  happen with doctors);
• Lack of confidence in the accuracy of telephone or online diagnosis and prescription. One
  person was dubious about taking medicine which had been prescribed remotely;
• Lack of privacy in which to conduct the relationship. For example, people said they disliked having to discuss sensitive issues with receptionists in front of others in the waiting room;
• Ageism, both direct and indirect. One person said that the doctor had asked them what they expected at their age. Numerous older people said that practices did not understand what it was like to be old and ill and did not make allowances for the fact that they were in advanced old age.
• Insensitivity. People said that their doctor did not look up at them from the computer screen, that they had been given worrying test results in an inappropriate and insensitive
  way, or that some reception staff could be rude and inconsiderate at times.

Some of these issues are matters of empathy, kindness and respect, and do not cost anything
in financial terms to remedy. Others can be addressed through, for example, providing information to patients (such as making clear who is who in the practice and how different staff
can help) and encouraging staff to reflect on issues such as ageism and how to combat it, which
can be done at low cost.

Examples of these kinds of low-cost initiatives were highlighted through engagement with
stakeholders, such as a practice in Powys where all non-clinical staff have specific training in customer services at induction and then annually. Similarly, a practice in Gwent included
discussions about safeguarding, dementia, managing challenging encounters and seeing
situations from the patient’s perspective as part of the agenda for an off-site staff training day.

Modern models of service delivery make it more difficult for older people to form long-term
relationships with individual clinicians than previously. While some older people said they do
not mind seeing a different clinician, and in some cases welcome the chance to have a fresh
opinion, many others value continuity of clinician, and want their practices to make every effort
to provide it.

If this is not always possible, it is even more important that older people feel that they have a
relationship with the practice overall. It is vital that practices consider how to mitigate the factors
which can further undermine many older people’s relationship with their practice, so that people
can still see it as a safe space.

Many GP practices are already addressing these issues to help maintain a relationship of trust with older people, and reinvigorating relationship-based care is also a priority for the Royal College of General Practitioners. The RCGP wants to increase understanding of the benefits of relational care, and ensure its members have the time and space to deliver it. The findings of two policy reports will underpin work in this area: The power of relationships: what is relationship-based care and why is it important12 and Fit for the future: relationship-based care.13

Preventing abuse

GPs play a vital role in protecting older people from abuse and neglect. The findings of the
survey suggest that the effectiveness of the safeguarding roles and responsibilities of GPs will
be significantly compromised, when older people cannot easily access their local surgery. It can
be very difficult for an older person to talk about abuse, and it may take individuals a long time
to build up the courage needed to ask for help. A GP can often be the first point of contact for an
older person wishing to disclose abuse.

Difficulties in accessing a GP practice (either because of congested phone lines, digital exclusion, or issues with transport for example), may mean that an older person ‘gives up’ seeking an appointment and that vital opportunities for disclosure are lost. An older person living with abuse may not be able to ask someone else (like a family member) to make an appointment on their behalf, for example. It could also be the case that this family member is responsible for perpetrating the abuse, or that the older person is not comfortable discussing their experience with others.

Difficulties securing a home visit, highlighted in several responses from older people, might
also result in lost opportunities to identify abuse or neglect, given that the physical home
environment can provide vital information in situations where these are suspected. Such
information may not come to light when GP consultations are limited to other methods.

Even if an older person can access their local practice, it is important to remember that
opportunities for disclosure are likely to be contingent upon the quality of their relationships with
GPs. The survey shows that older people are reluctant to discuss sensitive issues when they do not know a GP (in such situations, it is understandable that an older person may be cautious in the information they provide).

Continuity of relationships of trust is therefore vital to ‘opening up’ challenging and sensitive
conversations. When a GP knows an older person, they are also likely to be in a better position to gauge changes in personality or presentation which may indicate possible abuse, as well as to recognise recurrent patterns in injury or poor physical health.

Some of the possible challenges associated with maintaining continuity of care may be overcome when GPs are ‘relational’ when in contact with older people (that is, when they are warm, welcoming, and respectful in their manner). However, some survey participants described GPs as “rude” and as “barely looking up from their computer screens”.

While the time pressures facing practitioners working within health and social care are well
recognised, the likelihood of disclosure will be significantly reduced if these issues are allowed
to adversely shape the quality of interaction between GPs and older people. Such pressures may  also result in GPs making assumptions as to the cause of an injury sustained by an older person without asking the sorts of questions, which may indicate potential abuse.

It is also important that older people whose first language is Welsh can access Welsh-speaking
GPs. It may be easier for older people to disclose their experiences of abuse when speaking in
a language of their choice.

The survey shows that a lack of joined up care can also lead to other potential safeguarding
issues – responses show for example, that a lack of communication between front-line
practitioners has resulted in some older people experiencing situations where medication has
been missed, or where follow up consultations have not materialised.

Practical issues

Contacting the practice

Some two-thirds (65%) of older people who responded found it difficult to contact the practice
online or by telephone, while an even higher percentage (70%) said they had difficulty contacting the practice by other means. Family and friends often had limited capacity to help them.

The digital exclusion of those who do not use the internet is a serious problem frequently raised
with the Commissioner by older people, often in relation to health care and difficulties in booking
GP appointments. In November 2021, the Commissioner issued guidance to health boards and local authorities on ensuring access to information and services in a digital age. A follow-up report by the Commissioner, based on older people’s experiences of digital exclusion was
published in January 2024 and explores topics, including health, in more detail.

The new General Medical Services (GMS) Unified Contract and underpinning 2023 Regulations
came into effect on 1 October 2023, shortly after the OPCW survey was launched.14 Under the
new contract, GPs must ensure a member of staff answers their telephones for the duration of core hours (8.00am to 6.30pm, Monday to Friday), and ensure their main practice premises
have their doors open between 8.30am and 6.00pm so that patients can physically access the
premises to discuss their care needs.

The contract also mandates that practices must have a telephone system in place which can
stack incoming calls, with a standardised message for those waiting on hold, and a digital method of contacting the practice for non-urgent requests.

Health boards are responsible for monitoring and providing assurance on compliance with these
standards. Practices are responsible for collecting patient feedback proactively and developing
Access Improvement Plans in response to this.

An example was shared via stakeholder engagement of a practice in Cardiff and the Vale which
has reduced telephone wait times through the introduction of virtual and remote appointments
and triage systems. This has led to a drop in maximum waiting times from 51 minutes to 16.7
minutes, with an improved average wait time of eight minutes. However, engagement with a local GP practice patient participation group revealed that many people are not aware of any improvements in access that their practice may have made.

Making Appointments

In April 2022, the GMS Access Commitment required GP practices to offer a mix of remote,
face-to-face, urgent, on-the-day and pre-bookable appointments, and made clear that the release of all appointments at 8am was no longer acceptable. At 31 March 2023, 95% of practices across Wales reported that they had changed their booking systems and processes to implement this, that people could contact the practice all day to make an appointment, and that they had trained staff to direct people to the right care for them, to offer an appointment the same day or in the future if less urgent, or to signpost them to pharmacies and other sources of health care as appropriate.15

Even so, making the type of appointment older people wanted was one of the biggest difficulties
reported – so much so, that 11% of older people said they had stopped trying. 21% of older
people’s responses referenced the phone booking system or improving the telephone system
in their responses, and the ‘8am phone call’ was also mentioned numerous times. It is not clear
whether this is because older people are still experiencing the ‘8am bottleneck’, or because they are unaware that things have changed, or both. As part of the Commissioner’s work on digital exclusion undertaken in summer 2023, 8% of older people suggested having a separate number to call and book an appointment with their GP, which they said would make accessing their GP easier. Older people were conscious of staff shortages in primary care, with 12% calling for more/permanent members of staff, and some people feeling guilty accepting an urgent appointment when someone else might need it more.

While some examples of practices having Dementia Champions and providing training for staff
were highlighted during engagement with stakeholders, cognitive impairments were highlighted
by some people as barriers to making appointments. Some people with sensory impairments faced similar issues, and examples were shared where practices had not made allowances for these kinds of impairments even when they had been informed about them. Other people said that they had to overcome psychological barriers to try to make an appointment, and that sometimes these had been caused by previous experience of trying to make one.

The timing of appointments could be inconvenient for some older people who were working, as
it made no allowance for this. Similarly, not having any idea when to expect a callback could be very disruptive. Some people also said the length of appointments could act as a barrier, as there is not sufficient time to discuss more than one health issue – something which is likely to become more necessary as the number of us living with more than one condition continues to increase.

Digital exclusion

As highlighted above, 65% of older people said that contacting or getting information from their
GP practice online was very difficult or quite difficult.

The increasing use of digital technology has led to significant changes in the ways in which we communicate and access information and services, including GP and other health care services. This creates significant challenges for people who are not online or are unable to access services digitally, and puts older people at particular risk of being excluded and left behind. Available statistics for Wales demonstrate the scale of the issue: 31% of over 75s (95,069 people) do not have access to the internet at home and 33% of over 75s do not use the internet (including Smart TV and handheld devices), compared to 13% of 65-74s and 0% of 25-44s.16 This means around 101,200 people over 75 do not use the internet.

In parts of Wales, poor internet coverage makes trying to undertake activities such as booking GP appointments online impossible, even for older people who have the right equipment and skills to do so. The cost of the equipment and access to the internet via broadband is also prohibitive for some older people. Research on behalf of the Commissioner undertaken in March 2023 showed that 64% of older people polled had cut back on spending in the last 12 months and, of these, 27% had cut back on phone/internet expenditure.17

Follow up work on digital exclusion, undertaken by the Commissioner in summer 2023, highlighted that many older people face difficulties when trying to make GP appointments, in some cases being told that they could only do this online. Other issues shared included problems with video consultations, lack of access to the required devices (often a smartphone), barriers relating to the design and accessibility of websites and apps, and limited digital skills, all of which made interacting with GP practices difficult, if not impossible.

Incidents where older people had been told by practice staff to ask friends or family to help them with the online elements of services made people feel dependent, a burden, or left behind. People often did not want to discuss details of health conditions or the reason why they want to see a GP with friends or family, or to disclose such things to staff if trying to use IT facilities in libraries or hubs. The experiences gathered as part of the digital exclusion work echo many of those reported in the survey on access to GP surgeries.

The Commissioner published her report on digital exclusion – Access Denied: Older people’s
experiences of digital exclusion in Wales – in January 2024. The report includes a number of
recommendations, including some where health boards should play a leading role. Work to discuss the findings and make progress on the recommendations in the report is ongoing.

The practice environment

Some older people described a “shabby, unclean environment” in the practice, inappropriate
seating, having to shout through a grille at reception and not being able to hear the answers,
and being subjected to sensory overload when waiting to be called for their appointment via a screen which was also showing adverts. The impact of the environment on people’s mood and confidence should not be underestimated. Involving older people in improving the practice
environment can be an important mitigating factor, and an example was shared of a practice
that seeks advice about renovations and modifications from their patient participation group and
from representatives of local disability groups.

Continuity of care

Proactive and systematic services

As well as expressing a preference for more continuity of individual clinician, so that they can
develop relationships of trust with them, older people have indicated that they want GP services
to be more proactive and more systematic, so that experiences of health care are less reactive
and less fragmented.

For example, some people wanted more routine checks, e.g. for blood pressure, while several
said there should be regular health checks for people with deteriorating cognition or with
disabilities, so that carers are supported in understanding their loved one’s health status and in
caring for them appropriately.

People also said they wanted to be given test results as soon as they were available, without
having to chase them up, and to be able to get answers to their questions quickly.

Other responses indicated some people were looking for assurance that their practice was
‘keeping track’ of things on their behalf, such as all of the medications they were being
prescribed, or that they expected plenty of notice if certain tests (e.g. blood tests) were required
ahead of their next prescription. Some people also did not understand why there was not an
automatic follow-up from their GP following discharge from hospital after a major event like a
heart attack or stroke.

The Welsh Government’s Older people and people living with frailty: integrated quality statement, published in January 2024, recognises that continuity and co-ordination become
increasingly important as care and support needs become more complex, and that a whole
system focus on older people and those living with frailty is imperative.18

Some practices have begun trialling the application of workflow analysis, automation and
artificial intelligence to their internal systems to provide a more joined-up experience for
patients, free up practice capacity and reduce workplace stress.19

Support to access services and follow clinical advice

The 2023/24 Access Standards require practices to have a clear understanding of patient needs
and demands within their practices and how these can be met.20 Numerous older people said
that they thought that their practice staff did not understand what it was like to be older while
also being ill or depressed and trying to navigate their practice’s systems. Several said that their
practice made no allowance for people in advanced older age, and people in their nineties, or
living with severe disability, reported being unable to get home visits. Many older people had
found it too difficult to access their practice and had given up trying, placing their health at risk.

It is clear that a significant number of older people in Wales are unable to access primary care or adhere to medical advice without support, but do not have the support they need. This includes people in advanced older age who may also be living with frailty.

It is important to note that there are already some mechanisms that can be used to raise and
address the issue of support.

For example, the Welsh Government’s Older people and people living with frailty: integrated
quality statement, recognises that, as the population ages, the number of older people living with frailty or at risk of developing it will increase, and that the right anticipatory care and early support can prevent crisis in someone living with frailty.21 It requires the NHS Wales Executive
providers, commissioners and organisations to work with people living with frailty, their families,
and carers better to understand the lived experience.

The GMS Contract Access Commitment for 2023-2422 requires practices to carry out a National
Patient Experience Survey and demonstrate how it has informed an action plan, showing how the practice will respond to patient feedback, and move forward with implementing and communicating change effectively, discussing all improvements in General Medical Services
Professional Collaboratives.23

The Integrated Quality Standard also requires a National Leadership Team, providers,
commissioners and other stakeholders to co-design the system and standards associated with an ‘outstanding place based (integrated) system of care’ and associated care pathways for older people who are at risk of developing frailty or are living with frailty. The National Leadership Team, which is responsible for the implementation of the Standard, is currently being established.

The responses to the Commissioner’s survey show that some older people’s support needs go beyond traditional clinical services into more practical and social support issues. It is therefore essential that the co-design of place-based care identifies the older people in in those communities who cannot access primary care or adhere to medical advice without support and
involves them in co-producing solutions to ensure that that support is available for those who
need it.

Older people’s experience of service reconfiguration

Problems with continuity of care were sometimes made worse by service reconfiguration, such as a merger of two practices. People reported confusion: in waiting rooms; on which services were being provided on different sites, and in their prescriptions being sent to different pharmacies.

Others said they were concerned about the potential impact of new housing developments on
already stretched local practices.

Older people’s experiences of disruption to services when they are reconfigured highlight why
patient and public involvement is essential to help maintain continuity of care for patients, and
why the provision of infrastructure such as primary care premises within the planning system
and development consent, aligned with health board service model and workforce plans should
be more rigorously enforced.24

Transport

Travel to GP practices is becoming an increasing issue for older people, especially in rural areas.25 Some older people said they had to travel long distances to their practice, sometimes
having no choice but to incur the expense of a taxi. Some people said that practice staff did not
seem to consider their transport difficulties if they were slightly late for an appointment. Even if
people were able to drive, some said they were concerned about getting to the practice if they had to stop driving in the future.

These results echo the findings of the Commissioner’s 2021 report Accessing Health Services in Wales: Transport Issues and Barriers26 on older people’s transport-related experiences of
accessing health services in Wales, including primary care. It was clear in that report that a
significant number of older people found travelling to primary health services difficult, with
almost a third indicating that this was usually or sometimes the case. The most common reasons were services not being within walking distance, people not having access to their own car and a lack of public transport.

These kinds of difficulties were highlighted as to why over a quarter of older people who responded to the Commissioner’s 2021 survey had missed or were late to appointments at
primary health services. This meant that transport issues are having a potentially negative impact on the health and well-being of those who might find themselves unable to attend appointments. Around two-thirds of respondents reported visiting primary health services every 8-12 weeks, and around half of those aged 80-89 were visiting these services every month. This means that transport difficulties and the subsequent issues they create are regularly affecting significant numbers of older people throughout Wales.

Equalities

Under the Equality Act, those delivering services and public functions, such as GP surgeries, have a duty not to discriminate against individuals unlawfully due to their age, disability, gender reassignment, pregnancy and maternity, race, religion or belief, sex or sexual orientation. These
are known as protected characteristics.

The Equality Act also introduced a Public Sector Equality Duty (PSED). The aim of the PSED is
to ensure that public authorities and those carrying out public functions (such as GP surgeries)
consider how they can positively contribute to a fairer society through advancing equality and
good relations in their day-to-day activities.

The duty states that equality considerations are built into the design of policies and the delivery
of services and that they are kept under review. This should achieve better outcomes for all.

In undertaking this work, the Commissioner captured the experiences of a diverse range of older people, gathering information about the extent to which people’s needs are being met and
whether people’s rights under key legislation, such as the Equality Act 2010 and PSED, are
being upheld.

Black, Asian and Minority Ethnic older people

1.6% of responses came from Black, Asian and Minority Ethnic older people, who, alongside
highlighting common issues such as delays or difficulties making appointments, described
additional barriers to accessing GP services. For example, Black, Asian and Minority Ethnic
older people were most likely to say it was very or quite difficult to access services in a language
other than English or Welsh.

Furthermore, while 20% of Black, Asian and Minority Ethnic survey respondents had raised a
complaint about health services (compared to 24% of White respondents), none were satisfied
with the outcome (compared to 31% of all respondents).

Suggestions to improve services were often focussed on staff being kinder and more patient,
especially where language was a problem.

Experiences of Black, Asian and Minority Ethnic older people

In 2022, the Commissioner began working with 14 organisations and individuals with strong
community connections to explore the lived experiences of Black, Asian and Minority Ethnic
older people. This research, and follow up engagement, highlighted commonly shared issues,
including several relating to health services, which reflect the kinds of concerns raised in
responses to the Commissioner’s survey from Black, Asian and Minority Ethnic older people.

For example, some Black, Asian and Minority Ethnic older people who took part in the
Commissioner’s engagement sessions shared that they feel that they, or their family and
friends, receive poorer services due to being unable to speak English.

“… at the GP surgery I feel a little discrimination because of my language. Once
they didn’t support me even though I was suffering, they just asked me to leave.”

As part of this engagement, Black, Asian and Minority Ethnic older people also reported
difficulties they had faced when trying to access health services, something that seemed to be a
very frustrating and demoralising experience. Common issues experienced included difficulties
contacting GP surgeries by telephone to seek advice or make appointments – phone lines were
often engaged or not answered, or people found themselves being cut off when waiting on hold – as well as long waiting times for appointments (up to three weeks in some cases) and treatment.

People described not being able to understand text messages cancelling appointments and trying to get receptionists to spell names correctly when looking up electronic records. One person suggested that the receptionist should ask for their date of birth first instead.

People who did not speak English or Welsh well pointed out that, in a face-to-face appointment, they were able to communicate through gestures and point to the part of the body that was
causing them concern, which they could not do over the phone.

When Black, Asian and Minority Ethnic older people did manage to access health services, they
faced further issues and barriers, finding it difficult to ‘navigate the system’ and found that health
care environments were often busy, with lots of patients and queues, leaving people feeling
overwhelmed and stressed.

Language barriers also often created difficulties when using health services, and some shared
that they felt like ‘staff did not want to deal with them’ when they sought information or help.
People also described confusion over changing rules which seemed inconsistent and had not
been explained to them, such as paying for immunisation for foreign travel.

Perhaps the most concerning issue was that some Black, Asian and Minority Ethnic older
people felt discriminated against when using health services due to their ethnicity.

Support for Black, Asian and Minority Ethnic older people within the health system, such as
translation services, was often very limited, which left them unable to make their voices heard
like other patients and could lead to staff becoming impatient.

People also shared examples of being spoken to in a patronising way, or even shouted at,
which left people feeling worthless.

It was also suggested by some Black, Asian and Minority Ethnic older people that diagnoses
were being made on the basis of an individual’s skin colour, rather than properly assessing their
health or symptoms.

In addition to these examples, some older people also highlighted how they felt discriminated by
health services due to their age in addition to their ethnicity.

“I feel like they fob me off and put everything down to my age. Yes, especially when I seek medical treatment. They care less when you’re older. I try my best to stand up for myself.”

“There was an incident at my GP surgery when I turned up for the appointment, was not seen for more than an hour, when requested information, was told that ‘I called but you didn’t show up and now you need to book another appointment’. As if this waste of time wasn’t enough, they sent out a letter stating that you didn’t come for the appointment, and we will strike you off our list. That was very bad experience for an 81-year-old lady.”

While the Commissioner’s engagement with Black, Asian and Minority Ethnic older people
highlighted a number of difficulties and barriers, it is important to note that, for some, accessing
health services in Wales was a positive, straightforward experience: people were happy with the
treatment and services offered and received and were grateful for the NHS.

“Good GP experience. I feel listened to when I go.”

“GP and hospital appointments have been good. They understand my needs and
support me accordingly.”

Many of these individuals felt confident and independent enough to visit GPs themselves, and
praised doctors, nurses and receptionists for their behaviour, professional conduct, and ability to
provide a good service, even in times of great strain, such as during the Covid-19 pandemic.

People whose experiences were positive said they felt listened to and that their needs had been
taken into account, providing a more ‘personal’ service. For some, this meant timely, face-to-face appointments, while others valued being able to seek reassurance over the phone.

Many Black, Asian and Minority older people also spoke about improving their own personal
health, and the benefits this could bring as they got older, highlighting that improving access to
health services was a key part of this. These older people said they would benefit from face-to-face appointments and regular check-ups, with support to overcome language barriers, as well
as culturally specific services and additional support for Black, Asian and Minority Ethnic older
people living with dementia.

Ageism

Comments along the lines of ‘what did people expect at their age?’ were reported by older
people, suggesting ageism – the stereotyping, prejudice and/or discrimination against people
on the basis of their age or perceived age – on the part of some GPs. This has the potential
to impact health care through, for example, affecting the types of treatments that people are
offered.27 28

Ageism can also affect the ways in which professionals respond to the abuse of older people.
Sometimes professionals are slower to investigate the abuse of an older person assuming,
perhaps, that a bruise or physical injury has occurred because of physical frailty rather than
considering that abuse might have occurred.29

Furthermore, ageism can overlap with other forms of discrimination, such as race, something
examined further below.

Carers

Survey respondents included carers and people who were being cared for. There were complaints that, although carers had stated multiple times that they were carers, and had filled in multiple forms, the information did not seem to be flagged on systems.

Some older people mentioned that they relied on their carers to make GP appointments for them, because it was too difficult for them to get through on the phone themselves. One carer also said that they had to take hard copies of important information from a Liverpool hospital where their spouse had been receiving treatment to the surgery to ensure that the GP received the information.

Funding and resources

If older people’s experience of accessing GP practices is to match the standards set out in the
Access Standards and the Integrated Quality Statement, sufficient funding and resources will
need to be made available over time to implement them. The Commissioner recognises the
constraints of the current financial climate and while service redesign and modernisation of
systems and infrastructure will require investment and an increase in staff capacity, there are
also practical steps GP practices themselves can take to improve older people’s experiences, at
no or little cost.

Recommendations

Build relationships of trust

Older people told the Commissioner that the relationships of trust with their GPs they have
valued all of their lives have become more ‘transactional’ in later life, with different aspects of
their care distributed between a wider range of clinicians. Building relationships of trust between
older people and clinicians is essential to help ensure health care is effective and safe.

• Working together in their local area through discussion in their GMS Professional
  Collaboration, GP practices should:
  – ensure that all staff are polite, friendly, considerate and respectful in their
  interactions with older people.
  – ensure that staff are patient and considerate in their interactions where people
  experience language and/or cultural barriers to communication, for example with
  some Black, Asian and Minority Ethnic older people.
  – raise awareness of ageism and age discrimination and how to combat them
  amongst staff.
  – ensure that older people have the privacy they need in which to build relationships
  of trust.
  – review their home visit and other policies and practices in the light of the Integrated
  Quality Statement on Frailty, to ensure that older people living with frailty get the
  proactive, wrap-around clinical care and support they need to remain as well and as
  independent as possible.
  – work with Health Education and Improvement Cymru to ensure that the GP practice
  workforce receives consistent training and development in customer service, antiageism and communications, so that older people have a consistent experience of
  their relationship with their practice.
• Health boards should work with GP practices to raise older people’s awareness of what
  they are entitled to expect from their relationship with their GP practice.
• Health boards should work with GPs and wider primary care providers to raise public
  awareness of the full range of primary care services available where older people live.
• Health boards should work with GP practices to design services which increase continuity
  of clinician for older people, in line with the Integrated Quality Statement on Frailty.
• Health boards should work with GP practices to ensure that older people are involved in
  service design and reconfiguration, and that continuity of care is maintained during any
  reconfiguration process.

Remove practical barriers to older people’s access and improve communication with older people

Older people highlighted a range of barriers that make it more difficult to access GP practices,
including difficulties making appointments and issues relating to communication with and from
their GPs. Action is needed to remove these barriers, which would significantly improve the
experiences of many older people.

• All GP practices should speed up implementation of the GMS Contract Access Commitment 2023/24 to ensure that older people can contact the practice all day to make an appointment, and that they can make an appointment on the same day, or in the future
  if less urgent.
• GP practices should provide information and communicate directly with older people in
  their practice populations to publicise the new access arrangements and encourage them
  to come forward for health care.
• GP practices should monitor whether the changes they have made have resulted in
  improvements in older people’s ability to contact their practices.
• GP practices should pay particular attention to older people’s access needs in GP
  practice Access Improvement Plans.
• Health boards, through their Communications Teams, should publicise good practice to
  older people and GP practices in their areas, to speed up the pace of improvement and
  encourage older people to come forward for health care.

Support older people to attend GP practices and take clinical advice

Some older people told the Commissioner they are unable to access their GP practice or follow
clinical advice without support. It is crucial that this support is available and accessible to ensure
that older people are not excluded from services and/or treatment.

Primary Care Clusters, local authorities and third sector organisations should work together to identify any older people in their areas who cannot access primary care, or who cannot follow clinical advice without support, and ensure that support is there for those who need it, including people with cognitive and sensory impairments.

Ensure older people are not digitally excluded from accessing GP practices

Many older people have said that they are unable or find it difficult to contact their GP practice,
make appointments or take part in consultations online. While much good work is underway
to support older people who are digitally excluded, further action is needed to ensure digital
barriers do not prevent older people from accessing their GP practices.

• Health boards and GP practices should work together to ensure that older people who do not or cannot go online have equitable access to information and services, in line with the Commissioner’s guidance, Ensuring access to information and services in a digital age: Guidance for Local Authorities and Health Boards, issued under Section 12 of the
  Commissioner for Older People (Wales) Act 2006.
• Welsh Government should ensure that support for older people who want to go online is
  made more widely available via organisations who provide training and support.
• The UK Government should invest more in rural broadband and mobile phone
  connections.

Ensure sufficient resources are made available to modernise GP practice systems and ensure that older people’s experiences match access and quality standards

Many older people’s experiences of accessing GP practices do not currently meet the standards
set out in the Access Standards and the Integrated Quality Statement. While the Commissioner
recognises the constraints of the current financial climate, investment in practice systems over the longer-term will be important to help ensure a positive, joined-up experience for older patients.

• The Welsh Government should ensure that sufficient resources are made available over time to implement the Access Standards and the Integrated Quality Statement on Frailty.
• The Welsh Government, the NHS Wales Executive and Digital Health and Care Wales,
  should work with GP practices to:
• Modernise practice systems to provide end-to-end continuity of care for older people.
• Streamline and automate routine administrative processes to free up the time of
  practice staff, reduce stress and improve patient experience.
• Engage older people in co-producing the design of patient-facing processes.

Improve public transport to GP practices

Older people told the Commissioner that a lack of public transport is a major barrier to accessing health services, reflecting findings from other research and reports. Public transport to GP practices must be improved to ensure that all older people are able to access their GP practices and other health services:

• The Welsh Government should ensure that routes enabling access to health care settings
  are a key consideration in its Bus Bill.
• Health boards and Pan Cluster Planning Groups should consider the transport issues older people raised in the Commissioner’s 2021 report, Accessing Health Services in Wales: Transport Issues and Barriers together with the results of the Commissioner’s 2023 survey on access to GP practices, when deciding on the location of practices.
• Health boards and Pan Cluster Planning Groups should ensure that where bus services
  are currently being redesigned, discussions and planning involve Community Transport
  and preserve routes which facilitate access to GP surgeries.
• GP practices should be flexible enough to accommodate the fact that long journeys on
  unreliable transport will have an impact on punctuality which is beyond people’s control.

Wider infrastructure

Older people shared concerns about the effect of further pressures on already stretched GP
practices, such as the impact of new housing developments. Ensuring the right services are
available in the right places is a crucial element of age-friendly communities, the development
of which the Welsh Government has committed to encourage and support throughout Wales.
Ensuring that health care infrastructure is prioritised within planning and development is
therefore vital.

• Planning authorities should ensure that provision of local health care infrastructure, such
  as GP practice premises, is prioritised as a contribution to the goal of Sustainable Places
  in the land use planning system in Wales.30
• Local authorities should ensure new GP practice premises are easily accessible and
  at locations convenient for older people to reach, in line with the “Community support
  and health services” domain of the World Health Organisation’s Age-friendly Cities and
  Communities Framework.31

Commissioner’s Actions

The Commissioner’s findings and the powerful quotes from older people provide a strong
evidence base that will be invaluable in helping the Welsh Government and other public bodies
to understand older people’s experiences of accessing GP practices, and will support the
Commissioner’s ongoing work to influence policy and practice within health services, and more
widely.

It is clear that many older people want their experiences of accessing GP practices to improve,
and the Commissioner’s engagement with statutory and professional health bodies highlighted
that this is increasingly recognised, as is the importance of engaging with patients and using
their feedback to deliver improvements.

Building on this will be crucial, so the Commissioner will continue to encourage and support
health services, GP practices, and other key organisations to reach out to and engage with older people throughout Wales in a meaningful way so that the voices of patients of all ages help to shape policy and practice.

The Commissioner also wants to empower older people by helping them to better understand
what they can expect in terms of access to GP practices and where people can find help and
support if they experience issues or barriers. Alongside this, the Commissioner will continue to provide information and support directly to older people through her Advice and Assistance
Service.

The specific action the Commissioner will take is outlined below:

• Ensure that the experiences of older people and the recommendations in the report are heard and understood by the Welsh Government and other organisations that can implement change, and that action is taken.
• Publish a guide to accessing GP practices for older people in spring 2024, explaining what people can expect from practices and what to do if they are having difficulty with access.
• Work closely with the Royal College of General Practitioners and the Institute of General
  Practice Management to help make improvements in access a reality for older people.
• Publicise the report widely, discussing the findings with groups of older people across
  Wales.

The Commissioner will monitor progress against the action she is calling for within this report
and will produce an update on initial progress in summer 2024.

Appendix 1: Methodology

The voices and experiences of older people covered in this report were gathered through a
survey sent out to older people throughout Wales.

The survey was developed by considering the findings of the Commissioner’s 2017 access to GP services report, and supplementing this with meetings with, and information gathered from,
stakeholders including Health Boards, Community Health Councils, professional bodies and third sector organisations. The survey questions were distilled from the self-reflection questions contained in the Commissioner’s 2017 Section 12 guidance, appended to that report.

Feedback on the draft questions was obtained from the RCGP, and questions were subsequently piloted with a representative of an older people’s charity and at a meeting of an older people’s group.

Surveys were sent out and completed between 27 September 2023 and 4 January 2024.
Copies were distributed to older people via internal mailing lists and publicised via the Commissioner’s newsletter and social media, as well as through engagement visits to older
people’s groups. They were also disseminated electronically through a wide range of public and
voluntary sector organisations, committees and networks, for onward distribution.

People were able to respond online, in hard copy or by telephone. We received 880 responses
in English, and 15 in Welsh, plus a further 11 which arrived too late to be included in the analysis. Throughout November and December, responses were reviewed and analysed, and developing themes emerged, on which the Commissioner’s findings are based.

While not all respondents provided demographic information, of those that did, 70% were
women (571), and 30% (240) were men. 2.2% of respondents (18 people) had a different gender identity than the one they were born with or preferred not to say. 85% of respondents were heterosexual, 2% were bisexual, 1% were gay/lesbian, and 12% preferred not to say.

57% of respondents were married, 10% were divorced, and 18% were widowed. 42% (333 people) considered themselves to have a disability.

67% were Christian, 7% had another religion, and 26% had no religion. 4.2% (34) were from a
Black, Asian, or Minority Ethnic background. 45% of respondents considered themselves to be
Welsh, 23% English, 28% British, and 5% other.

38% of respondents (293 people) were aged 60-69, 45% (352) were aged 70-79 and 17% (135)
were over 80.

No specific question was asked about where people lived or received primary care. However,
some people did mention place names in their responses. Responses were received from
throughout Wales, from every health board area, and from people living in rural and urban areas. Of those that provided demographic information, 54% (416 people) lived in urban areas and 46% (349) lived in rural areas.

A variety of questions were asked relating to ease of contacting GPs and attending appointments, public transport, home visits, continuity of care, complaints, accessing services in languages other than English, other health care services available, and what could be done to improve services.

Responses were received on a range of topics, often relating to appointments and booking
systems, continuity of care and a lack of permanent GPs. Whilst problems were discussed in
depth, some positive responses were also received, which are included throughout the analysis
sections.

A copy of the questionnaire can be found below.

Appendix 2: Engagement with Older People

The Commissioner’s 2017 report on access to primary care and Section 12 guidance, from
which the survey questions derive, was itself based on extensive engagement with older people.
Between September and November 2023, the Commissioner and her team made engagement
visits to a variety of older people’s groups, gave presentations which included the survey,
discussed it with members and encouraged them to complete it themselves and to disseminate
it more widely.

In November, the Commissioner’s Health and Care Lead also presented the survey at a local
GP Practice Patient Participation Group and took part in discussion.

The Commissioner has also carried out engagement with older people on other issues, such as
transport, digital exclusion and the issues specifically experienced by Black, Asian and Minority
Ethnic older people. These other conversations have helped to inform discussion of the results
of this survey.

Appendix 3: Engagement with

Stakeholders

Stakeholder engagement on the 2023 survey included:

• Age Cymru
• Llais
• Royal College of General Practitioners
• Royal College of Nursing
• Institute of General Practice Management
• British Medical Association
• General Medical Council
• NHS Wales – Strategic Programme for Primary Care
• Health care Inspectorate Wales
• Welsh NHS Confederation
• Welsh Government.

In addition, the Commissioner’s 2017 report on access to primary care and Section 12
guidance, from which the survey questions derive, was itself based on extensive stakeholder
engagement.

Appendix 4: References

1 Older People’s Commissioner for Wales (2017), GP Services in Wales: The Perspective of
Older People. Available at: https://olderpeople.wales/wp-content/uploads/2022/05/GP-Services-in-Wales-The-Perspective-of-Older-People.pdf
2 See:
Cwm Taf Morgannwg CHC Engagement Report – Patient experience of Forest View Medical
Centre: https://www.llaiswales.org/news-and-reports/reports/cwm-taf-morgannwg-chc-engagement-report-patient-experience-forest-view
Swansea Bay CHC – Accessing GP services Summary Report – August 2022: https://www.
llaiswales.org/news-and-reports/reports/swansea-bay-chc-accessing-gp-services-summary-report-august-2022
Aneurin Bevan CHC – GP Exit Surveys – August 2022: https://www.llaiswales.org/news-and-reports/reports/aneurin-bevan-chc-gp-exit-surveys-august-2022
West Wales GP Access documents – March 2022: https://www.llaiswales.org/news-and-reports/
reports/west-wales-gp-access-documents-march-2022
Report of GP Access Survey November 2020: https://www.llaiswales.org/news-and-reports/
reports/report-gp-access-survey-november-2020
Written Report Patient Experience of GP Services in Powys – August 2022: https://www.
llaiswales.org/news-and-reports/reports/written-report-patient-experience-gp-services-powys-august-2022
3 Age Cymru (2023), What Matters to You? Current experiences of people aged 50 or over
in Wales. Available at: https://www.ageuk.org.uk/globalassets/age-cymru/documents/policy/
annual-survey/what-matters-to-you—current-experiences-of-people-aged-50-or-over-in-wales—
october-2023.pdf
4 Older People’s Commissioner for Wales (2021), Accessing Health Services in Wales:
Transport Issues and Barriers. Available at: https://olderpeople.wales/news/accessing-health-services-in-wales-transport-issues-and-barriers/
5 Older People’s Commissioner for Wales (2024) Access Denied: Older people’s experiences of
digital exclusion in Wales. Available at: https://olderpeople.wales/resource/access-denied-older-peoples-experiences-of-digital-exclusion-in-wales/
6 Welsh Government (2019) Access to In-Hours GMS Services Standards Guidance for
the GMS Contract Wales 2019/20. Available at: https://www.gov.wales/sites/default/files/
publications/2020-11/access-to-in-hours-gms-services-standards_1.pdf
7 Welsh Government (2023), NHS Wales Performance Framework 2023-2024. Available
at: https://www.gov.wales/sites/default/files/publications/2023-06/nhs-wales-performance-framework-2023-2024.pdf
8 Welsh Government (2023), Guidance for the GMS Contract Access Commitment 2023/24.
Available at: https://www.gov.wales/sites/default/files/publications/2023-06/gms-access-commitment-guidance-2023-to-2024-i.pdf
9 Welsh Government (2023), National Patient Experience Survey 2023. Available at: https://
thepracticeofhealth.nhs.wales/news-events/practice-news/national-patient-experience-survey-2023/
10 Welsh Government (2024), Older people and people living with frailty: integrated quality
statement. Available at: Written Statement: https://www.gov.wales/written-statement-older-people-and-people-living-frailty-integrated-quality-statement
11 Welsh Government (2023), Guidance for the GMS Contract Access Commitment 2023/24.
Available at: https://www.gov.wales/sites/default/files/publications/2023-06/gms-access-commitment-guidance-2023-to-2024-i.pdf
12 Royal College of General Practitioners, The power of relationships: what is relationship-based care and why is it important, June 2021, https://www.rcgp.org.uk/representing-you/policy-areas/relationship-based-care
13 Royal College of General Practitioners, Fit for the future: relationship-based care, June 2022,
https://www.rcgp.org.uk/representing-you/policy-areas/relationship-based-care
14 Welsh Government, NHS (General Medical Services contracts) (Wales) Regulations
2023, 17 July 2023 https://www.gov.wales/nhs-general-medical-services-contracts-wales-regulations-2023
15 Letter from the Minister of Health and Social Care to Members of the Senedd, 23 October
2023, Update on access to GP services in Wales.
16 Welsh Government (2022) National Survey for Wales April-June 2021. Available at: https://
gov.wales/national-survey-wales-results-viewer
17 A total of 503 interviews were conducted with a representative sample of the Welsh
population aged 60+ years. All interviews were conducted by telephone using CATI (Computer
Aided Telephone Interviewing) technology between 28 February and 17 March 2023.
18 Welsh Government (2023), Guidance for the GMS Contract Access Commitment 2023/24.
Available at: https://www.gov.wales/sites/default/files/publications/2023-06/gms-access-commitment-guidance-2023-to-2024-i.pdf
19 Management in Practice, Reinventing patient access: How one practice used AI to cope with
rising pressures, 3 February 2023, https://managementinpractice.com/practice-intelligence/
reinventing-patient-access-how-one-practice-used-ai-to-cope-with-rising-pressures/
20 Welsh Government (2019) Access to In-Hours GMS Services Standards Guidance for
the GMS Contract Wales 2019/20. Available at: https://www.gov.wales/sites/default/files/
publications/2020-11/access-to-in-hours-gms-services-standards_1.pdf
21 Welsh Government (2023), Guidance for the GMS Contract Access Commitment 2023/24.
Available at: https://www.gov.wales/sites/default/files/publications/2023-06/gms-access-commitment-guidance-2023-to-2024-i.pdf
22 Welsh Government (2019) Access to In-Hours GMS Services Standards Guidance for
the GMS Contract Wales 2019/20. Available at: https://www.gov.wales/sites/default/files/
publications/2020-11/access-to-in-hours-gms-services-standards_1.pdf
23 NHS Wales, Accelerated Cluster Development Toolkit, Professional Collaboratives. Available
at: https://primarycareone.nhs.wales/tools/accelerated-cluster-development-toolkit/acd-toolkit-index/2-professional-collaboratives/
24 Shelter has drawn attention to the issue in relation to affordable housing in England, but
it applies to other kinds of infrastructure as well: Revealed: The ‘Loophole’ Developers Use
To Avoid Building More Affordable Homes | HuffPost UK Politics (huffingtonpost.co.uk) 2017.
Available at: https://www.huffingtonpost.co.uk/entry/affordable-homes-loophole-developers_
uk_59f8e311e4b00c6145e25708
25 BBC News (2023), Wales NHS: Hywel Dda warns patients of travel to see GP. Available at:
https://www.bbc.co.uk/news/uk-wales-67577305
26 Older People’s Commissioner for Wales (2021), Accessing Health Services in Wales:
Transport Issues and Barriers. Available at: https://olderpeople.wales/news/accessing-health-services-in-wales-transport-issues-and-barriers/
27 For more information on ageism, see: Older People’s Commissioner for Wales. (2020)
Taking Action Against Ageism. Available at: https://olderpeople.wales/resource/taking-action-against-ageism/
28 World Health Organisation. (undated) Ageism. Available at: https://www.who.int/health-topics/ageism
29 See for instance Ward, D. (2000) Ageism and the Abuse of Older People in Health and
Social Care. British Journal of Nursing 9(9), pp. 560 – 563; McGarry, J., Simpson, C. and
Hinchliff-Smith, K. (2011) The Impact of Domestic Abuse for Older Women: A Review of the
Literature. Health and Social Care in the Community 19(1), pp. 3-14.
30 Welsh Government, Planning Policy Wales, February 2021 Planning Policy Wales – Edition
11. Available at: https://planningaidwales.org.uk/planning-policy-wales-edition-11
31 World Health Organisation, The WHO Age-friendly Cities Framework: https://extranet.who.
int/agefriendlyworld/age-friendly-cities-framework/