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10 ways to make services easier to access

Overrun with emergency appointments or failing to meet the needs of your patients efficiently? Dr Agnelo Fernandes, Croydon GP and RCGP clinical champion in urgent care, offers tips on streamlining access

By Agnelo Fernandes

Overrun with emergency appointments or failing to meet the needs of your patients efficiently? Dr Agnelo Fernandes, Croydon GP and RCGP clinical champion in urgent care, offers tips on streamlining access

1| Understand your demand

Understanding your practice's demand is crucial but not always straightforward. Review actual patient contacts by day of the week to gain a view of weekly demand in terms of the numbers of surgery appointments, telephone consultations and home visits. Determine demand for same-day appointments versus appointments booked in advance, and variations on a Monday or after bank holidays.

Examine the need and frequency of routine appointments for monitoring long-term conditions and try to avoid multiple appointments for patients with co-morbidities. Review variation in behaviour between clinicians – for instance in bringing patients back for multiple reviews.

Consider how ethnicity and the language spoken by your patients may influence access, and use patient feedback – such as your GP Patient Survey results – to gain a more complete picture of demand.

2| Match capacity to demand

Estimate the overall number of appointments needed relative to your list size, based on the average consultation rate of 5.3 per patient per year (on average 100 appointments per 1,000 patients on the registered list per week).

Ensure about two-thirds of all appointments (for all practice health professionals and including face-to-face and telephone contacts) are booked in advance, keeping one-third for same-day requests, as proposed by the Primary Care Foundation as the optimum way of planning appointment capacity.

The daily patient contacts in excess of those with a booked slot – often called on-the-day ‘extras' or ‘emergencies' – represent part of the mismatch between capacity and demand. Build in increased same-day appointment capacity for expected peaks in demand on Mondays or after bank holidays. You could, for instance, offer 20% additional same-day appointments at these times.

3|Respond to clinical urgency

Ensure there are an adequate number of telephone lines, and that staff are available to answer variations in call volumes, with the highest peak between 8am to 9am. You could use the Erlang formula to maximise accessibility and efficiency (see further reading, right). Ensure you have policies for reception staff induction, their learning needs and updates on how to determine and respond to urgent calls.

Develop a system for the identification

of life-threatening emergencies for direct referral to a 999 ambulance, and ‘primary prioritisation' of urgent requests. These could be in the form of paper-based lists

of emergency conditions, a primary prioritisation protocol or an electronic protocol integrated with the clinical system.

Ensure calls determined as clinically urgent by receptionists can have rapid clinical assessment by a doctor or nurse – for example, if a request is made for a home visit. Having a duty doctor system allows rapid clinical assessment of these clinically urgent requests on the telephone.

4|Develop good triage systems

Systems for triage help manage the volume of demand and effective use of the practice skill mix, but they should not compromise patient safety.

Develop a standard telephone script for receptionists so they can process calls efficiently both to book appointments (same-day or in advance with the appropriate health professional), identify urgent cases and offer patients a choice between face-to-face surgery appointments and timely telephone consultations. Triage of all requests for same-day appointments by a doctor or nurse on the telephone can benefit some practices by reducing the need for face-to-face surgery appointments. However, you need to ensure there is adequate training of clinicians to achieve consistency in the outcomes of telephone triage and audit monitoring.

5|Use telephone appointments

Telephone consultations are now an integral part of modern general practice. Patients often choose and can be offered telephone advice through appointments booked in advance or on the same day. Telephone consultations are preferred by some patients, from those who have simple queries or need specific advice, to those who have more complex inquiries but do not want to take time off work to attend the practice. Experience shows upwards of 50% of contacts in the out-of-hours period and upwards of 25% of appointments in hours are already conducted on the telephone in many areas.

Receptionist training must ensure the choice of a consultation on the telephone is made available for every patient who requests an appointment, especially for same-day requests.

Whereas some practices still use the most expensive resource of a GP conducting telephone triage and consultations for same-day requests, others have introduced a skill mix involving nurses, nurse practitioners or physician assistants. To ensure consistency in the quality of consultations on the telephone, whether conducted by GPs or other health professionals, there is a need for audit and training. Some practices have introduced recordings of telephone conversations for these purposes.

6|Get clinical skill mix right

Traditionally GPs have done it all themselves. Now, however, many practices use specifically trained nurses, nurse practitioners or physician assistants to triage or carry out clinical assessments of same-day requests from patients, or to use nurses or healthcare assistants for routine monitoring of long-term conditions.

Ensure receptionist training involves maximising the use of the skill mix within the practice when booking appointments to deal with different problems – such as long-term condition reviews, dressings, minor illnesses or injuries and so on. Pharmacists are increasingly part of the practice skill mix and well-placed for medication reviews. Again, ensure systems are in place for ongoing training of all staff.

7|Set up internet access

Most practices now have websites and are increasingly encouraging online booking of appointments and requests for repeat medications by this route. Future national GP surveys are likely to give an indication of what proportion of registered patients would prefer further development of this facility. Depending on take-up, the capability to book and cancel appointments online has potential to reduce the number of telephone calls received and DNAs, increasing overall accessibility to the practice. Offering email consultations is still in its infancy in most practices and will benefit from an assessment of need, good governance and training of clinicians who may be working outside their comfort zone.

8|Change perception of access

It is possible that at least some of the inappropriate attendance at A&E and responses in the patient survey at some practices is due to patients' misconception that they may not get an appointment at their surgery the same day. This may be based on previous personal experiences or those of relatives and friends, or it may actually reflect the current situation because of a capacity-demand mismatch. Tackle any misconceptions by developing a proactive campaign to inform patients of the different portals of entry to the practice (online, by telephone, at the practice or at home) and the different health professionals available.

9|Consider extended hours

Many practices now offer routine appointments during extended hours. This may include routine appointments before 8am or after 6.30pm on weekdays, or on Saturday mornings. Survey findings rarely suggest there is demand for appointments on a Sunday. However, the proximity and impact of GP-led health centres, which offer GP appointments 8am to 8pm to registered lists, remains to be seen. Furthermore, the DNA rate and case-mix of patients attending extended hours clinics – such as the elderly with long-term conditions rather than working patients – may indicate a mismatch between capacity and demand during normal working hours.

10|Manage routine monitoring

Addressing GP access is a dynamic process and routine monitoring systems for assessing appointment capacity versus demand need to be in place to take into account demand for appointments for a specific GP or other health professional, annual leave, staff sickness, seasonality and prevailing factors such as pandemic flu. GP computer systems are not always helpful for routine monitoring and manual systems will need to be devised.

Dr Agnelo Fernandes is a GP in Croydon, south London, chair of the Croydon Federation of General Practices and RCGP clinical champion in urgent care

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