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How to make patient access pay off

Payment for patient access is now based on a new patient experience survey ­ it is the patient who decides whether the GP service is satisfactory or not. Dr Jim Sherifi explains how his practice tries to keep patients onside

Payment for patient access is now based on a new patient experience survey ­ it is the patient who decides whether the GP service is satisfactory or not. Dr Jim Sherifi explains how his practice tries to keep patients onside

Patient access to primary health care services has been a contentious issue within general practice since the inception of the NHS and its founding principle of free access to health care for all.

Since then much thought and energy has gone into devising systems that marry patient expectations to the medical availability that is limited primarily by time but also by resources, both physical (space) and human (doctor/nurse numbers).

The dilemma is further confounded by the need to ensure that serious, 'urgent' or 'emergency' cases are dealt with immediately and efficiently.'Patient access' therefore has to reconcile two very different, almost opposite, perspectives. For example, patients want to be seen at their time of choice but there are only a limited number of appointments within set surgery times each weekday and once these are filled, no more can be made available.

Again, most patients would like to be seen at a place of their choice (ie their home) but this is not practical from the GP's point of view. Patients need to be seen at the surgery except in the most exceptional circumstances.

Prior to 2004, the Government interceded to reconcile these differences by introducing regulations governing patient access to primary care services which included a suggestion that no one should have to wait more than 48 hours to see a health care professional. GP surgeries responded in a variety of ways, including:

  • Totally open surgeries with no pre-booked appointments. This was a system commonly used in the early days of the NHS and somewhat discredited with time due to its inability to control the workload, resulting in overcrowded waiting rooms with patients having to wait several hours to be seen.
  • A loose interpretation of 'health care professional' to include practice nurses, nurse practitioners and paramedics who in turn would triage patients into those who needed to see a doctor that day, those who could wait and those who did not need to see a doctor at all.
  • Mixed surgeries with some pre-booked and 'open' appointments, available for same-day booking. This system usually also had a doctor running 'emergency' surgeries only.

No system was problem free. The 48-hour rule resulted in patients having to ring up on the day they wished to be seen, resulting in an unseemly early-morning rush and blocked telephone lines. Paradoxically, as highlighted in the 2005 general election campaign, patients also complained that they could no longer book appointments into the future to deal with non-acute or follow-up problems.

Indeed it seemed 48-hour access was not as vital a priority as being able to book a planned appointment that suited an individual's diary. It should be noted that patient access was not included in the QOF targets within nGMS of 2004 and, to date, there is no suggestion it will be in the 2006 revised metrics.

However, it was a part of the patient experience questionnaire in which practices were encouraged to take part (worth 70 points in total) and it is this questionnaire, independently managed and beefed up, that will have a far greater influence on GP remuneration in 2006.The agreement between the BMA and NHS Employers to develop nGMS in 2006 includes the following paragraphs:

'A new, independent national patient survey is being introduced to capture the public's experience of health care services, initially focusing on access and choice. The results will determine the level of practice awards for payments against the new direct enhanced services (DESs) for access and choice.

'Alongside this survey, practices will still have the opportunity to carry out an in-house survey through QOF and will continue to take part in the primary care access survey.'

'A new DES worth £108 million bringing together the 2005/6 access awards in QOF and the 24/48-hours DES. This now focuses on four key areas; the ability to consult with a GP within 48 hours; the ability to book appointments in advance; ease of telephone access; and ability to wait for a practitioner of preference (no time limit).

Awards will be based on two components: ·a firm commitment from practices to deliver on the first three access areas (48 hours, advance booking and telephone access) as well as continuing to participate in the existing primary care access survey (PCAS) and results from the new patient experience survey on local access.'

In order to qualify for these new payments, GP surgeries will need to ensure their patients' perceptions of the service offered by their practice are favourable and positive. How can this apparently hopeless task be achieved within the bounds of an 11-hour day, five-day working week?

The answer lies, as with so many other areas of clinical practice, in managing expectations and with the doctor-patient relationship.In our practice we attempt to work in partnership with our patients in a variety of different ways. We have a practice-patient forum that meets six-monthly to discuss major organisational issues. We have a patient newsletter that includes a section on NHS changes and initiatives. We have previously highlighted the problem with meeting demand, surgery times, telephone access, etc, and we will do so again.

In the waiting room a name board details which doctors are working that day.Our receptionists are trained in customer relations management and we have the best possible telecommunications systems, including e-mail, so that we can liaise well with our patients.We are maintaining the mixed appointments system that has evolved over decades and is best suited to our patients. The proportion of booked to open appointments varies depending on the seasons, availability of doctors and acute pressure on demand, for example as with a flu outbreak.

But ultimately the patient experience is predominantly governed by their interaction with their doctor (or practice nurse). This article does not have space to cover the consultation process, but in essence, if the patient feels their doctor has listened to their problem in an empathic way and then competently dealt with it, then they usually forget any frustration they may have experienced in getting to see him or her in the first place.

Jim Sherifi is a GP in Sudbury, Suffolk

Keeping patients happy

  • Regular practice/patient forums
  • Regular patient newsletter
  • Name board in waiting room giving names of doctors working that day
  • Receptionists trained in customer relations management
  • Best possible telecommunications
  • Good use of e-mail to liaise with patients
  • Appointment system that suits our patients (in our case a mixed appointments system)
  • Real attempt by GPs to empathise with patients during consultations ­ this is the most important thing of all

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