In general practice, patient demand can seem inexhaustible. GPs either work excessively long hours or set up barriers to block demand. This often results in appointment systems where receptionists are used to filter patients before they reach the doctor, leaving some confused and dissatisfied.
But what if there was another way to manage patient demand? One that could save you money and improve care?
In this article, I will detail our experience in changing the way we provided access to patients and show that with a few small changes to your appointments system, you can ensure 99% of patients are seen on the day of their choice.
Our initial idea
In the late 1990s, our practice had an increase in practice list size of over 1,000 patients in a year, creating more demand than we had appointments. We had no room for additional GPs or nurses in our building, and no more plot upon which to build.
Like many practices, we coped by working longer hours. Our surgeries ran late with extras squeezed in, we had dissatisfied patients, harassed staff and stressed doctors.
Eventually, we reached our own tipping point – we had to change. In a fit of desperation, we produced what we thought was an unobtainable wish list of working less, reducing stress and having no patient complaints. We then developed the idea of using a GP to filter out on the telephone the patients who didn't need an appointment, in order to free up time to help those who did.
Once we had the agreement of all of the partners, trialling this approach was simple. We picked a day far enough ahead so that one GP had no pre-booked appointments, reserved his clinic and blocked out the last three appointments of all the other GP clinics solely for his use to book patients who wanted an appointment in by telephoning them. We noticed a difference immediately.
GP workload was reduced and patients were much happier with the new system. Following this successful trial, we then looked at how we could revamp the access we offered patients across the board.
Putting our idea into action
We started our overhaul of the practice's appointment system by analysing when and where we saw increased patient demand. We noted the following trends:
• Mondays were the busiest day, followed by Tuesdays and Fridays, then Wednesdays and Thursdays.
• Two-thirds of our workload, even in the revised system, came in before midday (half by 10:30am).
• Most of the people who were very ill called the practice before 10:30am.
We looked at our previous activity by counting how many people we saw and spoke to in the previous four weeks. We then worked out our backlog by counting how many people were booked ahead on a given date. We put in temporary additional resources to cover the extra work of the backlog, and also factored in the GP triage system we trialled to reduce the demand on GP appointments.
We also changed the way we worked to clear appointments before 10:30am, to free up GPs to answer calls from patients as they phone in.
This was a rolling programme, as we also studied our patient demand going forward by recording when every patient wanted to come in (not when we could give them the appointment). This enabled us to estimate the capacity we needed going forward, and match this with sessional GP support.
Results
We discovered that this system saved huge amounts of GP time – increasing our capacity by 50% and improving patient care at the same time. The median time taken for a patient contacting the surgery to talk to a doctor was less than 30 minutes. Most of the very ill people were spoken to immediately or within a few minutes.
After speaking with a GP by telephone, only a third of patients wanted to have a face-to-face consultation. This saved us about an hour a session (see below for full calculations)
How we boosted our capacity
• Average list size is 1,800 patients per whole-time-equivalent GP.
• On average, every patient seeks help five times per year.
• That's 9,000 consultations per GP per year.
• Take out bank holidays – there are about 50 working weeks per year.
• So on average, 180 people want help per week, per GP.
• Over 10 sessions, that's 18 people per session.
• It takes 10 minutes to see one patient, so each session is three hours' work.
• Three patients can be consulted over the telephone in 10 minutes.
• So 18 people can be helped in one hour by telephone.
• Having done so, only a third will want to come in to be seen by a doctor.
• That means six people will want a face-to-face consultation, that's another hours work.
• Now something that took three hours of work takes two.
• In three hours we could now help 27 people rather than 18 – increasing our capacity by 50% without it costing a bean!
It also resulted in major savings for the practice – of approximately £100,000 per annum in reduced doctor time, with a third of GP time saved per annum (the equivalent of one GP salary).
In doing so, we also improved the quality of patient care, with a measurable decrease in the number of patients accessing alternative medical services. This has had a direct effect for the better on our commissioning budget, with an estimated further £100,000 saved by reducing emergency admissions via A&E.
DNAs became very rare and we GPs found we were going home at the end of every day knowing that we had done everything we could for our patients. By having fewer stressed doctors and staff, the quality of the patient experience rose and complaints fell dramatically.
The future
This has been an 11-year journey – from just talking to those patients who couldn't get an appointment when they wanted it, to a fully fledged direct access system that allows patients to be seen on the day of their choice in over 99% of cases.
The system we developed has now been rolled out to another 40 practices and is called ‘Dr First'. To save practices having to reinvent the wheel, we have developed a series of tools to automatically calculate how many doctors and nurses they need for every session using basic practice data.
Dr Stephen Clay is a GP in Leicestershire, primary care adviser to NHS East Midlands and clinical director of Productive Primary Care Ltd. Dr Clay can be reached at s.clay@medically.org.uk
