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Patient complains they have to fight for an appointment

Three GPs share their approach to a practice problem

Three GPs share their approach to a practice problem

Case history

Your first patient complains: 'Why do I feel as if I have to fight to get an appointment with a doctor? When I ring my dentist I feel as if I am welcome and I put the phone down happy with the outcome. Is that because I go private? Your receptionist makes me feel I am an importunate beggar, not a taxpayer who pays for the NHS.'

What should you do? Your receptionist is best friends with your senior partner's wife and their families socialise.

Dr Elizabeth Scott

'Have there been other similar complaints?'

I would tell my patient that she is right to say the reason she finds it so easy to get an appointment with her dentist is because she has gone private. Her dentist has limited the calls on his time by charging. If I knew her well enough, I would congratulate her on having found a really good dentist at a price she can afford. I might even ask his name!

I would then remind her that there is nothing to limit the calls made on GPs' time and that the only way to avoid impossible waiting lists is to have our receptionists screen calls for urgency and actual need to see a doctor. And I would apologise if she felt the screening had been too abrupt and would offer to try to improve our approach.

What to do? I hate practice meetings where minutiae are rabbitted on about but if ever there was a case for them, this is it. I would put the subject of receptionists' approach to patients on the agenda so that all my partners could think about the subject and perhaps ask patients for feedback.

At the meeting, I would simply repeat what my patient said to me and allow the discussion to develop. This is a case for a collective decision. My colleagues may already have faced this kind of accusation about this receptionist. Alternatively, my patient may be well known as a complainer. If it seems there is substance in the complaint, the practice manager should mention it to the receptionist concerned.

Also, the practice could send the receptionists on a training day as a career enhancement opportunity. They are not going to complain about a day off! It may even have some effect on their telephone approach. The practice manager, as the person with immediate responsibility for the receptionists' performance, can be asked to monitor what is going on, thus distancing the senior partner from the problem. If it persists, there is little alternative but formal written warnings.

A real dragon may protect her doctors, but her training does not equip her to spot when there is a genuine emergency and she is a danger.

Dr Rodger Charlton

'Receptionists have to make tricky decisions'

One of two things is going on here. First, the patient is right. Second, the receptionist is being fair, reasonable and equitable to all patients and not obstructive, but this patient does not believe so. The GP receptionist's job is not an enviable one, given the number of people who want to be seen, particularly by their 'own' GP, and the number of available appointments.

With the nature of private dental practice, the numbers requesting to be seen are likely to be less. Having worked in a country where you pay to see the GP, access to health care cannot be guaranteed for all. However, in the UK anyone can see a GP irrespective of their means. Receptionists have to make tricky judgments and decisions and I would explain to this person the situation I have just outlined.

The receptionist does not intend to make the person feel 'an importunate beggar' but the GP contract has increased workload and we now have to deal with complex access targets. The receptionist will consult with a nurse or doctor if the patient feels the appointment offered is not soon enough and whether it should be brought forward.

There is, however, great variety between receptionists and the way they do their work and they have to please their GP employers and the patients. I would explain that the receptionist is conducting the difficult process of triage and trying her best to please everyone under extraordinary pressures – meeting requests for appointments, house visits, repeat prescriptions, investigation results and much more.

Furthermore, that when I have been involved in triage the front desk can rapidly become chaotic and I just end up seeing everyone and run hopelessly late, which irritates patients even more. Nevertheless, this patient may have been dealt with unfairly and if they still feel this is the case following our discussion, I would ask them to write to or meet with the practice manager so that the situation can be carefully reviewed, regardless of whether the receptionist is best friends with the senior partner's wife.

I would reiterate that in a health service with escalating demands for healthcare and limited staff and resources it can be difficult to get appointments when somebody wants one, but where it is urgent a receptionist will do their level best to get a patient seen.

Dr Alison Lennox

'It is unfair to compare GPs with dentists'

It is not necessarily the case that you have a dragon receptionist. It may be that the receptionist feels pressured and that demand for appointments far outstrips supply.

It is unfair to compare dentists with doctors. Emergency dental appointments are the minority. Dentists always insist on an assessment appointment before a treatment appointment, which makes their time easier to manage. It is normal for people to take time off work to go to the dentist whereas they expect to fit a GP appointment in around whatever else they are doing.

Lots of dentists impose fines for missed appointments and it is common for late arrivals to be told to rebook. How often have you heard 'no one ever died of toothache', and yet GPs are expected to arrest a dental haemorrhage. The fact that this receptionist is 'family' is irrelevant.

My first step would be to observe her. I would listen to her telephone manner, and to her dealing with people at reception while seeming to be reading my mail or looking for notes. I would try to assess whether the problem is hers or the system's. If her telephone voice was unwelcoming or her words or tone inappropriate I would arrange an appraisal.

I would bring up the subject by saying 'some patients have commented that you sometimes have difficulty finding a suitable appointment for them. Does it seem like it to you?' This might unleash a torrent about how she feels about the patients, which might give clues about how to manage the problem.

I would try to find a course for her to go on. She might return full of ideas about how to improve reception services. I like receptionists to think of themselves as facilitators, there to smooth the interface between busy doctors and worried, busy patients. Above all they must appear helpful.

It is important to look at the appointment diary. Is there a range of appointment times? Or are all surgeries run at the same time? I have found lunchtime appointments are convenient for a lot of people if they work.

What does this teach us?

Learning checklist

What are the rules on access to GP appointments?

  • nGMS contract says GPs must see 'patients who are ill or believe themselves to be ill' if they are registered with the practice and in the practice area. Non-registered genuine emergencies must also be seen
  • The GMC says that in an emergency, wherever it may arise, you must offer anyone at risk the assistance you could reasonably be expected to provide
  • The access direct enhanced service3 includes ease of telephone access to the practice and the facility to consult a GP within two working days, see a practitioner of preference, and book appointments more than 48 hours in advance
  • A practice's normal booked appointment length must be 10 minutes to attain QOF points
  • QOF points are also obtained if patients are able to access a receptionist via telephone and face to face in the practice, for at least 45 hours over five days

How can practices meet demand?

  • Publicise the various types of appointments, and how they can be accessed, in the practice leaflet, newsletter and website
  • Provide a mix of appointments (telephone, routine, emergency, extras and booked ahead) at different times of the day and week
  • Audit appointment use – waiting time, unused appointments, peaks in demand, non-attenders, GP-initiated follow-ups and so on
  • Use a doctor or nurse to triage requests for emergency (or all?) appointments. Many problems can be safely sorted out without meeting face to face
  • Plan for holidays and other absences
  • Perform patient satisfaction surveys
  • Reflect on patient complaints
  • Produce a system that allows for variation, but makes best use of resources, including receptionist time. Consider online booking
  • GPs cannot currently charge their patients for additional private appointments

What skills should receptionist training include?

  • Recognising emergency requests and acting appropriately – for example chest pain, bleeding
  • Elucidating patients' needs and providing an appropriate response (which may include 'no' or 'not yet') while maintaining satisfaction
  • Teamworking
  • Feeding back problems with the appointment system
  • Dealing with attempts to manipulate individuals/the practice
  • Dealing with dissatisfied patients –and doctors
  • Managing their stress (with support)

Dr Melanie Wynne Jones is a GP and trainer in Marple, Cheshire

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