Try appropriate, rather than advanced, access
Advanced access, despite its many advantages, may need customising for it to be of optimum benefit to a practice and its patients, says Dr David Jenner
The concept of advanced access has a lot to recommend it but for our practice we felt it was too unfocused.
We liked the way advanced access matched supply to demand. Also the way it espoused good management techniques of planning as a team and making small changes with a review after each change.
But there were deficiencies. It could not produce extra capacity. It seemed to limit the capacity of individuals to book ahead. It challenged the concept of continuing personal care.
And we felt it did not really address the major concern of patients – the time spent in the waiting room.
So what did we do? First, we looked at the nature of our practice (four sites, part-dispensing, in rural market towns). Second, we looked at our pattern of GP provision (10 partners, most of them part-time, one salaried GP, one nurse practitioner).
Then we looked at patient concerns such as waiting time, choice of own doctor, choice of surgery and so on.
We took into account the concerns of the partners (for example not having enough time in consultation). We looked at our locum expenditure. We looked at the capabilities of the phone system, asked the receptionists their opinions and looked at our previous experience with triage.
Then we made an action plan. We decided to try to match supply to demand. We decided to increase the length of appointments for chronic disease follow-up to 15 minutes. We decided to try to keep surgeries running on time. We decided to allow patients to choose their local surgery or preferred doctor for planned care where possible. We decided to provide a rapid response to acute illness – for example to see patients the same day.
We decided to guide people to the most appropriate clinician to address their needs and to give receptionists more available appointments. Also to stop asking people to ring back on the day to access an appointment and to maintain continuity, especially for planned care. Finally to avoid congestion on the switchboard and allow patients to get through easily.
Our proposals were as follows:
lTo use the money spent on locums over the year to fund a part-time salaried GP and employ them on the days where we were historically short of appointments.
lTo offer five book-ahead appointments per GP surgery (16) of 15 minutes in length for planned care.
lTo invest in a new phone system that directed patients to different staff.
lTo rationalise leave arrangements and review branch surgery cover.
lTo use our nurse practitioner to advise patients who were not sure whether they needed to be seen or who they should see.
lTo encourage patients not to book ahead for acute illness or unscheduled care, in the assurance that they would be seen on the day.
lWhere a GP or nurse needed to review a patient after a fixed period, the GP gave the patient the appointment by booking direct on the computer before they left the consultation.
This is what we have named 'appropriate access'. We introduced it at a time when all the partners were present and to coincide with the start date of our salaried GP. It is true we needed to work harder in the week before this start date to clear the backlog of appointments, but that will always be necessary and is a recognised part of advanced access. Without the available manpower any such system will struggle.
Our experience to date
Our system has so far been universally popular with receptionists and with the majority of doctors and patients. For doctors the longer appointment times have enabled surgeries to run on time and have allowed time for paperwork/ referrals to be done at the end of consultations. So the working day is not longer, even though surgeries extend slightly. We no longer plan in catch-up time except for the duty GP or when teaching is in progress.
Inevitably there have been problems. The plan to ask patients to use a press-button menu option on the phone to access different staff failed because patients could not understand the system. The other problem remains with the balance of book-ahead appointments and same-day availability – working patients in particular like to plan ahead.
These patients, and one of the doctors at the practice, desire more book-ahead appointments. Our plan is to increase the number of these appointments as needed, but we will need to protect against prebooking whole surgeries.
Illness and holiday
There is no easy way of protecting against the combined influence of these events. For us a flu bug that took out two doctors and three nurses meant we temporarily could not match the increased demand to supply. Whatever the advanced access evangelists may say there is no way you can avoid working harder in these circumstances. We have coped to a degree by doctors working their days off in lieu to help address this hitch and rematch the supply equation as quickly as possible.
My concern though is for practices with vacancies and no access to locums – nurses and triage can help to a degree but will not solve the problem.
We are committed to appraising and revising our schemes on a regular basis and it seems likely we will need to vary the proportion of book-ahead appointments to ensure continuity in our practice where the majority of GPs are part-time. We also feel the advanced access concept of no differentiation between urgent and routine appointments only works where demand and supply are in equilibrium.
Audit and evaluation
We plan to evaluate our scheme with our patient group and look to adapt it to improve patient care and health outcomes. But we would call for a national independent evaluation of advanced access to ensure it does make a difference to patients as well as to practice staff and does not compromise continuity or quality of care.
We think advanced access is good in parts, but in our case we really did feel we needed to fine-tune it.
David Jenner is a GP in Cullompton, Devon
Access is not only about time to see a GP or nurse
It also reflects the following:
lAccess to the most appropriate clinician
lAccess to the doctor or clinician of the patient's choice
lAccess to a convenient service
lAccess to a quality consultation of adequate length
lAccess to someone who listens and cares
lAccess to appropriate and timely health advice
and advanced access does not really address them