Every practice is different, so there is no generic solution or quick fix to improving access – but this is a common example of a practice struggling to meet the expectations of its patients.
To make changes you need to understand the relationship between clinicians, patients and staff. Success depends on identifying all these groups' needs and striking the balance between their often disparate ‘wants'. Here are five questions you need to ask to do this.
How many patients come through your doors and when?
Take a step back and assess patient demand properly. Results are affected by many variables, so take great care in formulating your questions to ensure the information you get back is useful.
Useful questions are: How many patients come through your surgery doors and when? How many calls have you had in the past week for urgent versus non-urgent appointments?
Equip a receptionist with a tick-sheet template and record when a patient requests an appointment, even if one isn't available. Separate requests for same-day and advance appointments and collect this information on a weekly basis.
This will enable you to identify variations in demand for same-day and pre-bookable appointments, roughly how many appointments you might need each day and what proportion needs to be kept for same-day.
It is also valuable to do several types of survey – electronic, telephone, face to face, and paper questionnaires – to capture information from differing groups of patients.
If you accept that monitoring is a way of working, not a quick fix, then managing demand becomes an integral part of the process. The most successful practices can spot unexpected changes and trigger a more in-depth review.
What capacity do you have in your practice?
The best place to start is to count all the routine appointments available for the week. Include same-day appointments, pre-bookable appointments and pre-planned telephone consultations. Don't forget telephone triage and open-access clinics.
Split these by members of practice staff and figure out which times and days are your crunch points. Usually Mondays are the busiest day, followed by Tuesdays and two-thirds of your day's workload will come in before midday. Can your appointments be adjusted to reflect this?
Compare consultation rates with national averages to give you an idea of where your practice is. Nationally, each patient is seen just over five times in the year [1]. But there are wide variations between practices – significant numbers of practices have consultation rates lower than four or higher than eight. A rule of thumb is that the median level is approximately equivalent to 100 appointments per week for every 1,000 patients. If yours are greater or less you may want to consider why.
Is your emergency surgery needed?
Asking patients to call back in the morning or at specific times will double the demand on phone lines and receptionists and can cause more problems.
Here are some alternative ways to shape patient demand:
•Tailor appointment styles – for instance, group sessions or telephone consultations.
•Adjust appointment length – patients with long-term conditions may need double appointments, but others can be routinely monitored by nurses in relatively short slots.
•Adjust your practice skill mix – use the duty doctor to monitor same-day requests, steer patients towards nurses or complete cases with a telephone consultation.
•If DNAs are an issue, consider internet booking or text-based reminders. They are not a magic bullet but can reduce DNAs.
•Use telephone triage – consider practice nurses or even receptionists (if they are given suitable protocols and training)
•Educate your patients to see other healthcare professionals, such as pharmacists for minor ailments.
•Consider offering extended hours – but despite their popularity with commuters and politicians, reaction to them is variable. My first extended-hours patient complained that he had to get out of bed too early!
Most patient demand can be met with good accessibility through telephone and electronic communication and only occasional face-to-face consultations. This should mean a more responsive, flexible approach to managing demand and you may not need to replace that GP who is leaving.
Have you planned for contingencies?
So you have looked at the appointments you offer in a week – but is it really typical?
•Are there occasions when staff have commitments that reduce their availability to see patients? Schedule fewer appointments in those weeks.
•What happens in a week with a bank holiday Monday? Plan more appointments for the Tuesday after.
•Have you considered the impact of trainees and how they can contribute more over time, or looked at the impact of local support schemes?
By understanding the impact of these variations you may need to adjust the average number of appointments offered in some weeks.
Have you communicated any changes?
Marketing of your appointments system is crucial to maximising its effectiveness. Think of every patient contact, physical or electronic, as a marketing opportunity. An up-to-date website is essential but do not forget posters, leaflets and prescription reminders.
Also, keep talking to your local colleagues who may alert you to the impact of local activities and initiatives. If nothing else it keeps you sane.
Hopefully your journey will now feel less like a Monty Python sketch and more of a noble quest.
Dr Greg Simons is a GP in Buckinghamshire and lead for the ‘Achieving a Responsive Practice' workshops run by the RCGP. The content of this article is based on this workshop
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