Rising demand for appointments at our practice meant we could see our waiting time for routine appointments was steadily climbing each month – many patients were waiting at least two weeks.
We have one main site at Thurmaston in the suburbs of Leicester and two smaller surgeries in Leicester city centre. Recruiting another salaried GP seemed inevitable, as we began to see some very unflattering comments on the NHS Choices website about our service.
As we are the lowest per capita funded practice in the PCT, having to find £90,000 to fund the sessions was not a welcome prospect.
We had heard of Patient Access, a triage now used by over 50 practices and a system which seemed to be getting some publicity over claims it could provide better access for patients and reduce practice workload. We knew Patient Access had something to do with telephone triage and we already did a lot of GP phoning, but this tended to be reserved for some of our ‘same-day’ appointment requests.
The first step was to bring in Harry Longman, chief executive of Patient Access, to talk to the partners about implementing the method.
Under the Patient Access system, the patient is offered a phone consultation before booking an appointment. If they first speak to a receptionist, they can give the receptionist brief information about their medical problem confidentially. The doctor then triages the patient, rings them back within the hour (or at an agreed time later) to discuss the problem and, if necessary, books an appointment. In some ways it seemed fairly simple, but we needed the confidence to set it up properly as the implementation period was just three weeks.
We had two meetings with the primary care team in the practice, and another with our patient participation group. We knew from these meetings that access was the one factor which patients complained about most often and which caused the greatest distress for receptionists.
The whole practice team would be affected and had to be involved, so Harry asked all of us what we wanted to achieve through the system change.
What we did
Before implementing the Patient Access system, we had tried many tweaks to our appointment system to try to manage or limit demand – but patients always seemed to find the loopholes and we would be swamped again. We did telephone triage, extended surgeries and allowed walk-ins, but none of this improved patient or doctor satisfaction. We felt we needed to focus on patient access, but also prioritise care, arrange tests instead of appointments, direct patients to the appropriate staff and consequently reduce the need for GP appointments.
How we did it
We stopped booking GP appointments from 25 July 2011 and explained to patients what would happen.
We set aside time for training receptionists, to help them work out how to put patients in contact with the right clinician, what to say and what the new role would mean for their daily workload. We also trained our managers and designed daily and weekly templates to project and match expected demand. Charts generated from our own clinical system data showed our current demand, with a warning we should expect it to go up when the system was implemented. But the 8am peak when our lines open was expected to flatten, which was something our receptionists looked forward to.
GP preparation was woven into our normal workload as we met with the Patient Access team to plan the system launch, and we talked to other practices to find out their experiences of service implementation.
Safety was an important consideration for us, but research showing a 20% lower A&E use in 40 practices already using Patient Access pointed to high patient confidence in the service.
We were encouraged to make no staff changes in the early days, as the evidence pointed to significantly lower costs in terms of GP sessions once the practice and patients became accustomed to using the system. The fee of around £8,000 for our practice included all our team training, and we could call for help at any time during the transition, which we did on several occasions with questions about patient communication and setting up our clinical system.
We had a morning rush when we first launched, as people did not believe all we said about the service being the same all day, but very soon this evened out. We had a GP unexpectedly off for part of the first week, but we did not have to cancel patients or bring in a locum to cover for him, and the flexibility of the new system became apparent. After a month we felt confident that it was working, as we were finishing clinics well before the end of the day and getting on with paperwork.
When we first implemented Patient Access, there was a massive surge in calls that lasted a couple of months – they doubled, and so did our phone costs as we made many more calls to patients. It was all hands on deck when we first switched, and our eight incoming lines were jammed. We didn’t hire any temporary reception cover, but all our receptionists were busy all day.
We have since installed three more outgoing phone lines for doctors at a cost of £200 a month on top of existing phone costs, and we plan to switch providers to get a better deal now that we’ve committed to the new way of doing things.
I’d strongly discourage GPs from starting a new scheme like this around busy times such as end-of-year QOF returns or holiday periods, because paperwork suffers for the first couple of months.
It goes without saying that it was quite stressful explaining the new scheme to patients, and there was initially a misconception among a lot of people that we were making it harder for them to book appointments. However, with patience from all staff members, and a bit of time, we’ve managed to get the message out to most that access has improved.
Some partnerships may also find that it’s hard to agree on the initial outlay for joining the scheme, but that wasn’t a problem for us – especially once we realised the cost savings.
We decided to try the Patient Access system when we were at the point where the level of demand was unsustainable without employing another doctor. After making the change, we were able to more than manage our patient list without requiring an additional GP. This would have cost around £90,000 with all contributions.
The system allows the GP consultation to be managed by the most senior clinician. Doctors at the practice can now take on extracurricular clinical work on some afternoons. The time saving is hard to believe, but data collection has shown our median response time to patients, by a GP, is under 30 minutes.
The average wait to see a GP face-to-face fell from six days to one day in the first month. We were offering same-day appointments to every patient we needed to see, and finding most wanted to come in immediately. Some would ask for a later date, and we were happy to allow patients to book ahead in this way through the GP. Patient satisfaction was clearly rising, with compliments starting to appear on NHS Choices.
At the same time we were amazed to see a 50% rise in patient contacts. Most of these were by telephone, so we were able to handle them quickly and were bringing in only about one in five for face-to-face appointments. Most patients came in to see GPs, some were allocated to our trainees and some would see the nurse, often saving an appointment as blood tests could be carried out before the patient needed to see the GP.
Do not attends had been an intractable problem for many years, but we found they fell by over 80% with the introduction of the scheme – and in some weeks, we had none. It seems when the GP personally arranges a same-day appointment, the patient nearly always turns up.
Staff stress is also markedly lower under the new system. Receptionists are no longer having to say no to patients, and they have noticed a change in patients’ behaviour too – most no longer feel it necessary to exaggerate their symptoms to gain access to a GP.
A patient survey was carried out, polling those who had just been called by the doctor. Approval of the new system was high – at 75% – and the rating was similarly high across age ranges.
One man interviewed on radio told how he had only called for advice, and was surprised that when he described his symptoms the doctor called him in to be seen.
The Patient Access method is now embedded in the practice for good, with performance data showing consistent service quality and sustained cost savings. Our list size, after staying flat for six months, is now starting to rise again.
What we want to do now is turn our attention to providing training for telephone consultations.
Dr Kam Singh is a GP in Thurmaston, Leicester, and is now honorary chair of the Patient Access steering group