It’s never easy to juggle access with continuity of care. But a personal-list model and a flexible appointment system can do the trick, says practice manager Marilyn Long
Personal lists may seem old-fashioned and sometimes unworkable. But personal lists are at the core of the care we provide at our practice. Our appointment system has stood the test of time. We introduced it more than a decade ago, based on matching capacity to demand and ensuring all our doctors offer a mix of routine and urgent appointments each day they work.
From our practice in a small market town in Cambridgeshire, we care for just over 9,600 patients in the town and its surrounding villages, successfully balancing good access with our desire to provide continuity of care. How do we make it work for us?
1. By adopting a personal-list system.
We let all our patients know that we believe in the value of an ongoing patient-doctor relationship. We are clear about the benefits of personal lists. At registration, patients are offered the opportunity of an appointment to meet their GP, allowing them to discuss past medical history without the need to address an acute problem.
Patients with long-term conditions in particular will be invited in, and the GP may raise any issues regarding their condition or medicines highlighted by the registration questionnaire.
Appointments, whether routine or urgent, are preferentially booked with the registered GP unless there is a specific request to be seen by someone different, as when, for example, gender is an issue.
2. By offering a mix of routine and on-the-day availability for all doctors.
We have a duty doctor, who offers 45% urgent and 55% routine appointments, but even our non-duty doctors offer 25% urgent appointments alongside 75% routine.
Having on-the-day availability for all doctors means in most circumstances
a patient will see their own GP even for urgent issues. There are clear benefits for this, since the urgent condition may be linked to other conditions for which the patient is being managed. We see this as better than a system that directs all urgent requests to a duty doctor – and perhaps from there, via another appointment, back to their own GP.
Routine appointments can be booked up to eight weeks in advance. Patients value this opportunity to plan and it doesn’t seem to adversely affect the DNA rate, which overall is low.
3. By offering enough appointments.
It’s not rocket science, but it is vital to keep overall demand and capacity under review. There are ‘standing orders’ to add additional routine appointments for all partners at times when GP numbers are reduced.
Our list size is growing, so the number of appointments offered has been increased in order to ensure we meet access targets. It is not without cost in terms of both partner time and money, but we feel it is essential to provide the kind of care we want to give our patients.
4. By offering patients faster access if they want it.
We know we must offer patients a routine appointment with a GP within 48 hours, and this means we have to be flexible in adherence to the personal list.
If the patient’s own GP is fully booked and the patient does not wish to wait longer than 48 hours, they will be offered an appointment with one of the other GPs. But because we offer enough appointments, this doesn’t happen too often.
5. By working as a team.
There is no benefit to having a duty doctor who is swamped by their workload while another doctor has spare capacity. It is practice policy to ensure all doctors have their full quota of urgent appointments filled before the duty doctor starts seeing the remaining ‘on the day’ requests. In addition, once the appointment demand for the duty doctor reaches
a trigger level, the team steps in, sharing the balance of any excess demand evenly. There are eight urgent appointments for each non-duty doctor at the beginning of the day and 16 for the duty doctor. Anything over this is shared.
6. By having a clear plan for dealing with excess demand.
Some days, patient demand exceeds all normal activity – and it’s important to have a plan for these, and make sure your whole team knows it. It’s an efficient use of your most precious resource – your time. The key is to ensure that your practice offers safe, if not optimal, healthcare on those days when there is simply too much to do. Our plan has been formulated after assessing what it is essential to do and what things can be deferred, and by knowing our team and how to use them most effectively in extremely busy periods.
7. By recognising the value of telephone consultations.
We ensure our team understands what can be dealt with over the telephone and what can’t. We do not use telephone triage and largely do not encourage non-clinical staff to ask patients what their problem is (the exception being urgent calls when someone has collapsed or has chest pain).
But it’s often possible to deal with two or three telephone calls in the time allotted for one face-to-face consultation. Patients requesting advice, or asking for a prescription they have received before, will be asked if a telephone call can help. And if we can’t offer a convenient appointment, we would ask whether a telephone consultation might be helpful.
Marilyn Long is practice manager at Cromwell Place Surgery in St Ives, Cambridgeshire
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