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Outstanding appointment system

Outstanding appointment systemThe subjects of triage and signposting within general practice are never far from the headlines and this week a practice made the news for right reasons – after being given an outstanding rating by the CQC for its innovative, patient-centred appointment system.

The Care Quality Commission rated Conisbrough Group Practice in Doncaster to be outstanding for responsiveness and for being well-led – thanks in no small part to its appointment system – which was introduced following negative feedback from patients.

Continuity

Following feedback from patients in early 2015 that the appointment system did not work – it was difficult to be seen on the day and there were long waits to see a GP of choice – staff conducted a four-week review of telephone calls to the practice and appointments made during that time.

Writing in the RCGP’s Bright Ideas magazine, Dr Ben Jackson, one of the six partners in the circa 10,000 patient practice, said: “We weren’t satisfied with our appointment system and it seemed from the comments we received neither were our patients. We had moved, a number of years ago, to a same-day system where all requests had to be managed that day through the on-call doctor but had found that the demand made this unsustainable. It was becoming chaotic. We had developed this system after hearing of similar ideas elsewhere and though we were aware there were certain key aspects we had not adopted, it was not working for us.”

Dr Jackson added that the partners were worried that individual relationships with patients were suffering and subsequently, the continuity of care they cherished. “We wanted a system founded on continuity and led by patients that was still efficient enough to avoid us feeling out of control,” he added.

People first

Following many meetings, much discussion and a full review the practice came up with a solution. It identified that people’s individual needs and preferences were central to the planning and delivery of appointments. The busiest times were identified and the GPs developed a new person-centred appointment system, implemented in October 2015.

The new system offers continuity of care whilst ensuring those who need an appointment receive one. The system works by asking the patient if their concern is new, whether they considered it urgent and who they would usually see.

Urgent concerns are referred to the on-call GP to contact the person the same day. That GP works in the same room as the receptionists allowing any emergency calls to be passed directly to the on-call GP. According to inspectors, staff told them they felt supported as they could ask the GP questions and it negated the need to make other telephone calls to practice staff.

Routine enquiries would be added to a list for the person’s GP of choice to contact them on the GP’s next working day. The GP would then contact the patient on the pre-arranged day and specific time, if indicated, and invite them to the practice if they needed to be seen. The GPs determined the time and length of appointment with the patient when they booked it.

During the inspection, patients told inspectors this offered flexibility and continuity of care and they liked that they did not always have to come to the practice as their queries could be dealt with over the phone. This included the likes of a change to a medication.

CQC’s Deputy Chief Inspector of General Practice in the North, Alison Holbourn said: “Patients we spoke with and written comments reported a significant improvement in accessing a GP, particularly offering choice and continuity of care. Some reported it was not always necessary to see a GP and their query could be dealt with over the telephone.”

Dr Jackson adds: “We no longer try to manage all the requests for care on the day, allowing the patient to decide if they wish to wait for their usual doctor or opt to speak to someone sooner. The only real point where triage takes place is when the receptionist hears why the patient is calling and alerts the on-call doctor if they are worried, much like traditional appointment systems. The system results in a daily list of telephone calls for each doctor plus an on-call list. As our aim is to support relational care and continuity, sometimes a patient who does not initially feel able to wait is later booked in with their usual doctor after some reassurance or advice.”

Additional features and benefits of the system include:

  • The on-call doctor must ensure that the available appointments on the day are utilised fully, but if appropriate can also use future appointments.
  • There is also an agreed responsibility for all the team to help the on-call doctor if required.
  • Each Doctor is responsible for managing their workload.
  • The same-day list closes at 3pm but can be closed earlier if the on call doctor feels they will not be able to call everyone that day. After this, it is explained that the next time a doctor can call them back will be the following morning, unless of course it appears to present a more urgent problem.
  • Similarly, on any day any doctor can simply close their personal list if they think they will struggle to call them back that day. Once seen, a patient can be given future appointments by the clinician without going back through the system, otherwise they need to enter the system at the top again.
  • As the first contact is on the phone, there is reduced face-to-face contact, freeing doctors up to offer longer appointments for more complicated problems.
  • Traditional surgery times have blurred allowing greater flexibility in offering appointments that suit patients’ lives, rather than the practice’s own ‘timetable’.

The downsides

The practice does admit that it’s not all positive. Two comments received by inspectors related to difficulty gaining an appointment in general and the new system did not allow patients to walk in off the street and book an appointment for that day. Staff explained this was possible if the patient had a telephone number they could be contacted on. They appreciated not all patients could be contactable by telephone – including deaf patients – so they will book appointments in for those where this has been identified.

It was also recognised that important clinical information might be missed on the phone, so alerts have been put on some records to identify anyone that is felt to be more vulnerable, and a list of examples of such information put by the triage station.

Overall though, the new approach seems to be working. As well as accessibility improving, and patients being happier, A&E attendances are falling compared with a rise across Doncaster. Out-of-hours requests have fallen and there have been no further negative comments on NHS choices and the partners say that they now have more time. That, along with the Outstanding CQC rating, suggest it’s a positive move.

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3 Responses to “Outstanding appointment system”
  1. Steve Mowatt Says:

    Really??!! I don’t wish to rain on the this practice’s parade because I know any result like this from CQC is like hen’s teeth but there isn’t anything that different about this set up.
    What about the initiatives to navigate patients away from GPs?
    What about the use of other healthcare operatives for minor illness or home visiting?
    Again, it just proves that your CQC inspection is only as agood as the inspector’s mood on the day!

    Reply

  2. SJG Says:

    Steve, I absolutely agree. We have been working the same appnts system as Conisborough forever – in fact, I would say our appnt system goes further as the duty doctor is available until 6.30pm and will often make evening calls.

    We actually got a glowing written report but ended up with a “needs improvement” because we didn’t have locks on our printers and one nurse hadn’t had her appraisal…..seriously! I am sure you can imagine the words we use to express our opinion of CQC.

    Reply

  3. Chetan Says:

    I agree with Steve abt CQC inspection. we have a similar triage / appointment system where patients get appointment based on needs, same day or any other day based on clinical needs with no limits on number of urgent appointments same day & they are given a choice about GP too. It works with audits to back it up (significantly reduced OOH attandence on week days, most days none !) also sign posted to other providers if needed. well Did not get Outstanding !

    Reply

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