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Finding balance when it comes to appointments

AppointmentsAccess to appointments tends to go hand-in-hand with patient satisfaction. At a time when patient demand is higher than ever before and many practices are struggling to fill GP vacancies, is there such a thing as the perfect balance of same day and future appointment booking?

The answer is, of course, no as too many variables are in play. List size, opening hours, number of GPs employed by the practice, the wider clinical team including nurses, healthcare assistants, counsellors and pharmacy staff and even the number of consultation rooms all impact on availability of appointments. Then there’s patient demand, practice popularity, growth in list size, growth in the number of patients per whole time equivalent (WTE) doctor and a high prevalence of patients with specific long-term conditions.

With the above in mind, what can practices do to ease the pressure and ensure patient access is as good as it can be given the resources available? Here are a few ideas:

Adjust supply

With so many variables in play it really comes down to individual practices to work out their own appointment system and how many can be booked in advance and how many can be saved for same day bookings. This starts by measuring supply and demand.

Start by looking for evidence of too few (or too many) appointments per 1,000 registered patients per week as well as over- or under-supply on certain days, or over- or under-supply at specific times. All are indications of problems in the availability of appointments. It’s worth bearing in mind that the average national ratio – when you take out nurse appointments – is said to be around the 72 consultations per 1,000 patients mark. Once the pressure points and areas where there is capacity are identified, the fun begins!

Sell the less popular slots first

When taking advance ‘bookings’, try to fill quiet times first. Wednesday is a relatively calm day in many practices, whereas Mondays can be manic, so why not try to offer midweek appointments first while keeping more appointments free for same day appointments on Mondays? The same applies to less popular times of the day. The other alternative here, where a practice has part-time GPs, is to ensure more hours are worked on busy days.

Mix it up

Mixing up the types of appointment offered to patients can ease the pressure and improve access – something the CQC does look for when inspecting practices. Could some working people who can’t make daytime appointments be spoken to over the phone or on Skype? Practices should consider local patient context when identifying the optimal mix of appointment types.

Pool appointments

GP partners in Dundee have set up a novel GP appointments system that allows for patients to be seen on the same day by offering a ‘pool’ of appointment slots rather than individual appointment times.

The GPs say their system – which does not limit the length of appointments and prioritises patients according to need and whether they want to see their usual GP – has helped them address ‘a major access problem’ and led to improved satisfaction for both patients and staff.

GPs Dr Ron Neville and Dr Simon Austin, from the Westgate Health Centre in Dundee, instead worked out their “high water mark” of patient demand, allowing for the maximum number of appointment requests on their busiest days. They set up the daily appointment pool guaranteeing patients would be seen that morning, while still providing pre-booked appointments.

They invite patients telephoning for an appointment the same day to attend the surgery at 10.30am, 11.00am or 11.30am – allowing for 20 patients per half-hour slot and advising them they may need to wait a little longer than usual. Patients were asked, if they wished, to say what the problem was, or indicate if they had a ‘personal problem’ or wanted to see a preferred GP or a female doctor.

The team made a minimum of four doctors available for the appointment pool, aiming to have six, and said it was ‘rare’ for the pool not to be empty by midday. Children or distressed patients were seen first, followed by patients who wanted to see a specific GP, and the doctors saw as many appointments as needed – with male partners aiming to make up for additional appointments for female GPs by, for example, dealing with any potentially difficult patients.

The system led to patients being more appreciative, the atmosphere in the reception became calmer and nurses were able to plan their work more easily, the GPs reported, while their patient experience survey scores shooting up.

Automate phone bookings

Earlier this week, it was revealed that a 24-hour, automated telephone appointment-booking system is ‘saving time’ for practices in south-west England. The pilot, which allows patients to book, amend and cancel appointments round the clock, has already saved time by reducing the number of no-show patients just one month into its existence, commissioners said.

The ‘Patient Partner’ system, funded by NHS England and NHS Bath and North East Somerset CCG for a two-year trial, has been installed in 25 out of 27 GP practices in the region, and is intended to save time for practices as well as improving patient access. A CCG spokesperson said that it has ‘already seen hours of practice time saved including from people using the system to cancel appointments and therefore avoiding no-shows’.

Oliver Walton, practice manager at Batheaston Medical Centre in Bath said: “The telephone system gives all our patients the option of managing their appointments when they want or need to. For us, it helps to reduce the numbers of calls coming through and releases our time to spend with patients – we’ve already had a great response to the new system.”

Appointment availability will no doubt continue to be a big problem for practices everywhere. We would love to know how you’ve addressed the issue!

How have you addressed this issue? Are there any magic tricks that you can share with your fellow practice managers? Let us know by commenting below or in the forum here.

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8 Responses to “Finding balance when it comes to appointments”
  1. Harry Longman Says:

    I’ll declare an interest first, I run GP Access Ltd, clue is in the name. This is our specialist area.
    Unfortunately the above suggestions simply do not work. Adjust supply? That just means spend more money. You may not find that palatable, and those slots will fill up anyway.

    Selling less popular slots? Oh please. Patients want help, mostly now/today and they hate being fobbed off.

    Mix it up? Well, changing the channel is getting nearer, but not mixing for fun. 2/3 of patient issues can be dealt with remotely, saving vast amounts of time, but you need to understand demand first and see it as a whole system change.

    Pool? Creating a lot of extra face to face appts, most of which aren’t needed because they could be remote. Pretty chaotic. All the practices we’ve worked with have taken out these open access systems with a sigh of relief.

    Automate phone bookings? Fine, the patients will now take all the appointments you make available that way, same for online booking. But that won’t save a minute of GP time. Much better to let patients seek help online (which we provide through askmyGP) but keep the GP in control of who they see, when, and how best to help.

    Folks, there is really good evidence here of what works and what doesn’t. It’s too important to leave it to hunches. We have to address the problems of access and workload as one.

    Reply

    • Sheraz Khan Says:

      Quite often we find those giving advice and selling services to General Practice as being those who have never actually worked a day in a practice.

      I frequently provide consultancy advise and support to practices across the country and frequently this involves a review of where the largest pressures exist and inevitably this is around access.

      Those working in General Practice will know that approximately 25% of the activity conducted is probably better suited in another setting, pharmacy, minor injuries unit etc. It for this purpose the NHS has spent millions on marketing, advertising and promoting the choose well campaign. So diverting and managing demand is a very sensible approach for practices to consider – is that not the very essence of what GP Access does? Provide telephone triage to divert non essential activity, i.e. deal with what can be dealt with on the phone.

      My experience (almost 20 years) of working within various types of practices is that there is definitely no one size fits all model for General Practice and appointment systems. I have found that a trial and error, approach is usually what works best.

      Currently at a few practices we are trialing a 1:1:1 approach;
      A third of capacity pre booked up to six weeks in advance
      A third of capacity for on the day
      A third of capacity for 48 hours

      I think it is always going to be a trial and error process.

      Advance bookings can result in higher DNA’s.

      Also in places where there are high BME populations (most of London), there is usually a far greater demand for on the day activity, so you will have to flex your appointments system to local needs and demand.

      Systems like GP access might be useful for areas like leafy green Surrey etc. However for places like Tower Hamlets and others with high deprivation and high BME groups and upto 65% of patients having English as a second language – I am not convinced that telephone triage is the answer.

      I would be keen to see the data on patient satisfaction comparing practices that offer telephone triage systems for All appointments as opposed to traditional methods.

      Telephone triage is not a new concept, GP practices have been offering telephone appointments which is a mode of triage for over a decade. It is for each practice to decide whether it is actually any better for them and their patients to have their GP’s sitting on the end of a telephone or actually seeing patients. E.g. I’ve been working with a lovely little single handed practice in Hertfordshire that offer on the day / walk in appointments. Needless to say satisfaction rates with access are through the roof.

      GP’s are the most resource heavy way to deal with all and any activity. Practices may find it more useful to see if they can introduce Pharmacists; Nurse Practitioners for acute minor ailments (sore throats etc), also some of the feedback from practices that have introduced paramedics also looks interesting, but needs more time to evaluate the benefit / impact etc.

      p.s. I’d love to see the really good evidence of what works and what doesn’t, as after 20 years, I am still looking and have concluded that whatever system you introduce it will never be perfect, you just have to think about what works best for your own practices and patients.

      Reply

      • Harry Longman Says:

        Sheraz, we have bags of good evidence and the model is being independently researched by Cambridge Uni/RAND Europe. If you’ve been doing this 20 years and are still at “trial and error” it might be time to take a long hard look. Measurement and evaluation are bound up in everything we do, which is why we are confident in the model working transferably in very diverse settings and with only minor adjustments. Tower Hamlets, yes, one of the GP pioneers of the model was there. He told me it wouldn’t work elsewhere. Another GP pioneer in a leafy suburb told me it wouldn’t work elsewhere. To those who say, “no one size fits all” I say, look at this, it works, find me a better model and prove it with objective measures of demand, response, efficiency, continuity and yes patient satisfaction.

        Reply

  2. Mark Armstrong Says:

    An analysis of how our patients approach the practice has shown us how our patients priorities have changed over time and that different groups of patient have differing expectations.

    We cannot expect our patients to simply accept the same service their parents received in the past ……So it is up to practices to continuously change to reflect these changes in patient demands.

    Younger Patients – Now expect to be able to see a clinician immediately when they feel unwell … whilst seeing their preferred clinician is a secondary consideration to actually being seen
    Older Patients – and those with chronic illnesses expect to be able to book an appointment in advance with the doctor or nurse who knows them best
    All Patients – Like to feel they are being given the time to explain the reason for their visit or to absorb what the clinician is advising them of … they do not like to feel they are being rushed.

    All our patients are allocated a “Usual GP” ..i.e. the GP they prefer to see whenever possible and when a patient calls for a routine appointment they are given one with their Usual GP. This helps to develop consistency of condition management, safer medication management and helps the GPs with continuity without having spend lots of time revising the patient’s history to acquaint themselves with the patient’s medical condition. Also the Usual GP manages all results and letters for their own patients.

    If a patient is acutely unwell then it is less important for them to see their Usual GP and more important to be seen as soon as possible to quickly address the problem.

    Approximately 25% of all our appointments are “Same Day” appointments for acute requests and a large proportion of these are seen by Nurse Practitioners providing a Minor Illness Service (including prescribing).

    We also have a “Duty Doctor” available as needed immediately if the NPs (or GP trainees) feel that the presenting patient requires more in depth experience and / or knowledge. The “Duty Doctor” does not see patients during this time except those “referred” by the NPs or Trainees.

    This means that we can see more patients on the same day and the patient does not have to return to see a doctor as they are seen on the same day.

    Our Practice decided some time ago that triaging patients’ demand for appointments was a waste of time ….. We felt that it was absolute folly to spend approx £40,000.00 employing a Triage Nurse to look at ways of telling a patient they can’t have an appointment.

    We decided that it would be much more satisfying for the nurse and the patient to give them an appointment and to manage the patient appropriately once they had arrived in the practice.

    Our Practice no longer works to a “48 Hour Access” measure …we provide an On-The-Day service to any patient who feels that they need to be seen on the day ….This is in addition to the practice’s capability of providing appointments daily up to six weeks in advance …We call this … “Doing today’s work today” … if a patient is turned away today they will only call again tomorrow to get an appointment… so what is the point?

    In the event that all appointments are used for the same day and yet there is still some residual demand we put on an “Emergency Clinic” for anyone who feels their needs must be dealt with today.

    We do advise the patient that it is for urgent problems only (although it is difficult for a receptionist to determine what an urgent problem is) but we rarely refuse a patient’s request for an appointment. The patients are asked to arrive after 4pm and to wait to be seen by an available GP as and when they can. The patient may have to wait for some time but they will be seen.

    It is our view that the demand for on the day appointments, whilst unpredictable, is finite and eventually anyone wanting to be seen gets seen without seriously delaying GP at the end of the day….In fact, so far, none of our GPs has had to see patients beyond 6pm no matter how busy the day has been.

    The practice continuously monitors the need for On the Day appointments depending on availability of GPs and NPs and manages changes to the appointment templates on a weekly basis… and waiting times are reviewed, discussed and managed at our weekly Practice Meeting

    Additionally, we have invested a lot in providing improved consulting for patients by increasing all clinician’s (including GPs) consulting from 10 minutes per appointment to 12 minutes per appointment. This is a 20% increase in consulting time and gives both the GP and the patient a sense that they are not being rushed in their consultation which results in improved service provision.

    The single most important change which has been introduced in our Access Strategy is getting all GPs to agree to “Do today’s work today!”

    If GPs cannot agree this simple strategy and work together as a Team then the ability to provide an improved Access service cannot be optimised and in fact could lead to acrimony between those GPs who are willing to “do what it takes” and those who are not… Thankfully our practice’s GP Team is fully committed to doing what it takes to fulfill 100% of the demand every day!

    Reply

    • Harry Longman Says:

      Agree with you that demand is finite but you are working far harder than you need to, seeing patients who could be dealt with remotely by GPs. 10 minutes, 12 minutes? Arbitrary numbers, when actually each patient needs different time and the key is flexibility, not simply “more”. We find that average consult times don’t change when GPs are in control of who they see, dealing with 2/3 remotely and much faster.

      Reply

  3. Sheraz Khan Says:

    The issue is that we are dealing with people, algorithms and formula’s do not always apply and at best will only be an indication or guide. People dont fit in neat little boxes.

    Sure you can find a process that may improve certain aspects of the journey either for practices or for patients, but there is always a balance to be struck.

    E.g. Walk in Access – high on patient satisfaction, patient demands and patient wants. But also very high on practice resources.

    Telephone triage – perhaps in some cases might improve aspects of efficiency, but in my experience many patients can find this frustrating.

    I’ve know of GP colleagues who have looked at GP Access and other similar models and found that it wasnt for them, but appreciate that it may well be well suited for others. Goes back to the point – One size doesn’t fit all.

    You see that the main problem is actually there was nothing wrong with the historical method of patients consulting a GP (as it was 15 years ago).

    So we need to ask ourselves what has actually changed??? This is where the research data and analysis is really useful.

    If people accessed their GP appropriately we would not have to find any and every solution to the problem.

    We have an ageing population, we have an increased population, we have experienced significant changes in the demographic makeup of populations, the social demands on healthcare etc. Putting Paramedics and pharmacists in General Practice etc. All of this is a reaction to the lack of funding and shortage of GP’s. So getting more GP’s to speaking to patients on the phone rather than seeing them in person is circumventing around the actual problems facing general practice.

    Reply

    • Harry Longman Says:

      Formulae don’t apply to individual patients, as I’ve said, but they are very useful in aggregate understanding of demand. Ignoring this evidence you are going to remain stuck in an endless loop of trial and error. People need help, they need it to be based on understanding and knowledge. Not the same as a cursory look and a feeling of “we like it or we don’t”.
      The population is aging, and demands increase in a non-linear way with aging. You can’t change that, but you can change the system in general practice. This is not circumvention, it is addressing the problem head on.

      Reply

  4. Chris Frith Says:

    This article does not discuss making appointments online which whilst not addressing the fundamental workload pressure can and does help the efficiency of the practice and the patient experience and can be designed to free up phone lines.
    Viewing results online and seeing the GP comments can even reduce appointments.

    Chris Frith
    Digital Clinical Champion

    Reply

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