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Are we asking the right question?

Wednesday 19th Feb 2014 - Kate Hodkinson

There is a huge amount of pressure upon practice appointments and availability which has been growing over recent years. In 2003 patients visited their practice about 4 times a year on average. Now the average in a year is about 5.3 visits.  This figure is increasing year on year due to several important factors:

  • The increasing requirements under QOF and other audit  mechanisms to review and monitor patients
  • The aging population who tend to present with high levels of  disease
  • Increasing amounts of services being moved from secondary to primary care
  • Introductions of new enhanced services
  • Campaigns to raise awareness of diseases and promote public health and well being

Practices have tried many different ways to ensure that patients can be seen appropriately and to meet national and local targets set for access. The perception of the patient, in many cases, has changed over recent years and there is a very common view about what constitutes good access in the mind of the patient – some of this, the NHS has directly contributed to and is now creating a lot of problems.

The NHS standards and targets over recent years have created the impression that patients need to be seen today. Six or seven years ago, patients had very little expectation of being seen on the day unless they had a very urgent need. Patients were generally quite accepting of being given an appointment 3 or 4 days ahead. But this has all changed.

Has the workforce and capacity changed with it?

The make up of the clinical team in general practice has changed over the last ten years.

  • There are now 2475 more nurses than there were 10 years ago although many of them work part time
  • The number of GPs has also increased from 36,000 to 42,000 although there has been a drop in the number of partner or contractor GPs and a great increase in the number of salaried doctors who now make up 1/5 of the total GP workforce

Yet, despite these increases there is still a feeling of increasing pressure on appointments and this remains a cause of dissatisfaction for many patients.

Is the pressure real?

One of the first things that a practice needs to understand is whether this is a real problem to them in practice – i.e. are we offering enough of the type of appointments to meet the needs of our patient population?


Is this a problem of patient perception and use of the systems?

Both of these are real problems to the practice but they need to be resolved in different ways.

As the general practices range of services are offered by a combination of doctors, nurses, health care assistants and phlebotomists, it is worthwhile considering a review of who delivers what and to measure the capacity and range of each service.

Recent research in Denmark considered the issue of substituting a nurse for a GP in consultations. This was  considered appropriate in 14.8% of consultations according to GPs and when patients were consulted, the considered that this was appropriate in 11.7% of consultations – although there was little common ground over which consultations! This tells us that patients are definitely amenable to being seen by a different provider of the service in some circumstances. The challenge to practices lies in knowing where patients will find this acceptable and the ways of communicating any changes to them.

“What’s it for?”

I have heard this being barked by some poorly trained receptionists when instructed to ask patients the main reason for their consultation with a GP. I can understand why patients respond negatively to this and the subsequent problems this creates.

When trying to match a patient and an appointment – this is the single most important issue – why they need to be seen – as this will begin to indicate:

  • How quickly they need to be seen; and
  • Who they should be seen by; and possibly
  • If they need a face to face appointment; or
  • Their problem could be resolved without the need for a consultation

For these reasons many practices are now moving to a system whereby patients are routinely asked for the main reason for their consultation when booking by phone or in person. The vast majority of practices have used this approach for nurse appointments for many years and it has made a positive impact on the use and planning of appointments. So, why is there so much reluctance to implement the same thing for GP appointments?

  • Could it be resistance caused by patients concerns over confidentiality?
  • Do patients see their GP with more “personal” things than they see a nurse?

If a practice thinks that this type of approach would help in the planning of their appointment system there are a number of things for them to think about in terms of planning:

  1. Patients will adapt to new systems if you consistently do them for long enough
  2. You need to discuss with them their concerns beforehand and address these
  3. The staff need good training to be able to respond appropriately to the patients both during the period of transition and then routinely afterwards
  4. The planning period where you will be communicating the proposed changes needs to be long enough to give advance notice to as wide a group of patents as possible
  5. The practice needs a clear plan which must be reviewed along its timescales

Developing an appropriate appointment system

The benefits for a practice and their patients in being able to match need and supply are tremendous. Happy patients are easy to deliver services too and have a knock on effect in helping to create a happy team.  Saving one unnecessary appointment for each clinician in your team each day mounts up over a month, a quarter and a year and also reduces the amount of frustration felt by both parties.  You can ensure that patients are aware of all the services and options available to them and that they are used appropriately.

Taking control of the thorny issue of supply and demand for appointments begins with an audit of the current situation. First Practice Management subscribers can take advantage of a ready made assessment tool to assess this. Thornfields can also provide bespoke training for your team in communication skills and customer service to help the transition.

Remember, demand for GP consultations will only be increasing in the future, now is the time to start taking control in preparation for those increases.

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