Finding a way to meet patient demand can be a challenge. But there are ways to alter your current system that solve the problem
I am sure you all hear on a daily basis from patients: “I can never get an appointment when I want one.”
And with ever-decreasing budgets we are struggling to add more resources. Even if we were open 24 hours a day we would still not manage to please all patients.
Rowley Healthcare was struggling through a difficult uncharacteristically challenging time with demand for appointments and decided to change the way we offered appointments. The results have been on the whole very positive with patient satisfaction rising significantly.
Telephone triage was always an option but was carried out ‘as and when’ in between patient appointments and after surgery sessions had finished.
Patients can book at least a month ahead. We also offer routine appointments to be booked up to six weeks in advance. The six weeks is in line with the suggested minimum of six in Rowley Healthcare’s report on urgent care in general practice. Receptionists use a script that steers people towards booking further ahead rather than offering an appointment as soon as possible.
Requests for home visits are reviewed at the end of the morning and shared among the doctors.
We have made significant changes over the last year to enable us to manage demand for urgent appointments
Same day appointments
General practice workload splits, on average, into a third of same day presentations and two-thirds book ahead. This will vary by individual practice depending on a number of factors including the consultation style of the staff and the nature of the practice population – with younger lists generating more same day appointments and older lists tending to require more book ahead appointments.
The ratio includes all activity and not just GP appointments. We have found that having too high a proportion of same day appointments drives patients who would book ahead to seek a same day appointment as this is often the only option left when they call. It also makes it harder to get the doctor of choice and can drive a higher level of activity as patients return to see the doctor they really wanted to see the first time round.
Many practices are busy and staff feel as though they can never keep up. Their fear has often been that any review will inevitably lead to a dramatic increase in the number of appointments offered – so that their life will become even worse.
The two signs that indicate that the practice is not offering enough appointments are a consultation rate, which is below that of similar local practices and patients who are unable to get an appointment. The question that you must answer is: “Are we offering too few appointments, or are we using those we do offer in a less than effective way?”
In the majority of cases we find practices are offering enough appointments but not using them effectively. It is rare to find a practice that is simply not offering enough. Although, in a small number of practices where the patient perception is that it is very difficult to get an appointment, where appointments are all used up very early in the day, where booking a planned appointment ahead is difficult and where the productivity seems very low, we have recommended and gained agreement to an increase, in most this has not been the solution proposed.
Other things to consider include the ‘new to review’ ratio. Are some clinicians calling people back more frequently than might be expected –bearing in mind that they may have different case mix? All clinicians generate a large amount of their future work by suggesting when a review is needed. One way of checking this is to look at the review frequency recommended in the NICE guidelines. For example, the guidelines suggest clinical assessment is ‘at least annual’ for those suffering mild, moderate and severe (stages one to three) chronic obstructive pulmonary disease (COPD) yet we have found practices and individual clinicians who review all such patients much more often than this.
A second avenue is to look at the balance between same day and book ahead appointments. Patients sometimes find that they are forced down one avenue (typically towards a same day appointment) by the system the practice uses. This can increase the pressure and make it more difficult to plan – for example because it becomes much more difficult to flex follow-up appointments to move them away from the time when staff are on leave.
You should also check that the capacity that you offer is reasonably matched to the demand. Clearly if there are some days or parts of the day that are consistently comparatively easy and others that seem impossible you should look to balance capacity and demand more closely. As we describe elsewhere general practice has considerable scope to plan some of its work for the time when more capacity is available – so you may want to look at how you plan the book ahead appointments to leave sufficient same day slots to meet the predictable demand.
Another possibility is that if a follow-up consultation is with a different doctor that the patient had previously seen, the patient may come back again sooner. All clinicians will have experienced occasions when a patient has seen a locum and then come back soon afterwards on some pretext or another when the underlying reason is probably a feeling that the matter was not adequately addressed or understood by the locum.
There is little evidence that making the process of accessing care, complex or difficult, does anything other than annoy patients and, in some cases, increase demand. Certainly educating, teaching or training people has little impact on behaviour. In general, patients will do what works for them – so the quirks of previous approaches often lead to what might be called ‘learnt behaviour’ among large numbers of patients. The best way to change behaviour is to give them a different experience.
The term ‘managing demand’ is probably unhelpful and the process is best described as responding to demand. There are a very small number of individuals who for a variety of reasons will over use the service. This group probably requires the issues to be addressed via a clinical rather than a process route.
The majority of people only contact the practice when they feel it is necessary. There is a view that if the practice provides even more appointments then demand will increase exponentially. We have not found this to be the case. We have seen many practices in which it is easy to book a same day or ahead appointment who also have lower levels of activity than those in which it is difficult to book an appointment.
One of the main benefits of our primary care system should be that of giving continuity of care. Certainly, it is recognised as valuable and appreciated by patients and seems to be linked to a lowering of acute referrals from practices. However, the delivery of continuity of care in a medium sized or large practice is challenging, especially with the increase in part-time working. The practice can help with this by ensuring doctors do not do a disproportionate share of same day appointments in duty sessions as compared to their overall time commitment.
Dealing with change
GP practices may be relatively small organisations, but their operational processes and the way that patients interact with the operational process is complex, and often changes only slowly as they become aware that ‘things are different’.
Making a number of big changes all at once is likely to lead to extraordinary and potentially unmanageable distortions to the workload and to inevitable disappointment. To avoid this, it is important that any changes that the practice agrees to make are planned as modest steps and that you choose a time when there is sufficient resource available to manage any unexpected bulges in demand.
One further caution is that many practices make a change and, because there is pent up demand of patients who have been waiting to be seen, the immediate effect is an increase that can be difficult to manage.
You should anticipate this and may well want to choose to avoid making change while some staff are away and even to work hard to catch up as part of the preparation.
Taking the call
Our analysis of the telephone demand by hour of the day suggests that we have broadly enough staff to answer phones for most of the week, based on our average call length of 58 seconds.
To reliably answer the telephone promptly (without the caller ringing off) staff need to be dedicated to answering the phone.
While they can do a limited range of other things while remaining by the phone they need to be in a position to stop those tasks and answer a call as a priority (and within 15 seconds), so a receptionist speaking to patients face to face is not dedicated to answering the phone.
We have managed to finally satisfy our patients by keeping a proportion of appointments for on the day acute problems and also blocked sessions to use either by patients requesting an urgent appointment, or after telephone triage by the nurse or GP an appointment for the same day has been chosen.
A happy customer
We always see small children and babies on the day, this also decreases the chance of A&E attendances, and our elderly and palliative are also always treated as high priority patients.
Surveys show that trends change during the year regarding what patients prefer, either by pre-booking or waiting until the day.
We prepare to adapt as necessary and currently are just about keeping our heads above water without too many disgruntled customers.
Sonia Simkins is a practice business manager in the West Midlands.