How overhauling our appointment system helped increase work life balance

A Bristol practice that made the decision to offer patients longer GP appointments actually improved the work life balance of its GPs. Beth Gault finds out how

GP practices are increasingly being told they need to do more. Increase access for patients, see more people face-to-face, and expand opening hours .

Practice manager at East Trees Health Centre, Bristol, who was shortlisted for Practice Manager of the Year in 2022, Val Denton, says her practice got to the point in 2020 where the GPs felt  ‘desperate’.

‘They were tired, and they could just see that the pressures on their very long triage lists were growing and growing,’ says Val. They became call handlers, filtering out what did or did not need to be seen.  ‘It forced us into taking a radical step. I said to the team, “It can’t get any worse. Let’s throw our appointment and triage system out of the window so I can redo it.” ’

This new system included going from 10-minute GP appointments to 15-minute appointments, ensuring every GP had their own patient list, and limiting the number of hours GPs worked per day. 

‘It’s a mindset change,’ says Val. ‘I do think some practices struggle with the idea and think that although they’d love to have 15-minute appointments, believe they can’t because they’ll be short of slots.

‘But if you set up the right appointment system to make sure it isn’t rigid and train receptionists to navigate or signpost, then you have the flexibility to juggle the appointments.’

This, she said, has resulted in fewer patient complaints and better job satisfaction for GPs and practice staff.

‘I’m not saying it works amazingly well all the time – we do have problems and we’ve tweaked the system a bit. But there is capacity to be able to move things around and see patients when it’s urgent,’ says Val.

So, what does this new system involve and how did the practice manage the transition?

Beginnings

The overhaul at East Trees started with a merger of two practices – Maytrees and Eastville – in April 2020. Although they were both housed in the same building until then they had remained as separate surgeries.

‘The merger was a big thing,’ says Val. ‘Before, we were two entirely separate practices working in two different ways. One side had two partners, the other had three, and both worked very differently.’

In Maytrees, there were 5,000 patients and the staff knew them ‘intimately’, she says. The partners worked all hours, everything went via them, even paperwork and results.

On the other side of the building at Eastville, there were double the number of patients (10,000) with two partners and a few salaried GPs, who didn’t have their own patient lists.

It took until the end of the year to fully merge the two practices.

‘The first thing we did was to look at everybody’s roles,’ says Val. ‘We had to reinterview and streamline some roles, which was tough because we had to lose a few people.’

The next step was reviewing and improving procedures and systems. It was decided to put in place a reception hub consisting of receptionists, prescription clerks and care navigators who could signpost, so the doctors only saw patients that really needed to be seen by them. 

The new practice also developed an admin hub to relieve GPs of admin tasks to free up their time.

A more strategic review looked at the hours GPs were working and the amount of time they spent with patients. To look after wellbeing, it was agreed that GP working hours should be reduced, but it was also decided that the time patients get with a GP during an appointment should be increased.

GPs now have a greater amount of time to listen to the patient and deal with their concerns, and the patient is less likely to come back for a repeat visit, according to Val.

‘We aim to allow doctors to work a nine and a half hours day,’ says Val. ‘6:30pm is also the latest they should work, and we have no duty doctor. Usually, a duty doctor is present to pick up the overspill of patient requests, but we decided it would be better not to have that arrangement so all the doctors see patients from their own list.’

GPs either start at 8am and finish at 5:30pm or start at 9:30am and finish at 6:30pm. They have built in coffee and lunch breaks, home visit slots, and if they work a Monday, they don’t work a Friday as a rule.

‘You have to have work life balance,’ says Val. ‘And we have found that it works. For example, our patients haven’t noticed any change when trying to get an appointment. If they see their own GP for most things, they’re quite happy.’

Ensuring that each GP has their own patient list was also a key change made during the merger. It has retained the original ‘family feel’ of the Maytrees practice.

‘Maytrees has really added something special to Eastville in terms of continuity of care,’ says Val. ‘We’ve got better at this in the past 12 months and now our GPs have their own lists.

‘We encourage patients with ongoing problems to see that GP. Of course, if it’s urgent they’ll be seen by anybody. But it’s really helped improve access as our GPs are getting to know their patients and they only have a list size of about 1,500. We review this quarterly to keep the status quo.’

The practice offers extended access every other Saturday and has specific ‘GP continuity slots’ built into routine sessions that can only be booked by the GP doing the consultation for a patient requiring a follow up appointment.

However, the key to making all this work is ensuring flexibility in the system, says Val.

‘It’s manageable because it’s flexible,’ she says. ‘We’ve empowered navigators to know that the appointment system isn’t rigid. If you’ve got an extra appointment because there’s a sick child, you flex the system and juggle the appointments so you’re never giving the doctor extra work.’

But she adds that navigation is ‘only as good as your appointment system’. It has to be constantly monitored and reviewed.

Starting the switch

Making such a big change to the appointment system required a transition period. The practice brought in locum GPs to first try and clear a backlog of appointments. Two weeks’ worth of appointments were also cleared in order to implement this new system.

Val explains: ‘We told the navigators that during that two weeks they could give everybody an appointment but that they needed to start to send patients to other health professionals as well,’

The wider healthcare team comprises a prescribing hub with pharmacy technicians and a clinical pharmacist, care coordinators, HCAs, nurses, clinical admin support, a physio and podiatrist.

‘We now routinely only book up to two weeks for appointments, and we always have urgent on the day appointments available as well,’ she adds. 

If GPs are absent because they are sick, patients are re-triaged and asked if they want to be rebooked onto their own doctor’s schedule or if they want to see someone else more urgently. The practice also uses the occasional regular locum to manage if demand is high.

In addition, the surgery has held several ‘community open days’ where they invite patients to access services relating to a specific condition, such as diabetes, on a drop-in basis.

‘We capture an awful lot more patients on those days than we would by trying to get them to attend an appointment. It was down to the fact they had the flexibility of just walking in anytime from 8:30-5pm.

Val adds: ‘I’m looking to develop that and do a pilot project with a roving nurse in the practice. This is so when a patient seeing a GP also needs a foot check or blood test, there’s a nurse available who can do that then and there, which will save the patient coming back another time.’

A big difference

The start of the change process may have been difficult but the practice is now running well, Val says.

‘I used to get a lot of complaints from patients when I started who would say, “I can’t see my doctor, the phone lines are too busy, I can’t get an appointment”. Now, I very rarely get any complaints,’ she says.

That said, she admits, phone lines remain busy as always and patients still tend to think they have to see a doctor for most things.

Val concludes: ‘We make a really good team. The partners are really supportive and allow me to get on and manage. We all work closely together and there’s no real hierarchy in the practice. It took a long time and involved some difficult conversations to reach this stage, but we did it.’