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14 November 2011

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The access dilemma

Creating more appointments incurs large costs at the wrong time, says a Practice Management Network (PMN) member…

‘Access’ can cover a multitude of areas – from the ability to get through on the telephone or getting an appointment with the ‘preferred’ clinician to being seen within the perceived need of the patient – but here I’m considering the total availability of appointments.

Appointment availability is influenced by a multitude of factors, some within our control and others beyond it. Demand due to influenza campaigns, long-term condition reviews and general health checks we should be able to manage.

Peak demand, due to issues like a combination of public holidays – like this year’s Royal Wedding – or pandemic issues, such as the over-hyped swine-flu campaigns a few years back, may be more difficult.

The challenge of finding enough appointments to achieve the guidelines of our PCT or the Royal College of GPs (RCGP) can be a problem.

If guidelines are not met then ‘performance’ issues can arise! The PCT has a handle to interfere and minutely examine all aspects of service, particularly when allowed in for Quality and Outcomes Framework (QOF) and other visits.

What are the guidelines in our patch?

  • PCT – 72 face-to-face GP consultations per 1,000 patients.
  • RCGP – 5.3 patient contacts per patient per annum.

Our practice offers telephone consultations, a good number of prescribing nurse triage appointments and has a healthcare assistant. All these involve ‘contact’ with patients, hence our preference for the more encompassing RCGP access interpretation.

But why is this a challenge? Possibly because of:

  • The popularity of the practice.
  • Growth in list size.
  • Growth in the number of patients per whole time equivalent (WTE) doctor.
  • A high prevalence of patients with specific long-term conditions.
  • We are a GP training practice with the associated workload and impact upon appointments.

As the list size grows, the traditional model of adding another GP – whether salaried or a partner – incurs large costs, which in turn are usually covered by increased list size.

You see the conundrum: a vicious circle, which impacts upon team working, staff workload and individual profit shares. At this turbulent economic time, adding a big-ticket expense when the QOF is under intense review, enhanced service income could be diverted through Any Qualified Provider and the Carr-Hill formula is to be reviewed probably needs avoiding.

Alternatives that could come under consideration are:

  1. Grabbing the nettle and sticking with the traditional additional GP model.
  2. Upsetting the PCT and moving to an ‘open but full’ list and then considering alternative juggling of GP appointments.
  3. Getting existing GPs to offer more than the standard eight-session (full-time) week.
  4. Taking on additional GP registrars – albeit GP partner appointments will dip for ‘training’.
  5. Increasing the productivity of our limited nursing team.

None of these alternatives is pain-free. Each has a serious downside, whether a reduction in partner income, political difficulties with the PCT and beyond, a reduction in the work/life balance against the desired direction of travel, increased training workload or nurse unrest if they feel dumped upon.

Knowing the potential options as well as the individual pros and cons of each leaves the choice to the consensus of the partners of the practice, but all will undoubtedly have a knock-on impact upon the employed staff as well as the patient users!

There are no easy answers, but if you’ve gone through this dilemma why not share the solution you found and why you opted for what you chose?