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Goodbye to access targets

Daniel Brookbank is enthusiastic about re-designing the appointments system to meet clinical needs.

Patients who could not get through on the telephone early enough were forced to try another day (Photograph: SPL)
Patients who could not get through on the telephone early enough were forced to try another day (Photograph: SPL)

The government's decision to scrap the 48-hour access to GPs target introduced by the previous administration is good news for practices and patients.

The 48-hour access target was introduced to speed up waiting times as patients were telling the government they wanted to see their doctor sooner.

Unfortunately it ran roughshod over appointments based on clinical need and brought about a system where those who shouted loudest got appointments the quickest.

Health secretary Andrew Lansley said last month: 'I want to free the NHS from bureaucracy and targets that have no clinical justification and move to an NHS which measures its performance on patient outcomes. GP surgeries now have an opportunity to re-design their appointment system based on real clinical issues'.

This is exactly what the GPs and staff here at the Seaside Medical Centre in Eastbourne plan to do.

Priority slots
So how will we approach this? Patients who actually need an appointment because of a longstanding clinical issue or an emergency can be prioritised.

In the past we audited the numbers of appointments offered and then balanced the amount available 'on the day' against those booked in advance.

This created a mad rush by patients first thing in the morning to get appointments with none free for those contacting us after 9am.

Patients who could not get through on the telephone were forced to try another day or to lie that their condition was urgent. We now have the opportunity to look at what our patients need.

It may be that a selection of early morning, late evening and Saturday morning surgeries would be more flexible, or that having an emergency doctor available every day would be better. Patients with long-term conditions who need to see a GP regularly could be offered a priority booking system.

For example, they could be given a code number to identify them to the reception team when they ring up and have special slots put aside for them.

Our practice nurse could run minor aliments clinics for patients rarely seen or the 'walking well' to give them the reassurance without taking up a GP's time. The surgery might consider having specialist slots for particular diseases, similar to the diabetic clinics currently running. If, for example, a GP has an interest in cardiology offering a cardiology clinic may be a good idea.

Or possibly a GP colleague at another surgery could work with you in particular areas or a local practice nurse might have an interest in a specific disease that could benefit more than one surgery.

After years of a 'target approach' to medicine we have an opportunity to look at what is right for our patients from a clinical perspective. So it is time to look in detail at what we do.

Communication
I suggest GPs talk to their staff, colleagues, other practices and especially to their patients. One idea is to organise a conference with the patient forum and any other patients interested in coming along.

Or how about a questionnaire either sent out to patients or collected in at the surgery? It might be worth talking in particular to those patients who come in frequently and find out what would help them. How would they like to access their GP?

Consider what it is that the practice wants to achieve from a new appointments system.

Practices can mull over the problems of the current system and look back over the complaints patients have made about it.

What would make life easier for patients with serious conditions? Auditing how often and when they currently come into the surgery and asking them if this suits them will help clarify changes to assist them. Looking at how many emergency appointments you do each day on average. Seeing if they were actually necessary could be quite an eye-opener.

You may find that some people say it is an emergency just to get an appointment as soon as possible.

Clinical perspective
It is important to make changes to the system from a clinical perspective. Every decision and every change practices introduce should have clinical weight behind them. The service GPs offer is about clinical care so this is top priority.

When introducing a new clinic on a Saturday morning, for example, is this because patients tell you that they can only attend on a Saturday morning?

Or are there patients who need to be seen at that time? If it is about pure convenience and not about clinical need, what will the impact be on access at other times?

Just like everyone else, GPs have to balance their time. So could offering Saturday morning appointments jeopardise running a surgery session on a day and at a time more suitable for a group of patients with clearer clinical needs?

  • Daniel Brookbank is a practice manager in East Sussex
Changes to Consider

Being more flexible with appointments by:

  • Offering a range of appointment lengths at different times and on different days.
  • Having a priority booking service for patients with long-standing and serious illnesses.
  • Setting up nurse-run minor ailment clinics.
  • Making special slots available for particular illnesses.
  • Allowing GPs with specialist interests to take on and run clinics.
  • Having an emergency doctor on duty each day
  • Looking into working with other local practices.

Seaside Medical Centre's Action Plan
We will:
  • Audit our current system.
  • Speak to staff, colleagues and patients.
  • Organise a patient conference.
  • Audit our regular users.
  • Look at our current emergency appointment numbers.
  • Look at the complaints we have received about getting an appointment.
  • Put clinical need at the top of our agenda.

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