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How we improved our appointments system

Advanced access meant 8am phone logjams and did not ease demand, so we had to think again, say Dr Jason Victory and Sharron Norman.

Despite change fatigue we needed to devise a better system (Image: iStock)
Despite change fatigue we needed to devise a better system (Image: iStock)

Several years ago, the advanced access system was widely promoted as an efficient way to manage patient demand and to help meet the DH target of all patients able to see a primary care professional within 24 hours and a GP within 48 hours.

Advanced access promoted the ethos: do today’s work today. Key to the advanced access method is measuring demand, matching capacity to demand, managing demand in different ways and having contingency plans.

But it did not work at our practice the Bradgate Surgery in Bristol. It did not take account of patients’ needs and choice, continuity of care or intensity of practice workload. 

Why advanced access failed

Advanced access increased the pressures all round:

  • By 8am our telephones were extremely busy. ‘Let battle commence’ was the cry from all parties - patients, receptionists, GPs and practice manager.
  • Patients were annoyed that they could not pre-book and had to ring on the day that they want to attend. 
  • Patients were dissatisfied when they did not get the appointment time and/or the GP of their choice.
  • Receptionists were seen as the ‘dragons’ always saying ‘no’.
  • GPs were unable to move patients around the system.
  • Booking a convenient appointment was more down to luck than judgement. ‘Phone back tomorrow,’ patients were told if they asked for a time that suited them.

Overwork and confusion

We were working incredibly hard but somehow managing to fail on all fronts. The partners were overworked and confused. Receptionists and nurses were stressed.

Against this backdrop it is not surprising that our patient surveys showed that we were not meeting immediate demand. Neither were we able to offer sufficient appointments in advance – a double whammy for patients and for us.

It became clear that we needed to change the appointment system again, but the staff and patients were suffering from change fatigue and opinions were truly divided.

What we did next

This time we wanted to make sure we got it right and that access at Bradgate Surgery was patient-focused. We listened to patient and staff feedback. Armed with this data we took the initiative.

After all, access is not just about the number and timing of appointments but also the overall patient experience: the patient journey.  

In 2008 we formulated a new business model with core objectives. Patient care, finance, teamwork and development and marketing each had (and still have) a multi-disciplinary team that looks after each objective within their remit.

Making it happen

Each multi-disciplinary team contributed by:

  • Investing in time
  • Profiling demand
  • Training and acquiring of new skills
  • Making improving access a team objective
  • Communicating with patients

We also involved our patients in the decision-making process by setting up a patient participation group. The changes we made – see below and charts – in early 2009 started to work by June of that year.

Our appointments system improvements

Number of appointments

  • Longer afternoon surgeries to meet specific demand.
  • Open surgery sessions if need to be seen on the same day.  
  • Various extended hours appointments – weekday mornings/evenings and Saturday mornings.

Types of appointment

  • Unified clinic for patients with both coronary heart disease and diabetes.
  • More appointments for women with a specialist women’s health nurse.
  • Dedicated INR clinic.
  • Group clinic for first stop smoking appointment.

Focus on patients’ needs

  • Electronic check-in at surgery.
  • Improved telephone system.
  • Booking appointments online.
  • Ordering repeat prescriptions online.
  • Patients participation group views sought.

How well has it worked?

How do you gauge whether an implemented change has worked or not? With our appointments system changes it was not so difficult.

Since 2009 our list size has increased year-on-year and is now at an all time high. Word seems to have got out and the positive effects of improved access are reflected in higher levels of patient satisfaction.

Identifying changes that improve access met all the objectives of our business model. We believe our holistic approach has resulted in multiple benefits for patients and staff alike.

In the new NHS we are facing from 1 April 2013, the challenge of increasing access to primary care services needs to be met by providing patients with an appointment system that is both proactive and reactive to their needs. 

This will help us to avoid unnecessary referrals to secondary care, reduce A&E attendance and facilitate early discharge from hospital.

As a team we are positive about the part that we will play.When local people ask ‘how can I get help with my health?’ we hope that Bradgate Surgery is their first port of call.

  • Dr Victory is a GP partner and Sharron Norman is the practice manager at Bradgate Surgery in Bristol

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