It is now one year since our practice adopted a radical new approach to providing access to GP appointments.
Increasingly, our reception team had been telling us ‘there are no appointments available’, which basically meant we were more or less booked up for routine appointments for the following week.
The provision of a few ‘same day’ appointments allowed us to manage some of the demand for urgent care but, increasingly, we were having to advise patients who felt they needed to be seen the same day that the local walk-in centre was their best option. Many were resorting to attending the A&E department as their means of accessing primary healthcare.
Call back service
The approach we decided to adopt is best described as rapid response telephone consulting. It is based on the Stour Access System, first developed in 2,000 by Stour Surgery in Christchurch, Dorset. Since then, it has been tested in practices across the UK.
The model essentially involves an experienced GP phoning back all patients who call the practice to request a GP appointment, within one hour of their request. Basic details of the patient’s problem are recorded by the receptionist who also notes whether the patient would prefer a specific doctor to call back.
A GP speaks to the patient over the phone and undertakes a telephone consultation. The result is that well over 50% of problems are addressed during the phone call, usually within five minutes. Where the patient or the doctor feel a face-to-face appointment is needed, this is offered, with same day appointments being the norm.
Nurse appointments can still be booked in advance, but all GP appointments are triaged via the new system; retaining some advance GP appointments, and running a hybrid system, would not work. It is important to have a launch day providing a clean slate with no advance GP appointments booked, followed by close monitoring of capacity and demand.
The benefits of the system are obvious to patients, who are not only amazed to hear the reassuring voice of one of their own GPs so promptly, but delighted to be able to see their GP the same day when it is needed.
Most patients who are happy to have their problem dealt with over the phone are pleased to avoid negotiating with receptionists for an appointment and to have their issue handled quickly and efficiently by a doctor they know. The patient satisfaction with the new approach has proved extremely high with more than 95% preferring the new system, according to feedback. DNAs have been almost eradicated.
Benefits to patients include:
- Transformed access: 'see your GP today'
- A convenient, stress-free system
- A rapid response
- Improved safety
- Improved continuity of care
- A preferred model (according to feedback)
The GPs are finding the new approach beneficial, having gained a sense of increased control over daily workload and improved job satisfaction has been expressed by most in the practice team.
Benefits to the general practice team include:
- Efficient use of GP time
- Appropriate use of skill-mix
- Greater control over GPs' daily workload
- Reduced risk
- Reduced home visiting
- Reduced DNAs (almost none)
- Greatly reduced stress for the reception team
- Reduced complaints and high patient satisfaction
- Team development and improved communication skills
However, moving to this system does require a radical change in the mindset of the GPs and significant upheaval. It can be difficult to bring everyone on board at the outset; one objection voiced by some colleagues was that they ‘had not trained to become receptionists’. Implementation requires strong leadership and is easier to undertake in a progressive practice.
Instead of sitting in a surgery and responding to the needs of patients who have managed to obtain their 10-minute booked appointment, GPs now have to respond to the varying demands promptly and efficiently, drawing on the considerable skills required to consult safely over the telephone. Training in telephone consultations was undertaken to help prepare for the change of focus.
Resourced by our CCG, this was provided by an independent healthcare educationalist, and comprised multi-professional and inter-practice training, which encouraged many local practices to engage in more telephone consulting, though none felt able to implement the full rapid response telephone consulting model. We ran four half-day sessions which most GPs and many nurse practitioners attended.
There are considerable skills involved in effective telephone consulting, such as the compensatory telephone behaviours that make up for the lack of non-verbal cues and the recognition of para-verbal clues. In addition to the development of these skills, the training generated camaraderie which we felt would encourage future federated practice in our locality.
We all shared concerns that it might be risky to consult over the phone but it quickly became apparent that the benefits of a system which involves a quick response by an experienced clinician far outweigh the risks of the initial contact being by phone.
The access to patient records and low threshold for offering a face-to-face appointment certainly reduce risk but we are realising that the most crucial safety feature in this system is the fact that patients are able, rapidly, to speak to a doctor they know and trust.
Reducing pressure on A&E
Rapid response telephone consulting has revolutionised our patients’ access to GP care and is resulting not only in significantly increased patient satisfaction but in happier practice staff. Local A&E attendances are falling and we are confident we will achieve the predicted 20% reduction that most practices using this system are seeing. The evidence suggests unplanned admissions are significantly reduced, largely through improved continuity in care.
Benefits to the wider NHS include:
- Reduced A&E admissions
- Reduced unplanned hospital admissions
- Increased collaborative working between federated GP practices; between GPs and the CCG; and GPs and the community/local authority
- NHS111-and-future-GP-contract proof
- Greener: fewer car journeys to GP surgeries
So if rapid response telephone consultation works well, why are so few GP practices adopting this system, particularly in the face of increasing patient demand and expectation, tougher contractual requirements and increasing political pressures?
The simple answer is the cost and effort involved in implementing it and the fact that the benefits are mainly felt by reception staff, A&E departments, CCGs and, of course, by the patients. There is no denying that it is hard work for the GPs, especially early on.
Like many practices attracted to this radical system change we opted to engage with one of the businesses that facilitate its implementation, using an organisation called Patient Access, although another key player in this field is Doctor First.
It was certainly helpful to have outside support and expertise and access to convincing data on the benefits of this approach. The need to monitor the varying demand day-by-day and hour-by-hour is critical to success, with GP capacity fitting around demand, rather than around GP availability or convenience.
Receiving early support from Patient Access in monitoring the metrics of capacity and demand, plus the reactions of patients and the team during the transition period, was valuable. However, it was also expensive, costing the practice several thousand pounds at a time when, like most practices, we are under considerable financial pressure.
The cost of implementation is not only financial: to be successful, this radical change requires a dedicated and influential lead (ideally with very thick skin) and a practice committed to high-quality care. An effective clinical and administration team is vital.
Future of general practice
Is this access model the future of general practice? Certainly the RCGP has stated in its 2022 vision document that ‘delivering appointments in 10 minutes slots for all patients is outdated’ and that GPs of the future will need to offer ‘flexible lengths of appointment, determined by need’.
Meanwhile, ministers are demanding seven-day patient access to GPs, with prime minister David Cameron calling on pioneer practices across England to come up with ‘innovative’ schemes that enable patients to access GP services over extended hours. There are strong indications that a new GP contract will be less about ticking boxes and more about delivering high level indicators of success including excellent access, reduced A&E attendances and reduced unplanned admissions to hospital for ‘at risk’ patients.
Rapid response telephone consulting is one potential solution to the future access challenges facing GP practices. My own take on the ideal model is for federations of GP practices to adopt this system as communities of GPs, where leadership, expertise and clinical and administration resources are shared, and patients within local communities have ready access to primary care.
I really do have a dream that one day patients will say ‘the great thing about my GP practice is that you can always get an appointment when you need it.'
- Dr Ashley Liston is a GP in Tyne and Wear