General practice (GP) appointments are a nightmare.

I can never get one at my GP when I want one, and I’m not that choosy over which doctor I see either (I only refuse to see one GP at the practice of 8 GPs, as she  is a personal friend of mine, and that would just irk me a little.)

According to the advance access protocols and Department of Health guidance, a patient should be able to have an appointment with a health professional (GP or nurse) within 48 hours. This includes telephone triage and face-to-face (f2f) consultations.

I have had the benefit of working in several areas, all with different methods of allocation appointments to patients. I have yet to come across one that meets the ‘patient demand’, and satisfy all parties involved. In truth I personally believe that the patient demand itself will never be met, and that such a task is impossible, but that is beside the point.

In talking about appointments I thought I would round up my experiences (biased I will admit) to see if anyone else knew of a better way.

Practice 1- List size~5000:

Free for all:

Patients turn up in the morning, and wait. All who turn up will be seen in morning clinic as long as they register in person before 10am. Patients could choose which clinician working on that day they see, however if skewed to one clinician more than another (normally only two GPs and a nurse practitioner (NP) per morning working) then the reception staff would actively try and convince patients to shuffle over citing long waiting times.

The afternoon clinics were all for chronic care, booked mainly by the clinicians for follow-up, with a few slots for patients to book before hand, though this was limited.

Patients in one sense loved this format, as they knew in the morning they turn up and see a clinician, though disliked that they had to be up in the morning and wait to be seen, occasionally bringing on AE waiting room anxiety.

The clinicians perspective varied but more towards hating it. In one morning 15- 30 patients could be seen depending on the mood of the population. This is on top of duty doctor roles, chasing phone- calls and helping other staff i.e. NP or the practice nurse if something was wrong. It also meant a high chance of ‘dross’ (stuff that really did not need to be seen).

The reception staff generally found the morning busy but pleasant with no real stress until the afternoon calls for urgent appointments.

Summary- Patients generally liked it, doctor hated it, met ‘demand’ easily. Limited DNA in morning, higher chance in afternoon sessions.

 

Practice 2- List size ~10000

70/30 split:

Here the appointments work on the basis of 70% of the appointments for that day are book on the day, and 30% are pre-bookable by reception staff or doctors, in conjunction with patient demand. This meant doctors could arrange their own follow-up, or refer in-house with ease.

For patients, it meant they are likely to be seen on the day if they call early enough. A downside for the patient is that with so few pre-bookable appointments, the popular or more long standing doctors tend to be full much earlier in advanced, so then seeing the clinician of choice may not always be possible. This leaves a patient with an option of calling on the day for an urgent appointment with the clinician they want for what could be a non-urgent issue, or seeing someone new. Significant issue for continuity of care.

For the doctors it meant a significant portion of appointments were available on the day to cope with the 48 hour rule of access. This generally worked well, however suffered if there were not enough clinicians around that day for a ‘normal’ day, i.e. generally more appointments are needed on a Monday compared to a Wednesday. It also meant however with no triage that you could potentially see a lot of ‘dross’, in that the standard cough/cold that could have waited might take up an appointment on the day that a patient with an acute abdomen needed, purely because they got in there first. This could reflect upon the duty doctor role, as any urgent appointments would then be dealt by them or as extras.

For reception staff, it generally worked well till the appointments were booked, and then was an issue of negotiating if a patient really needed to be seen on the day and go via duty doctor/ as an extra, or meant they had to appointment find for a patient to be seen by their clinician of choice. However in comparison to other models, this was generally less stressful.

Summary– System that tends to work when everyone there, less so when short of clinicians, but massive effect on continuity of care, and high possibility of ‘dross’. Limited on the day DNA, but higher for the pre-bookable.

 

Practice 3- List size ~9000

Telephone triage:

Here the majority of appointments on a day with a GP or NP are book on the day with about 40% pre-bookable. The difference between this and the above apart from the ratio split, is that the book on the day appointments are ALL telephone triaged by a clinician on the day. Patients are advised and reminded to call between 8.00- 10.30 am and are placed onto the telephone triage appointment. Here the clinician then contacts the patient back and attempts to deal with the patients concern. If they feel this needs a f2f then this is booked into the appointment slots as agreed.

For the patients from my experience they tend to hate it. Having to call up for an appointment to be put on the triage list, then await a call back can be frustrating. It also leads to this expectation of what appointment the patient is getting, and also how the patient wants to be dealt with. It would not be a far cry to assume more elderly patients would prefer a f2f rather than dealing with something over the phone. The communication aspect also raises issues of confidentiality i.e. calling people back at work, or arranging appointments that the patient can make, and in reliability, i.e. patients picking up the phone, having the right phone number etc. However if advertised to the patients well it should reassure them that they will be seen when they need to be. The difficulty is managing the individual patients expectation of being seen, over the clinicians perception of needing to be seen. Also an issue of whether patients see a telephone appointment the same as a f2f in terms of encounters, especially when assessing access (GP survey).

For the clinician, well there two to consider. For the clinician doing the telephone triage, it can sometimes be a daunting list to get through, and requires confidence in handling uncertainty and experience in knowing what needs to be seen, what can wait, and what can be dealt with over the phone. For the clinician seeing the patients, it should mean of the ones booked on the day, are patients that needed to be seen, and unlikely any ‘dross’. It also means you are less likely to get any DNAs from that subset. The pre-bookables are therefore your standard issues. I must point out there is also nothing to stop the triage clinician from seeing patients they have talked too, however this does require good time management skills. Finally if a practice uses this system and the stops on a day i.e. staff shortages, then it can lead to chaos and rapidly a lack of appointments making the duty doctor role a potential nightmare.

For reception staff, they tend to get a high workload during the hours of the telephone triage booking, as all appointments made by phone. They undoubtedly will also get patients complaining about the system, or calling back as they missed the call from the clinician.

Summary- Manages number of f2f appointments well and limited ‘dross’. Patients generally don’t like it, and need to be confident managing uncertainty. Limited DNAs.

 

Practice 4- List size ~12000

Rapid Access Clinic (RAC):

Here clinics are generally more 70/30 split with pre-bookable as the former and less book on the day appointments available. Separate to this a clinician then runs a separate clinic which patients can be placed onto or request to be seen in on the day. In this clinic they get 3-5 minutes to deal with a SINGLE problem, of which this is highlighted to them when they book.

For patients, they were reassured in the sense they knew they would be seen that day. It did mean however that there was a likely chance they might have to see on the day a clinician they did not want to as that person is running the RAC clinic.

For the clinicians it is a mixed bag. The clinician running it generally might see up to 40 patients in some cases, and the key issue is dealing with things in such a short time frame, some could be shunted into the remaining clinics running, but invariably there will be patients presenting with either a complex problem that needs time i.e. mental health/ hospital admission, or the patient despite being told about the clinic still brings a list, which then requires the clinician to really manage expectations well in order to get through the list. For the other clinicians it generally meant less ‘dross’ but also meant a lack of quick appointments that can be useful for catch ups or breathers that occur in the standard working day. However it could work as an effective way of reducing the number of appointments needed, particularly for a large practice.

For the reception staff it means a busy morning having to make sure patients know it is one problem only for a RAC appointment, and also dealing with the storms when this doesn’t happen. It also puts some responsibility on them to check patients seeing the right person, questionable if that is appropriate.

Summary- Patients get seen, busy for RAC doctor, but the ‘dross’ is seen in appropriate places, but could lead to more DNAs with more the greater number of pre-bookable appointments.

 

There are several other methods I have seen, one where the non-clinical reception staff triage patients (bad bad bad bad bad bad bad……..if you do not know why this is so bad please stop reading, you are barred!), and a few which are mixes of the above. If you feel there are more please comment and let me know. Please note this deliberately avoids going into issues with duty doctor roles, and visits…that a whole other blog.

If I was put on the spot, I would say a combination of practice 2 and 3 might be best for handling patient demand, but all the staff would have to be behind it to work (uncertainty and unwillingness a bad combination). However as I mentioned at the start, I have yet to see a system which meets the patient demand and satisfies ALL parties involved. If anybody knows of one, then you just haven’t asked the right people. The key reason why, is that all practices are unique anyway. The make up of clinicians, the population area and patient expectations all create such variations that in truth no one system will work for everyone, and in truth someone will always find a hole or a problem with an existing system.

But it would be fun to find one that did. Fun being a nightmare that you just can not wake up from (see opening statement).