The idea

Review current ways of working to deliver more appropriate appointments that patients can access easier and offer patients more choice.

Identifying the root cause of the problem

With GP lists always full and patients experiencing difficulties accessing appointments, the team collected qualitative data over one week to ascertain the extent of the problem.  The data showed that patients felt they had not been able to cover everything they wanted within a ten minute appointment, and so had to book additional appointments to do this.  Subsequently this clogged up the availability of clinicians.  Clinicians also noted they often ran late as they could not get through everything they needed to cover for the patient.

There were various issues contributing to the problem. To pin these down the team undertook a root cause analysis which highlighted the following.

• Patients did not always need to see a GP; some appointments would have been better dealt with by another healthcare professional.
• The practice’s nurse prescriber was underutilised and could have dealt with some appointments currently seen by GPs.
• The urgent clinics quickly filled up but the majority of patients attending should have had a routine appointment.
• Staff at the front desk felt compelled to book an appointment straight away, because the waiting area is nearby and other patients can hear what they say.
• Staff felt it would reflect badly on them and the practice if appointments were turned away or signposted elsewhere.
• Self-care and signposting were not being encouraged. The information that reception used was vague and limited to a small number of symptoms.
• The booking of online appointments was low. Most appointments were either made by phone or in person, which gave reception less time to review and make a decision as to whether they were appropriate.

Greater insight into the reasons for so many inappropriate GP appointments gave the team a strong basis from which to start making changes to the way they worked.

Addressing the issues

An implementation plan was drawn up and agreed with the team. It broke down the issues and how the team intended to address them.  Small cycles of change were tested and refined for each area until staff were confident the changes were resulting in improvements and could be sustained in the long term.

• Information on the practice’s website was updated with advice about other services, self-care and when patients should see a GP.
• The signposting flow chart that reception use has been updated. This now includes more services and healthcare professionals that patients can be appropriately referred to, including redirection to the nurse prescriber.
• Unless an appointment is deemed urgent patients are now allocated a routine appointment.
• The phone has been moved away from the front desk so patients can no longer hear calls, giving staff time and space to confidently ask for information about why an appointment is required, and allocate or signpost accordingly.
• Staff proactively encourage patients to book appointments online. A new practice leaflet was produced that patients can use to help them, as well as a registration form. A note also appears on reminder cards and new patients are automatically encouraged to register online from the outset.

Helping GPs change working practices

Alongside the above changes the GPs have made additional changes to the way they work.

• All recalls are scheduled by GPs themselves at the end of the patient review, saving the patient from having to return to reception and for reception to schedule the review.
• Most of the GPs have extended their appointments from 10 minutes to 15 minutes per appointment, allowing time to see the patient, complete the appointment and deal with any admin immediately. This avoids a build-up of tasks towards the end of the day.

At regular practice team meetings staff are reminded of the changes made so they do not slip back into old ways of working.  This provides an opportunity for the team to raise any issues that need to be discussed.

Impact

• Reducing inappropriate appointments (those that can be seen and treated either through self management i.e. purchasing medication at a pharmacy, or by another more appropriate healthcare professional), has released over 600 GP hours a year. The time released has enabled GPs to spend more time on complex cases, hold a number of their own caseloads over the longer term (as they now schedule their own recalls) and run dedicated specialist clinics that they were unable to before.
• Over 1,200 hours of admin time has been released across the practice team for clinicians and administration staff through streamlining processes, self management, and reception staff covering bookings and calls. The released time has given the practice an opportunity for two members of staff to undertake healthcare assistant training and to spread some other areas of workload more equally across the team.
• GPs feel they have adequate time with the patient and are now able to complete any onward administration without it building up. Scheduling recall appointments promptly with patients allows them to be called back regularly allowing for better monitoring and prevention.
• Patient choice has increased. They are better informed of the different services and healthcare professionals they can see and that an appointment with a GP is not always necessary.
• Appointments are now released 48 hours in advance, giving patients more time to access them.
• Staff feel a sense of achievement. They are positive about the benefits achieved and have a real belief that change is happening in the practice.

Staff have become more positive in embracing change and improvement.  There is real determination across the practice team now to keep moving forward and progressing.  Challenges are dealt with positively and not seen as a block.

Sarah Herdman, Practice Manager, Chiswick Health Practice

If you would like to find out more about how you can access the Productive General Practice Quick Start programme, visit our ‘Releasing time for care’ web page.