Case study summary
Edge Hill Medical Centre in Liverpool is made up of 6.5 whole time equivalent GPs, serving a practice population of over 9,500 patients. The practice team was experiencing issues in providing appointments and having to turn a significant number of patients away each day. To find ways to overcome this it participated in the Productive General Practice (PGP) Quick Start programme delivered by NHS England’s Sustainable Improvement team. The programme is part of the Time for Care support available through the General Practice Forward View.
Redesign the appointment system to increase the number of GP appointments available each day and reduce the number of patients turned away.
A system not working for staff or patients
The practice collected data over one week recording how many patients visited the surgery for an appointment, whether it was emergency or routine, and the number turned away due to due to lack of appointment availability for non-urgent problems such as renewal of sick notes or coughs/colds. Of 150 appointments available each day on average 29 were not used, a further 27 on average were turned away. The team looked more in-depth as to why the reasons for this were and found the following.
- The ratio of routine appointments to emergency appointments was not working, on average there were 56 routine appointments available per day to 28 emergency. This resulted in routine appointments being booked quickly and plenty of emergency appointments left each day.
- The script used for emergency appointments was too restricted. Only patients who came in towards the end of the day and likely to need to go to A&E, and those whose condition had seriously deteriorated were accepted.
- Overall 29% of appointments were inappropriate, of which 53% were GP appointments. Some of these could have been seen by the practice’s AHPs (Allied Health Professionals) however, the AHPs were not always confident in dealing with certain appointment types.
- DNA rates were high largely due to six patients who had special needs. Often these patients were unable to get appointments on the day and were issued one for two weeks’ later which they would not attend.
Patient frustrations at not being able to book an appointment impacted on the welfare of staff. During one week 30 incidents were reported where patients either became agitated, angry or aggressive towards staff.
The lack of available appointments was an ongoing agenda item on partner meetings however, over time it had become accepted as the norm. Being presented with the data and factors creating the issues, the GPs were shocked to learn the extent of the problem and accepted changes needed to be made.
Restructuring the system
The practice team restructured the working week for the whole clinical team including nurses and AHPs. Ideas and changes were discussed at the weekly MDT (multi-disciplinary team) meeting that includes a GP, AHP and reception, to get a good spread of practice team feedback. After testing a range of solutions the following changes were made.
- All AHPs were given training and a list of appointment types they could now see, including mental health reviews (excluding complex needs patients) and exacerbations of chronic diseases. An on-call GP is available each day who they can go to should they have any issues.
- Patients with special needs now have an alert on their records stating they should be issued with an appointment on the day.
- The emergency appointments script has been extended and includes signposting to other more appropriate services.
- The practice only has one emergency GP on per day which is adequate.
The changes made have helped the team achieve the following impact.
- The practice has increased GP provision by 15%, this is an increase of an average of 57 appointments per week equivalent to a 0.5 whole time equivalent GP.
- Inappropriate appointments have reduced across the practice by 40%, of these 26% were for GPs.
- Due to the improvements made the practice has put on hold plans to employ an additional GP, giving it a cost avoidance of at least £60K.
- Patients are now getting easier access to appointments. Previously 30% of appointment requests were turned away each day, these are now used or the patient signposted to a more appropriate service.
- GPs and staff are really pleased and enthusiastic about the changes, their working day is less stressful and the team is much happier.
We’ve learnt that getting everyone together and using a process to tackle issues has really helped us to solve all sides of the problem.”
Dr R McGuire, Edge Hill Medical Centre
We’ve achieved more than we ever thought we could.”
Angela Broda, Practice Manager, Edge Hill Medical Centre