Managing high demands for GP appointments – Walnut Tree Health Centre, East of England

Case study Summary

Walnut Tree Health Centre in Milton Keynes has 4 whole time equivalent GPs serving a patient population of nearly 11,000.  On a daily basis the practice was experiencing long patient queues for appointments, putting pressure on GPs who were already stretched leaving staff to deal with frustrated patients.  To help address the problem the practice participated in the Time for Care programme.  The programme is delivered by NHS England and NHS Improvement and part of the support available through the General Practice Forward View.

The idea

Release unnecessary GP appointments and improve patient satisfaction by implementing the High Impact Actions; active signposting, develop the team and new consultation types.

A common understanding shared by all

The practice manager is a member of the Time for Care Primary Care Improvement Faculty, and used her experience and knowledge of quality improvement tools and techniques to help the team drive forward changes.  Along with a GP champion and members of the reception team, she formed a task and finish group that would discuss the issues, brainstorm and test new ideas and ways of working, whilst consulting the wider practice team for their input and support for new ways of working.

To get a common understanding of what was driving the work the whole practice team discussed and  developed the following shared purpose.

“To improve patient satisfaction of appointment availability from 3.5/5 to 4/5 over four months.”

Is active signposting working?

The team had previously implemented active signposting however, with large numbers of patients still struggling to get a GP appointment they reviewed the current approach and found more could be done.

  • Reception staff experienced difficulties extracting information from patients as to why they needed a GP appointment, making it difficult to signpost. In the future patients will need to provide more details before an appointment can be issued.
  • A telephone message recorded by a GP explained to patients phoning in that reception staff will ask questions to better understand their needs, and ensure they see the most appropriate healthcare professional in a timely manner.
  • All patients were sent a letter explaining the current NHS climate/high demand for GP appointments, and that all patients would be required to provide reception with more information, which would be treated in confidence, when requesting an appointment. This would help the practice make appointments available for everyone who needs them.
  • Information on the practice website was updated to include other services patients could access e.g. pharmacy, travel clinics. Information was also shared with the PPG, who were supportive of the changes being made, and included in the practice newsletter.

Once changes were made to active signposting it helped the team identify other areas to improve.

A new service for patients with MSK

The service would provide MSK clinical expertise, making expert decisions based on assessment and local knowledge.  The physio would either deal with the patient or signpost to a more appropriate service or diagnostic investigation.  Ultimately patients would get access to an appropriate clinician more quickly and GP appointment slots would befreed up for other patients.

The trial was hugely successful.  Over ten weeks the physio saw 125 patients of which 100 were assessed, diagnosed and managed in one consultation, with no further follow up or a GP appointment necessary.  The remaining 25 patients were either booked in for further treatment with the physio or referred to other services.


Developing the team

Following the success of the MSK trial the practice was more confident about making changes and started to think more widely about how they could work differently.  Having struggled to fill a vacant GP post it decided to appoint an in-house paramedic instead to run 10 sessions a week.  The role of the paramedic was to undertake the following that was currently being dealt by GPs.

  • Carry out all house visits.
  • Deal with any paperwork relating to insurance.
  • Deal with all minor illnesses.

The paramedic was supported by the GPs who would be on hand to help and offer advice when needed.

Having a paramedic in the practice has not only freed up GP workload and helped

patients access services quicker, it has also brought a new and valuable skill set that has helped develop the team.


  • Improving active signposting has increased the number of clinical face to face appointments by 182 per week, helping the practice manage patient demand better and clinicians see those patients who need their care.
  • The success of the MSK service trial has been extended from 10 hours per week (for 20 minute appointments) to 16 hours per week. Patient feedback has been extremely positive, “Matt is amazing – so helpful with advice on exercises to do”.
  • Having an in-house paramedic has released 8 hours of GP time per week helping GPs see more complex patients, go home on time and spend time with family.
  • GPs’ and staff morale have improved as the demand for GP appointments has reduced and staff are dealing with less patient frustrations.
  • Patient satisfaction has increased from 3.5/5 to 4/5, achieving their goal. Patients are happier because they are being seen quicker whether it be with a GP or other healthcare professional/service.
  • The practice brings new and innovative ways of working to its Primary Care Network, using tried and tested quality improvement tools and techniques. By sharing and spreading the learning with other practices the network could potentially look at rolling out similar changes across its locality to help improve patient experience and better meet demands for GP appointments.


“If you are going to be sustainable in the long term quality improvement empowers you to do things differently.”Emma Jacobs, Practice Manager – Walnut Tree Health

“It’s brilliant; it’s taken the pressure off us doing home visits, and with the physio it’s much easier as he can provide advice to us and offer a quick diagnosis for our patients along with treatment, advice and support.”Triona Withanage, GP – Walnut Tree Health

If you would like to find out more about participating in the Time for Care programme, along with details on how to apply, visit our web page.