We are a medium size practice (10000 patients) with 6 partners, none of whom work every day of the working week. We weren’t satisfied with our appointment system and it seemed from the comments we received neither were our patients. We had moved a number of years ago to a same-day, ‘doctor first’ appointment system where all requests had to be managed that day through the on-call doctor but had found that the demand made this unsustainable. It was becoming chaotic. We had developed this system after hearing of similar systems elsewhere and though we were aware there were certain aspects we had not adopted, it was not working for anyone.
We were particular worried that individual relationships with our patients were suffering and subsequently, the continuity of care we cherished. We wanted a system founded on continuity and led by patients that was still efficient enough to avoid us feeling out of control.
It was the only item on the next partners meeting. Opinions were different and feelings mixed but after a prolonged discussion we had designed something that everyone was comfortable with. Some of us were worried that we would ‘open the floodgates’ or possibly create demand, others that we would increase risk or not be using the team efficiently.
Person-centred continuity appointment system
This system does not differ greatly from some others described but its primary purpose is about promoting continuity as much as it is about managing demand via triage. We no longer try to manage all the requests for care on the day, allowing the patient to decides if they wish to wait for their usual doctor or opt to speak to someone sooner. The only real point where triage takes place is when the receptionist hears why the patient is calling and alerts the on-call doctor if they are worried, much like traditional appointment systems. The system results in a daily list of telephone calls for each doctor plus an on-call list. As our aim is to support relational care and continuity, sometimes a patient who does not initially feel able to wait is later booked in with their usual doctor after some reassurance or advice.
The on-call doctor must ensure that the available appointments on the day are utilised fully but if appropriate can also use future appointments. The other doctors book into their own appointment or agree other ways of managing the problem with individuals. There is also an agreed responsibility for all the team to help out the on-call doctor if required.
Before introducing the system we arranged a full practice meeting explaining that the aim was to support person centred care and re-assured the receptionists that it was ok to let the patient lead the way as they were worried about overloading us with work. This took some pressure of them.
Each Doctor is responsible for managing their workload. The same-day list closes at 3pm but can be closed earlier if the on call doctor feels they will not be able to call everyone that day. After this, it is explained that the next time a doctor can call them back will be the following morning, unless of course it appears to present a more urgent problem. Similarly, on any day any doctor can simply close their personal list if they think they will struggle to call them back that day. Once seen, a patient can be given future appointments by the clinician without going back through the system, otherwise they need to enter the system at the top again.
The system has become fluid. As the first contact is on the phone, we still benefit from reduced face-to-face contact, freeing us up to offer longer appointments for more complicated problems. We can also ensure appropriate investigations or other information is available. Our traditional surgery times have blurred allowing greater flexibility in offering appointments that suit our patients lives rather than our own ‘timetable’.
We recognise the there are still issues that are unresolved. We have concern about how we manage patients who are deaf or cannot easily speak on the phone and that for some people we might miss important clinical information (we have put alerts on some records to identify anyone we feel is more vulnerable to this). We do waste time when people are not available but we did not feel we had capacity to provide short call back times as with other models. We usually manage about 2-3 hours and try everyone at least twice, usually adding them to the next days list if unsuccessful.
We can usually manage to phone a patient during a specified lunch break but if we miss this have to ring later on in the day.
As a training practice it also has pros and cons – we can tailor surgeries to give our trainees the clinical mix they need – but have not yet exposed them fully to the new system until the last few months. Finally, a health warning – the on-call Doctor can be very busy but it’s not every day.
Nine months (and one Winter) later the system is bedded in and appears to have led to a much less turbulent flow through our appointment system for patients.
Our A&E attendances are falling (compared with a rise across Doncaster), our out-of-hours requests have fallen and there have been no further negative comments on NHS choices about access. The doctors too have adapted, recognising the system as supporting partnership and continuity with patients and brought the clinical team closer together.
Overall, the demand seems more manageable and it is unusual if we don’t have time to sit together properly for lunch these days!
Dr Ben Jackson, GP Partner, Conisbrough Group Practice, Doncaster.