NHS England commissioned the Strategy Unit to undertake a rapid research project into appointment booking and other working arrangements across general practices. This followed a recommendation from the National Audit Office that this type of research could help reduce variation in access for patients.
Access to general practice appointments can be described in many different ways, for this study we described it as the balance between a practice’s ability to supply appointments with their patient demand for consultations.
The aim of the study was two-fold:
- What is the potential for the ‘Ten High Impact Actions’ to improve access? These Actions have been widely promoted by NHS England to release time for care (supply) in general practice to appointments (demand)? We rapidly reviewed the peer-reviewed evidence base to explore the underlying evidence.
- How did general practices match up the available appointments (supply) with their patient need (demand)? We interviewed practice managers to understand their everyday issues with respect to appointment management.
A particular strength of this project was the input of an advisory group throughout, made up of policy, strategy, academic, clinical and practice experts. The advisory group added their experience-based knowledge to the study findings.
Our evidence review found that the wholesale application of the Ten High Impact Actions by general practice should be approached with caution. This was because not all Actions were proven to be effective in the peer-reviewed literature (see table). Based on the strongest evidence-base, our top three High Impact Action recommendations to improve access are:
- Consider telephone consultations as an alternative to face to face to meet demand.
- Enhance nursing roles as part of clinical team development to improve supply.
- Invest early in the supply of clinical staff time for self-management support. This will reduce demand for long term conditions care later.
Our interview findings revealed that a general practice’s ability to manage the supply and demand for appointments was a juggling act. Despite this need to juggle, some practices felt they were generally in control when it came to appointment access. Based on their explanations of how they managed, we have developed the following A-B-C suggestions:
- Actively think about your patients’ preference for access, is it more continuity of care or would they prefer timeliness for access? Be aware that this might be different between different groups.
- Be innovative in how you match your supply to demand. To deliver something new or different, you’ll need a champion who enthuses everyone else at the practice and enlists support (maybe even financial!) from elsewhere. Note that for champions to arise, there will need to be sufficient training and development opportunities through which to empower staff.
- Consider what is feasible for the practice with respect to staff. For instance can appointments for self-limiting illness be managed differently to those with long term conditions? Can consultations for social/holistic care be incorporated by working with other care professionals?
General practices also need help from all of us as users; we need to manage our expectations of general practices (starting with children’s TV!) and use primary care services more appropriately. Do we really need to see the doctor or can the pharmacist help? Can a telephone consultation be more convenient? Are we letting the practice know when we can’t attend so they can offer the appointment up to someone else?
Practices can also be helped by commissioners and NHS England. Please do support local primary care professionals by giving them access to training and skills development. Please do improve the quality of appointment recording (this recommendation has been heard, the Strategy Unit is supporting NHS England and NHS Digital to assess the quality of general practice appointment data) . Please don’t cut back on the funding of pilots before there is an opportunity to show impact. Please don’t overburden staff with reporting requirements, especially when it gets in the way of delivering patient centred primary care services.
Overall, we were heartened by the accounts of collaborative working to manage access to appointments. We feel that if primary care professionals have opportunities to develop skills to match supply with demand, then they can be directed (through the appropriate use of evidence) in their willingness to improve access for their patients.
For more information on the project, contact Karen Bradley or Abeda Mulla here.
|High impact action||Evidence base||Experience of practices|
|1 Active signposting||Under-researched; available evidence suggests training required for signposting||Requires non-clinical triage training; reduces demand for GP appointment|
|2 New consultation types||Well researched; telephone consultations most common and preferred||Telephone consultations Requires tailoring to patient demographics; provides convenience and better experience for patient and clinician|
|3 Reduce Did Not Attends (DNAs)||Under-researched for general practice; hospital settings evidence support use of text reminders||Text messaging Perceived to be cost-effective; improves management of demand|
|4 Develop the team||Well researched; emerging evidence supports additional tasks for nurses||Enhanced nurse role Requires tailoring to population need and raising patient awareness; reduces demand for GP appointments|
|5 Productive work flows||Under-researched for general practice; available evidence supports increased patient satisfaction||Requires opportunity and proactivity to develop flexible processes; improves staff experience through engagement and autonomy|
|6 Personal productivity||Under-researched for general practice; available evidence suggests necessity to train receptionists to be more proactive||Requires training especially for non-clinical staff; improves staff experience through increased resilience|
|7 Partnership working||Broad evidence base; multidisciplinary team evidence suggests improvements for self-management and quality of life for patients with long term conditions||Requires good professional relationships that can be facilitated through multidisciplinary team working; Improves patient experience through comprehensive and coordinated care offer|
|8 Social prescribing||Broad evidence base; inconclusive evidence for effectiveness||Requires care-coordinators to manage individual resource; reduces non-medical GP appointments|
|9 Support self care||Well researched: self-management ‘hallmark of good care’||Requires more use of self-care management; potential to reduce GP workload not realised as patient demand perceived to be low|
|10 Develop QI expertise||Under-researched for general practice; available evidence suggests effective approaches include: audit and processes for prescribing and patient review||Requires training and funding support; Improves management of demand|