Tweaking Appointments to Meet Demand
I am sure that every GP Practice and every GP Practice Manager has at some time or other suggested tweaking the appointments system to try to cope with demand. You can argue with the figures but generally GPs work for 46 weeks a year and if full time probably 4 and half days of each of those weeks unless they are part time. However, the four and half days can be adjusted downwards for up to 10 public holidays and then there are monthly half days for training and clinical commissioning group meetings. Again you can argue with the figures but using one calculation I had in mind that the approximate payment for each consultation is about £26 for seeing about 135 patients per week for 10 minutes each.
‘Need to See’ Appointments
You can call appointments what you like. You can call appointments ‘routine’, ‘regular’, ‘acute’, ‘chronic’, a short appointment, a double appointment’, ‘urgent’, urgent access’, and urgent extras, but when it comes down to it there are simply appointments. Patients don’t need to worry about what an appointment is called. Naming appointments is purely for internal use. So bearing in mind holidays, sickness, maternity and paternity leave, training half days, bank holidays and inclement weather how on earth can a doctor see all the patients who ask to be seen today, let alone the rest of the week. There are those who have come up ideas such as Advanced Access, Telephone Consultations, and Nurse Practitioners et al. But when it boils down to it there is an obligation to see patients who require ‘immediately necessary treatment’. The payment systems encourage 10 minutes appointments and seeing patients within two days. So patients need to be seen!
Attitudes to Appointments
In practices attitudes vary toward providing an appointments system. Some doctors like to see a cross section of patients, chronic patients and acute patients each session. Other doctors like to spend more time with each patient, say 20 minutes or even longer. This often leaves an imbalance in a practice meaning that some doctors see more patients than others. It can also lead to arguments and an atmosphere between doctors and between the doctors and their staff. The solution lies in either accepting the situation with complaint or setting up a system that means each doctor sees the same number of patients each day no matter how long it takes. This places a greater burden on the reception staff to manage the allocation of patients to doctors and again produces unpleasantness for staff who fail to keep the numbers even.
Busy or Not?
It is difficult to judge when the busy times are going to be; Monday mornings after a long weekend, Tuesday mornings after a bank holiday, Friday before a holiday weekend. I always found Christmas Eve afternoon extremely quiet. I suppose one could argue that the number of patients wishing to be seen is always going to be greater than the number of sessional appointments available whatever the day of the week or the time of the year. There is often great play about the number of broken appointments but in my experience there is usually a sigh of relief when a patient does not turn up unless it is the last patient and th4 doctor has just been twiddling his or her thumbs.
Meeting Variable Unpredictable Demand
So how do you tweak the appointments system to meet variable demand? In my experience it is a matter of knowing what the doctors prefer and working with it not against it. Changing the ratio between the number of regular appointments and urgent appointments is one way. Urgent appointments are those that can only be booked today. It might be possible to embargo the release of appointments until 24 hours before. Another way is to add one or two appointments to each session when demand is expected to be higher. In a practice of 8 doctors this might add up to 144 extra appointments. I worked in one practice where on one occasion 120 extra patients turned up to be seen one morning. The practice had a system of two doctors seeing the ‘extra’ patients whilst the others saw regular patients. When the ‘regular’ doctors had completed their sessions they dipped into the ‘extras’ session. Patients were still being seen at midday. In another practice the ‘extra’ patients were shared equally between the doctors on duty. This meant that the slowest doctor was always the last up for coffee if he or she was ever seen at all.
Try Over Egging the Pudding
Probably fairest way to balance the books is for each doctor to see the same number of patients each day and to fill appointments chronologically. Perhaps the key here is to allow say 20 patients per session rather than 15 but to embargo the last 5 until the day of the appointments. This way supply might appear to be greater than demand. What do you think?
Robert Campbell is a retired GP practice manager with 25 years experience.
This post has been prepared in response to a question raised by a member of GP Practice Managers UK on LinkedIn.