Managing practice appointment systems

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As demand for GP appointments increases, patient access has become one of the most contentious aspects of primary care. Practice managers may find themselves caught in the crossfire between anxious patients and overworked clinical staff.  Medico-legal adviser, Dr Beverley Ward, assesses the medico-legal challenges involved in managing practice appointments systems.

Today's practice managers face a considerable challenge – to find innovative ways of meeting  patient demand for appointments, without compromising patient safety or overloading the system.

The average GP practice dealt with 4,384 more consultations per year in 2011/12, compared with 2004/5 according to a recent estimate by the Royal College of General Practitioners (RCGP). Such was the pressure on resources that 10% of patients who sought a consultation with a GP or practice nurse in 2012/13 failed to get one. 

In an effort to ease the pressure and improve access, the government and doctor leaders agreed to end the contractual requirement for 10-minute appointments from April 2014, giving practices greater flexibility. Surgeries are also now expected to offer and promote online appointment booking and repeat prescription services.

Many practices have already been exploring alternatives to face-to-face consultations in a bid to alleviate pressure on the system and meet patient needs. For example, telephone consultations increased from an estimated 12.5million to 18.9million between 2004 and 2012, a rise of over 50%.

While such initiatives can improve operational efficiency, particularly for routine matters, practice managers must still ensure patient safety isn't compromised. More broadly, it's important to consider the medico-legal implications of all practice policies and procedures which concern patient access, from appointment booking to reducing Do Not Attends (DNAs).

Standard local rate

Patients should be able to call the practice on a number that charges the standard local rate. Since April 2010 there has been a veto on practices entering contracts which involve the more expensive 084 telephone number and practices were expected to amend or end contracts that didn't comply. 

But according to NHS England a minority of practices (around 8%) continue to use them. It has asked Local Area Teams to remind practices that they will be in breach of contract if they do not make this a priority. 

There are also plans to audit telephone services this year to check what progress has been made. If you are affected, speak to your telephone provider or seek advice from your Local Area Team.

Telephone skills

Poor communication and perceived rudeness during telephone calls are a common cause of complaint. But a patient who has been kept waiting a long time or wrestled with a convoluted automated system is just as likely to be annoyed and anxious when they are connected. The receptionist who picks up the call may find him or herself having to manage the patient's irritation. 

With this in mind, it's worth considering regular training for reception staff to ensure their telephone skills are up to scratch, including checking the identity of the caller, actively listening without interruption, being courteous and staying calm in the face of aggression. 

It's also important to ensure that calls are answered within a reasonable timeframe (it's a good idea to have a target) and that there are enough staff available to answer the telephone at peak times.

It's a good idea to have a practice telephone policy which covers points such as:

  • patient confidentiality
  • staffing levels
  • documenting calls and emergency contact numbers (which should be included in your out-of-hours answering machine message).

The policy should be regularly reviewed and updated. 

Triage and telephone consultations 

Telephone triage is a useful way of determining urgent and not so urgent cases so that appointments can be allocated according to patient need. However, the process must be properly thought through.

If non-clinical staff take down patient details for a GP call back, they must have appropriate training and there should be a full written protocol which includes red flag symptoms such as weight loss or a persistent cough.

There should be no need to go into detail about patients' medical history and those who only want to discuss their concerns with a health professional should not be penalised. To protect patient confidentiality, calls should be taken where they can't be overheard, rather than at a reception desk in the waiting room.

Many practices provide a call-back service so that patients can talk to a health professional or be allocated an emergency appointment. Even if the telephone calls are recorded (and if they are, this should be made clear to patients), the clinician or practice nurse assigned this duty should have access to the patient's records and make the same detailed clinical notes that would be expected in a face-to-face consultation. In the event of a problem, the practice should be able to document the reason for the call and the advice offered.

It's also advisable to document the call-back process used in case it is questioned during a CQC inspection or in the event of a complaint.

If the nurses in your practice triage patient phone calls, ensure they get in contact with our membership team to let us know.

Home visits

Home visits can be a sensitive area because the person making the request is often anxious about their own health, or that of a close relative, and their expectations may be unrealistic.

To help pre-empt any problems, it is a good idea to publicise your policy on home visits on your website and in practice literature, making clear that the service is usually for the housebound or seriously unwell and encouraging patients to use the system appropriately. The policy should set out how people can request a home visit (for example, if they need to call the surgery before a particular time), explain that a doctor or nurse may contact them to assess the urgency and make it clear that their preferred doctor may not be available. As with all consultations there should be a full note of such conversations in the patient's record.

If an appointment is made for a home visit, there should be a clear protocol in place to confirm the patient's address details and ensure the visit is documented in the records.

Online appointment booking

Practices are now contractually obliged to provide secure online access to services such as booking and cancelling appointments.

More than half of practices already offer patients this option but if your practice does not yet have this facility, we advise you to contact your Local Area Team. According to guidance from NHS Employers, NHS England and the General Practitioner's Committee (GPC ) all practices will have approved national software made available to them this year so that they can meet this requirement. 

The guidance also says that practices should ensure "that an appropriate number of appointment slots are able to be booked online". It suggests reserving 20% of appointments for online booking, although that will depend on the characteristics of your local population.

Text reminders

NHS England reports that more than 12million GP appointments are missed each year in the UK, at a cost of over £162m to the NHS and considerable disruption and delay to practices. As a cost-effective way of tackling the problem, some GP practices now provide a text reminder service to the patient's mobile phone.

Text messaging can work well in this context, though we advise practices to seek patients' specific consent and opt-in before texting. Ensure you explain clearly what information will be texted and the security arrangements in place. If the information is serious or important, such as requests for urgent follow-up, consider alternative or additional methods of communication.

Details of text messages sent to or received from patients should be noted in their medical record, including the date and time of transmission, the content of any message and the details of any reply.

Responding to DNAs

A competent adult patient is responsible for ensuring their own attendance at an appointment, but this is not to say that practices have no responsibility in cases of non-attendance. Ensure your practice has a clear and consistent protocol for prioritising and responding to missed appointments and that a record is kept of any steps taken to follow up with the patient. For example, if a patient who may be acutely unwell fails to attend an emergency appointment, it is important the practice can demonstrate that all reasonable and timely steps were taken to investigate the circumstances and need for care. 

Even if a patient persistently misses or is late for appointments, it would be difficult to justify their removal from the list unless the practice has spoken to them about this and determined whether there are any underlying causes such as confusion about the appointments system or anxiety. In the majority of circumstances, removal should be an option of last resort and GPs are contractually obliged to have given the patient a warning in the previous 12 months. Keep a clear and detailed note of any incidents that have led to the removal, any steps that have been taken to resolve the situation, the specific reasons for the removal and the process of removal that was followed.

Appointments policy

Your appointments policy should be available on the practice website and in the waiting area. It's also a good idea to communicate the policy to new patients when they register. The policy could include the following.

  • Surgery times and extended hours sessions.
  • Types of appointment available e.g. urgent, advance, 'arrive and wait', practice nurse, travel clinic etc.
  • Appointment booking methods (telephone and online).
  • The practice's commitment to answering telephone calls within a certain time and whether calls are recorded.
  • Requesting home visits and the circumstances when they are provided.
  • Whether patients can request a particular GP.
  • When patients can request a double appointment.
  • How to cancel an appointment.
  • Practice statement on DNAs.
  • How to summon medical help outside practice hours.

This article originally appeared in the printed version of inpractice July 2014 entitled "By appointment".

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