Abstract
Access to consultations with general practitioners (GPs) is an important health policy issue. One method of providing 24-hour access is through the provision of open-access surgeries. The study aimed to compare patients, perceptions of ‘bookable’ and ‘non-bookable’ (open-access) appointments. A cross-sectional survey design was used and recruited 834 patients in a general practice. There were statistically significant differences between the bookable and the non-bookable appointments for the questions on ‘choice of doctor’, ‘whether able to see the doctor in the time they needed to’, and ‘convenience of the appointment’. More patients with bookable appointments saw their doctor of choice. One-fifth of patients, equally distributed between the two groups, did not feel that they were seen within the time they needed to be. Almost three-fifths of patients, equally distributed between the two groups, reported that it was either ‘easy’ or ‘very easy’ to make the appointment. Greater convenience was reported by those with bookable appointments. These findings support the hypothesis that within a single practice, there is scope for a combined appointment system in which patients can self-select, with equal satisfaction, the type of appointment that they prefer, dependent upon their own preferences or needs at the time.
Keywords: access, appointment provision, general practice, cross-sectional survey
Introduction
THE organisation of general practice appointment systems attempts to meet the needs of the practice (‘practice-centred time’), and the needs of its patients (‘patient-centred time’).1 Appointment systems vary from completely ‘open-access’ systems to those with appointments that are bookable only in advance, although many practices use a combination of the two. All systems have advantages and disadvantages. For example, open-access systems can be seen as making it too easy for patients to consult with minor complaints, and fully bookable appointment systems can make it difficult for patients with urgent problems to be seen. The principles of demand and demand management are complex, with many factors having an influence.2 Access has become an important health policy issue, with 48-hour access targets featuring in The NHS plan3 and in the proposals for the new general practitioner (GP) contract.4 One ‘solution’ to problems of access is the concept of Advanced Access, an American model embracing the principles of ‘doing today's work today’ (essentially, a structured, open-access system). Although hailed as a panacea for struggling general practice appointment systems, and widely promoted by the National Primary Care Development Team,5 Advanced Access lacks a significant evidence base regarding its benefit.6
This study was undertaken in a practice that attempts to inform its decision making on the basis of good evidence. An important question for the practice was how best to organise its appointment system to meet the needs of its patients. A review of the literature found no comparable studies of patients' views of different types of appointments. The aim of the study was to compare the perceptions of a consecutive sample of adult patients who were consulting with their GP for either a ‘bookable’ or a ‘non-bookable’ appointment.
Method
The study was conducted in one group practice in Leeds, which had eight GPs, four of whom were part-time. The population of the practice is socioeconomically diverse but stable at 12 500 patients and a 10% annual turnover. For many years the practice has operated a mixed appointment system. Every morning there is an open (‘sit and wait’) surgery held by two or three doctors (in rotation), with patients being allocated to a doctor in turn. This is a non-bookable appointment, no specific time is allocated, and patients are unable to choose their doctor. The remainder of the doctors run appointments that are bookable up to 4 weeks in advance. These include a number of appointments embargoed until the day (26% during the study period). Patients requesting emergency ‘same-day appointments’ are seen as ‘extras’ at the end of each day, or occasionally at other times during the day. Patients requesting an appointment are given the option of the first available appointment, an appointment with the doctor of their choice (if available), or information about the open-access surgery. Patients then make a choice as to how they proceed.
HOW THIS FITS IN
What do we know?
Appointment systems vary from ‘open access’ systems where no appointments are bookable in advance, to systems with appointments that are bookable only in advance. Many practices use a combination of the two and all systems have advantages and disadvantages. Appointment systems and access are a focus of health policy in primary care.
What does this paper add?
Patients are able to ‘self-select’, with equal satisfaction, different types of appointments operating in the same appointment system. Primary care may find patients less accepting to appointment systems that do not offer an opportunity to gain bookable appointments.
All consecutively attending adult patients were asked to complete a short questionnaire, with fixed response options, relating to their consultations (Box 1). Administrative staff were trained in the recruitment of patients to the study as part of their normal workload of assigning patients to appointments. The data sheets were coded and analysed. Patients attending open and emergency surgeries were grouped together and compared with those seen in surgeries that were bookable in advance. The study was conducted over a 2-week period in July and August 2002. This was chosen primarily for pragmatic reasons. All time periods are in some way atypical, with demand management being affected by seasonal factors, holiday periods, and the availability of doctors. The 2–week period chosen was notable for doctors being on holiday, and it was therefore a relatively busy time, despite it being at the beginning of the holiday season. Ethical approval was obtained from St James' University Hospital Local Research Ethics Committee.
Box 1. Survey questions.
How convenient was your appointment today?
How difficult was it for you to get this appointment?
Were you able to see the doctor in the time you needed to?
Were you able to get to see the doctor of your choice?
How satisfied are you with the appointment system at the practice?
Results
Data were sought from patients and GPs regarding 1150 face-to-face consultations. Of these, 490 were non-bookable (open or emergency) and 660 were bookable in advance. Eight hundred and forty (73.0%) responses were received, although not all patients answered each question. The responses to the five questions are shown in Table 1. For the questions regarding convenience, timeliness and choice, there was a difference between the bookable and the non-bookable appointments. Less than half of the patients with bookable appointments saw their doctor of choice, and more patients (42.9 versus 29.3%) with non-bookable appointments expressed no preference. More patients with bookable appointments reported greater convenience than those with non-bookable appointments (79.1 versus 68.8%). One-fifth of patients, equally distributed between the two groups, did not feel that they were seen within the time they needed to be. Almost three-fifths of patients, again equally distributed between the two groups, reported that it was either ‘easy’ or ‘very easy’ to make the appointment. There were no differences in overall satisfaction with the appointment system between the groups.
Table 1.
Survey questions compared by appointment type.
| Non-bookable n (%) | Bookable n (%) | χ2 (df, P) | ||
|---|---|---|---|---|
| How convenient was your appointment today? | ||||
| Very convenient or convenient | 229 (68.8) | 386 (79.1) | ||
| Neutral | 62 (18.6) | 57 (11.7) | ||
| Inconvenient or very inconvenient | 42 (12.6) | 45 (9.2) | ||
| Total | 333 (100.0) | 488 (100.0) | 11.541 (2, 0.003) | |
| How difficult was it for you to get this appointment? | ||||
| Very difficult or difficult | 54 (16.7) | 106 (21.7) | ||
| Neutral | 71 (22.0) | 104 (21.3) | ||
| Easy or very easy | 198 (61.3) | 278 (57.0) | ||
| Total | 323 (100.0) | 488 (100.0) | 3.128 (2, 0.209) | |
| Were you able to see the doctor in the time you needed to? | ||||
| No | 68 (20.9) | 93 (19.3) | ||
| Yes | 213 (65.5) | 360 (74.8) | ||
| Don't know | 44 (13.5) | 28 (5.8) | ||
| Total | 325 (100.0) | 481 (100.0) | 15.538 (2, <0.001) | |
| Were you able to get to see the doctor of your choice? | ||||
| No | 139 (40.5) | 105 (21.4) | ||
| Yes | 57 (16.6) | 242 (49.3) | ||
| No preference | 147 (42.9) | 144 (29.3) | ||
| Total | 343 (100.0) | 491 (100.0) | 95.993 (2, <0.001) | |
| How satisfied are you with the appointment system at the practice? | ||||
| Very unsatisfied or unsatisfied | 115 (35.3) | 162 (34.3) | ||
| Neutral | 84 (25.8) | 101 (21.4) | ||
| Satisfied or very satisfied | 127 (39.0) | 209 (44.3) | ||
| Total | 326 (100.0) | 472 (100.0) | 2.935 (2, 0.230) | |
df = degrees of freedom.
Discussion
This study reports patients' views regarding different types of consultation operating within the same appointment system. The main finding is that there are relatively few differences in the responses to the questions by patients attending bookable or non-bookable appointments. One conclusion from this is that patients ‘self-select’ to one or other of the types of appointment depending on their own preferences or needs at the time. This may be because of the nature of their problem, their availability to attend at certain times, or their preference for a specific doctor. It is interesting that more patients with bookable appointments reported being seen in the time they needed to be. While this may be counter-intuitive, we suspect it may be a combination of less urgent problems being presented in bookable appointments, and patients' preferences for seeing the doctor at convenient times. The largest difference between the groups was the percentage expressing a preference for a particular doctor. Again, this may reflect the fact that people who choose the open-access surgeries are those less concerned with seeing a particular doctor. This may be because of differences in the problems that were being presented, since it is established that, while patients generally prefer to see their ‘own GP’ for serious illnesses, they are happy to see other GPs for more minor illnesses.7,8
The study was set within the working of a ‘normal’, busy general practice, and the findings reflect this. The 2 weeks in which the study was conducted were anticipated in advance as being ‘busy’ weeks for the practice, and more bookable appointments were embargoed than usual. The limited availability of doctors may have influenced the responses of patients regarding access. The effect of this on the study may have been to ‘dilute’ the two groups. Although some of the questions may have been perceived to be ambiguous by patients, the overall response rate suggests that this did not preclude them from providing an answer most representative of their experience for the majority of consultations.
The findings support the hypothesis that, within a single practice, there is scope for a combined appointment system in which patients can self-select, with equal satisfaction, the type of appointment that they prefer. Practices that abandon bookable appointments for open-access systems may find that it is less acceptable for patients who prefer bookable appointments because of their own time availability rather than their medical need. There continues to be a dearth of evidence regarding clinical outcomes from different types of appointments. This is needed to inform health policy on access.
Acknowledgments
We would like to thank all the patients and staff at Meanwood Group Practice for their cooperation. Meanwood Group Practice is a Primary Care Research Team Assessment-accredited research practice, funded through the NHSE (National Health Service Executive) Northern and Yorkshire R&D Directorate.
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