Abstract
Following recent concerns about patients' inability to book appointments in advance, this study examined the relationship between the proportion of GP appointments reserved for same-day booking, and patient satisfaction with appointment systems. In a survey of 12 825 patients in 47 practices, it was found that a 10% increase in the proportion of same-day appointments was associated with an 8% reduction in the proportion of patients satisfied. Practices should be wary of increasing the level of same-day appointments to meet access targets.
Keywords: appointments and schedules, family practice, health services accessibility, patient satisfaction, primary health care
INTRODUCTION
Recent policy initiatives related to government targets for primary care access in The NHS Plan,1 such as Advanced Access,2 have led to changes in the numbers of appointments that are reserved for patients booking on the day (same-day appointments).3 This has led to high-profile criticisms that patients are less able to book appointments in advance,4,5 a particular concern for certain groups such as older patients,6 and those with chronic conditions.6–8 There is also uncertainty about whether the success of these initiatives is related to the level of deprivation of the practice population.7 A recent evaluation of Advanced Access showed no difference in patient satisfaction with the appointment system between Advanced Access and control practices.9 However, there was considerable overlap between initiatives used by Advanced Access and control practices.3 Since difficulties in booking appointments in advance have been a focus of concern,4 this study has examined the relationship between the proportion of GP appointments reserved for the same day and patient satisfaction with appointment systems, regardless of practices' Advance Access status.
METHOD
Data from the recent evaluation of Advanced Access were used, described in detail elsewhere.10 The data were a comparison of 48 general practices selected from 12 primary care trusts (PCTs) in England. The study made use of two components of this evaluation: a survey of practices and a survey of patients. The survey of practices undertaken in 2004 involved 391 practices from 12 PCTs purposefully selected to be representative of England.3 This provided data on the numbers of GP appointments offered in each practice, both bookable in advance and same-day only. The patient survey involved 12 825 adult patients attending 47 of the practices, undertaken in 2005.9 This provided data on patient satisfaction with the practice appointment system.
Analysis
Responses to a question about ‘overall satisfaction with the appointment system’, which had been answered on a 7-point Likert scale, were dichotomised to ‘completely and very satisfied’ versus all other categories. This was the dependent variable in a multilevel logistic regression undertaken using the XTLOGIT command in STATA (version 9.2). The proportion of same-day appointments was grouped into units of 10 and treated as a continuous variable. The effect of the proportion of same-day GP appointments was tested, adjusted for potential confounding factors at the practice level (number of GP appointments offered in total by the practice per 1000 population, training practice or not, receiving deprivation payments or not, previously been fundholders or not, and list size), and at the patient level (age, sex, chronic illness status, and ethnicity). Interaction terms between the proportion of same-day GP appointments and being older, having a chronic condition (defined as reported longstanding illness, disability, or infirmity) and practice in receipt of deprivation payments were tested to determine whether the acceptable balance of same-day and booked in advance appointments differed by type of patient or practice.
How this fits in
Recent policy initiatives related to government targets for primary care access have led to changes in the numbers of appointments that are reserved for patients booking on the day. There has been concern about difficulties with booking appointments in advance. This study found that increasing the proportion of same-day GP appointments was associated with a reduction in patient satisfaction with appointment systems, particularly in older patients. Practices should be wary of increasing the level of same-day appointments to meet access targets.
RESULTS
The overall response rate to the patient survey was 84% (n = 10 821 received from 12 825 questionnaires sent out). The question about satisfaction with the practice appointment system was completed by 10 547 patients. Patient and practice characteristics are reported in detail elsewhere.10 Overall, 52% (5490/10 547, range 20–84%) of patients were completely or very satisfied with the appointment system at their practice. Among practices, the mean proportion of same-day appointments with a GP was 36% (range 0–100%). Practices mainly offered 30% or less of their appointments as same-day (28/47), with one-quarter offering over 50% of appointments as same-day (12/47). There was a negative correlation between the proportion of same-day appointments and patient satisfaction for the 47 practices (Figure 1). The mean proportion of patients completely or very satisfied with their appointment system was 58% for practices with less than 30% of same-day appointments, compared with 48% for practices with more than 50% of same-day appointments. Using multilevel modelling, there was an inverse relationship between the proportion of same-day appointments and the proportion of patients who were completely or very satisfied with their practice's appointment system. For each 10% increase in same-day appointments, there was an 8% reduction in satisfaction, adjusted odds ratio = 0.92 (95% confidence interval = 0.90 to 0.94). This relationship was more marked for older people (aged ≥65 years), and in practices that were not in receipt of deprivation payments (Table 1).
Figure 1.
Relationship between patient satisfaction with GP appointment systems and proportion of same-day appointments by practice.
Table 1.
Relationship between proportion of same-day appointments and patient satisfaction with appointment systems.
| Variable | UOR | AOR | 95% CI | P-value |
|---|---|---|---|---|
| Proportion of same-day GP appointments | 0.91 | 0.92 | 0.90 to 0.94 | 0.001 |
| Interaction between proportion of same-day GP appointments and: | ||||
| older patients | 0.93 | 0.90 to 0.96 | 0.001 | |
| chronic conditions | 0.97 | 0.95 to 1.00 | 0.100 | |
| deprivation payments | 1.18 | 1.12 to 1.24 | 0.001 | |
AOR = adjusted odds ratio. UOR = unadjusted odds ratio.
DISCUSSION
Summary of main findings
It was found that increasing the proportion of same-day GP appointments leads to a reduction in patient satisfaction with appointment systems, particularly in older patients. It was also more pronounced in less-deprived practices, suggesting that the ability to book appointments in advance is particularly valued in practices serving more affluent populations. The findings support previous concerns that the benefits of increasing same-day GP appointments for some groups of patients may be outweighed by the difficulties in booking appointments in advance experienced by other groups of patients.4,6–8
Strengths and limitations of the study
This study is the first to examine the impact of same-day appointments on patient satisfaction with appointment systems from a national sample of practices. The data on satisfaction with appointment systems is based on a survey of over 12 000 patients with a high response rate, although the information was obtained from a single item only. A limitation is that the analysis was restricted to appointments that could be booked, whether on the day only or in advance. It excluded ‘unscheduled’ consultations, such as open surgeries where patients could attend without appointments, and ‘extras’ seen at the end of surgery. However these consultations without appointments represented less than 7% of all consultations in the study, and when they were included in the analysis the findings were not affected.
Comparison with existing literature
Previous research suggests that younger people,11 and patients in deprived areas,12,13 are more likely to use same-day appointments, which is in line with the present findings. The relationship between the present findings and some other studies is less clear. Satisfaction has been found to be higher in practices with a high rate of appointments available at the start of the working day,14 and a recent study found that patients using same-day care were likely to be in work and have a higher educational status.11 The study's findings are compatible with others that advocate a combined appointment system, allowing both prebookable and same-day appointments, noting that different patient groups have differing requirements.11,15
Implications for clinical practice
This study is particularly pertinent as access to primary care returns to centre stage in government health policy.16 Attempts to improve access must be based on evidence if the Department of Health is to avoid criticism for rolling out initiatives prior to independent evaluation.17,18 In particular, practices should be wary of increasing the level of same-day appointments to meet access targets, and need to get the balance between pre-bookable and same-day appointments right for their particular patients, to optimise satisfaction. Although patients value speed of access, other factors, such as being able to book appointments in advance with a chosen doctor, must not be sacrificed for marginal gains in what are already fast access times in the UK in comparison with other countries.16,19
Acknowledgments
We would like to thank all the patients and practice staff who contributed to this study and also the other members of the Advanced Access Evaluation Team: Jon Banks, Helen Baxter, Alan Montgomery, Mary Wallace (University of Bristol), Lucy Simons, Karen Gerard, Val Lattimer, Catherine Pope (University of Southampton), Sarah Edwards, Helen Smith (University of Brighton), and Markella Boudioni (London South Bank University). We would also like to thank Alan Montgomery and Mike Bradburn for statistical advice.
Funding body
This article presents independent research commissioned by the National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO) Programme. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The NIHR SDO programme is funded by the Department of Health (SDO/70/2004)
Ethical approval
Thames Valley Multicentre Research Ethics Committee (MREC 04/12/024)
Competing interests
The authors have stated that there are none
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