GP access — time for a radical solution?

The recently published Patient’s Association report entitled Primary Care: Access Denied? makes uncomfortable reading for GPs.¹ Fifty-seven per cent of responders stated that they felt that booking a GP appointment was either ‘very difficult’ or ‘could have been easier’. Almost two-thirds of people waited longer than 48 hours to book an appointment and one in three were unable to book at least 48 hours in advance. One in five responders stated that they needed to take time off work to see their GP which, when weighted against working age translates to more than one-third.

There are some GPs around the country who are adopting a radical approach to try to address the perennial and increasing problem of GP access. This involves rapid-response telephone consulting where every request for a GP consultation results in a GP calling the patient back within 60 minutes. A consultation takes place on the phone which in the majority of cases addresses the patient’s problem or query. The minority who need to be seen are asked when they would like to be seen. Most request a same day appointment which as a result of the efficiency of system can almost invariably be provided. GPs will often indicate that a nurse practitioner would be the most appropriate person to deal with the problem or, when continuity in care is needed with a particular GP, this is arranged.

The experience of most surgeries is that over 90% of patients prefer this approach to accessing their GPs. Not only does it revolutionise access to GP services but for patients who work, frail older people who struggle to get out, or anyone who simply wants some timely advice without leaving their house, it is extremely convenient. Demand is managed but far more importantly, clinical risk is managed by a skilled GP. The reception staff find their lives transformed as they relinquish the role of gatekeeper and the label of dragon.² The constant negotiation with frustrated and disgruntled patients ceases and they are able to focus on other pressing administrative tasks in the office.

The CCGs are increasingly interested in this model. The evidence from practices that have adopted this approach is consistently showing reductions in A&E attendance of at least 20%.³ If you can be confident that your GP practice will see you or your child the same day, then why would you travel to your local A&E to wait 3–4 hours to be seen for what most patients know is not an accident or an emergency? But for many patients this remains the default mode to accessing NHS services driven by an assumption that you can never get an appointment at the GP surgery.

GPs can find the changes quite a culture shock. Fears about increased medicolegal risk can be managed through the application of important risk-reduction principles.⁴ Concerns about missed non-verbal cues or physical signs can equally be reduced through the development of skills in compensatory telephone behaviours and recognition of para-verbal cues.⁵ Understanding that the same skills in good communication and consulting face-to-face can be developed and honed on the telephone is important and requires dedicated training.⁶

The role of the GP as NHS gatekeeper has traditionally been seen as a means of managing referrals to secondary care. This expertise is increasingly being channelled into the CCG activities but could equally be applied to managing access to GP’s own services. Time is the most precious NHS resource GPs have. Optimising the use of this limited resource and ensuring it addresses the needs of all patients including hard to reach and disadvantaged groups of patients is something GPs need to take seriously.⁷

The NHS is an increasingly complex and potentially confusing place for patients. A core role of the GP is to act as the patient’s advocate helping them navigate to the most appropriate community or hospital-based service. Unfortunately it is a role that seems to be relinquished when it comes to helping patients access care provided by their own surgeries. Rapid response telephone consultations may be one potential solution.