Appointment systems

Most practices n = 32 (57.1%) had changed the way that they managed requests from patients for consultations as a result of AT. The remaining 24 practices (42.9%) had not altered their appointment systems.

There had been an increase in all types of pre-booked appointment systems, particularly the use of "emergency slots". Many practices reported seeing more patients who had not pre-booked appointments; referred to as "extras". Practices also reported an increase in telephone consultations. There was no overall change in the use of open surgeries (i.e. with no pre-booking required) in the Board area.

More practices (n = 19/26) in socio-economically deprived areas made changes to their appointment systems, compared to practices (n = 13/28) in more socially advantaged areas. The change in appointments systems ratio was 3.13 (95% CI 1.01 – 9.80, p = 0.0256).

Flexibility in booking appointments

Practices that limited the time allowed for patients to make advanced appointment bookings had larger list sizes (mean 6843, SD 2706) than those which did not limit advanced bookings (mean 3641, SD 2213), mean difference 3202 (1802 – 4602), p < 0.001.

Group practices were also more likely to limit how far in advance a patient was able to book an appointment when compared to single-handed practices. When single/group practices were cross-tabulated with practices which limited/did not limit advance booking, the chi square with Yates correction = 7.416 (p = 0.006).

In addition, urban practices were also much more likely to limit appointment booking when compared to rural-based practices. When urban and rural practices were cross-tabulated with practices which limited or did not limit advance booking, the chi square with Yates correction = 13.126 (p < 0.001).

After controlling for the confounding effects of rural/urban status, the odds of restricting appointment booking was 10.15 times more likely in group practices than it was in single-handed practices (95% CI = 3.86 -26.67, p < 0.001 (Mantal-Haenzel method)).

Practice management, staff roles and access targets

Practices that used nurses to telephone triage patients requesting an appointment also had lower list sizes (Mean = 4550, SD 3384), and those that did not use them for triage (Mean = 7002, SD 2694), mean difference 2452 (-137 – 5040), p = 0.062 (see table 5).

Summary of main findings

Practices used a variety of appointment systems and techniques to manage the patient access requirements of the new GMS contract (table 1). These systems have become increasingly structured since the introduction of AT and the associated financial gain. The odds of practices in deprived areas making changes to their appointments systems was three time greater than for those in more affluent areas. (Odds ratio 3.13 -95% CI 1.01 – 9.80, p = 0.0256). An increase in accommodating patients with earlier appointments was observed (table 2). This included more telephone consultations, triage, appointments within 48 hours and "extras" been seen. This may reflect a GP service more responsive to patient demand encouraged by the financial reward offered by the government within the new GP contract.

Nevertheless, practices' experience in the WHSSB area in managing access targets differed considerably. A significant minority had in fact not made any changes (n = 24) to their appointment systems. It may be that these practices had already been meeting the access standard before the new contract was introduced and saw no need to make changes.

Practices with larger patient list sizes (p < 0.001), or with predominantly urban patients (p < 0.001) and group practices (p = 0.006), were more likely to restrict the time bookings could be made in advance (table 3). Socio economic deprivation status was not related to appointment booking inflexibility.

Most Practice managers were satisfied with AT and the management of patient access within their practices (table 4). Despite receptionists playing a major role in the management of appointments, a number of practices n = 14 (25.5%) reported that their receptionists had received no training in doing this at all.

Nurses were more likely to be involved in seeing extra patients (p < 0.01) or in carrying out triage duties (p = 0.062) the smaller the patient list size (table 5). This was a counterintuitive finding.

Strengths and the limitations of this study

The high response rate to this postal questionnaire based study could indicate that practices felt that the issue of patient AT was important. The absence of data from the three practices (5%) which did not reply is unlikely to have had a major biasing effect on the results.

As no previous research on appointment systems in the Board area was found, it was not possible to directly compare appointment systems prior to the introduction of the AT arrangements and this was a weakness in the methodology. In addition, any comparisons with appointment management systems in English primary care organisations with The WHSSB must allow for the fact that the WHSSB is likely to be a more rural region.

Comparison with existing literature

We have highlighted the fact that patient access has remained flexible in the WHSSB area, and that 98.1% of practices allowed advanced booking of appointments beyond 48 hours. This contrasted with recent findings from the Health Commission [14]. The difference may be due to regional variation, or perhaps by practice managers biased reporting of flexibility, whether it existed or not given that under the terms of the new contract it is currently seen to be "desirable".

We have identified a lower use of the open access approach than previously reported [7]. By contrast, the use of pre-booked appointments was higher in this study (96.4%) than in others. Telephone triaging and the use of "extra" patients' surgeries (table 1), were also utilised more frequently and given more allotted time than has been previously reported [7]. Perhaps some of these changes could be attributed to the introduction of AT?

Implications for future research or clinical practice

We feel this is the first study in Northern Ireland to examine the effects of implementing AT in general practices. We have highlighted that Practices in deprived areas have made more changes to their appointment systems than those in more affluent areas. This in turn may have implications for the allocation of investment and resources within the WHSSB.

Further training in managing access may be required in light of the new contract's access target requirements. The lack of training for some staff was highlighted in the study and may have clinical governance consequences for practices and for the Board, which has a policy of encouraging all practices to use standardised training programmes for its employees. Further research to explore the varying nursing roles in different practice profiles, suggested in this study, in relation to access may contribute to the debate on patient access and AT. Given their central role in patient access, any debate about AT arrangements [4, 15] should consider the role of nursing in primary care.

Our study raises other questions about the clinical benefit of AT. Do the changes reported in appointment systems lead to an improvement in patient care? What effect does the requirement to offer AT to patients have on their behaviour and attitude to health, particularly self-care? Furthermore, has AT had an impact on secondary care as a result of earlier referrals, or a change in the workload at Hospital Accident and Emergency departments or even in the use of out hour's services?