Improving access for patients – a practice manager questionnaire

Background The administrative and professional consequences of access targets for general practices, as detailed in the new GMS contract, are unknown. This study researched the effect of implementing the access targets of the new GP contract on general practice appointment systems, and practice manager satisfaction in a UK primary health care setting. Methods A four-part postal questionnaire was administered. The questionnaire was modified from previously validated questionnaires and the findings compared with data obtained from the Western Health and Social Services Board (WHSSB) in N Ireland. Practice managers from the 59 general practices in the WHSSB responded to the questionnaire. Results There was a 94.9% response rate. Practice managers were generally satisfied with the introduction of access targets for patients. Some 57.1% of responding practices, most in deprived areas (Odds ratio 3.13 -95% CI 1.01 – 9.80, p = 0.0256) had modified their appointment systems. Less booking flexibility was reported among group practices (p = 0.006), urban practices (p < 0.001) and those with above average patient list sizes (p < 0.001). Receptionists had not received training in patient appointment management in a quarter of practices. Practices with smaller list sizes were more likely than larger ones to utilise nurses in seeing extra patients (p = 0.007) or to undertake triage procedures (p = 0.062). Conclusion The findings demonstrated the ability of general practices within the WHSSB to adjust to a demanding component of the new GP contract. Issues relating to the flexibility of patient appointment booking systems, receptionists' training and the development of the primary care nursing role were highlighted by the study.


Background
In a typical day in Northern Ireland, 30,000 people see a family doctor or practice nurse. Indeed Patient access has been made a major objective within the government's recent primary care strategic framework [1]. An Access Target (AT) was outlined for United Kingdom general practice, in the new general practitioner contract between practices and Health Boards [2] and linked to an enhanced service payment if achieved. This AT came into effect on the 1 st of April 2004 and stated that "by 2004, all patients will be able to see a primary care professional within 24 hours and a GP within 48 hours". Practices were required to provide evidence to the relevant Health Board [3] that they were meeting this standard, following which they would receive a payment. Payments for meeting this access standard have since been reviewed [4].
A wide range of appointment systems have been used to meet patient requests for consultations [ [5][6][7], and [8]]. Practice managers are involved in patient access [9,10] and to date seem satisfied with the introduction of AT [10]. Nevertheless, the Royal College of General practitioners (RCGP) in a comprehensive review questioned the appropriateness of using this standard [11]. Indeed Prime Minister Tony Blair has been publicly questioned about the inflexible way some practices have tried to achieve the AT by allowing patients to only book an appointment up to 48 hours in advance [12]. A Healthcare Commission report also found that 12% of patients were unable to see a GP within two working days and 13% did not get an appointment within that time because they wanted to wait longer to see a particular GP or for an appointment at a more convenient time [13].
No previous research on the management of primary care patient appointment systems was identified in Northern Ireland. The aim of this study was to survey practice managers in the WHSSB area and to examine what effect, if any, the AT was having on the management of patient appointments, and on practice staff, by assessing practice manager satisfaction with the scheme. We also explored whether any practices limited advance booking of appointments and in what way as it might suggest less ease of access for patients.

Methods
A postal questionnaire survey of the 59 general practices in the WHSSB area was carried out between the 14 th of August and 31 st of October 2005. It examined staff roles in managing patient access, the management options based on previous research findings [7,8], and assessed how AT might be changing these options. It also looked at the flexibility in appointment booking offered and compared practice manager satisfaction [14] with the introduction of AT. The questions relating to satisfaction [14] were based on three different aspects of task-related satisfaction (resource adequacy, challenge and workload management) and one based upon general satisfaction. The short scale questionnaire was used in this setting and modified for practice managers. The questionnaire had been used in a range of previous quality employment surveys where the Cronbach alpha coefficient was 0.55. The Cronbach alpha coefficient in this study was 0.817 among these 7 questions. The questionnaire was first piloted among 15 general practices in a district council area outside the WHSSB area. Descriptive data about each practice was supplied by the WHSSB. The questionnaire, along with a brief covering letter was sent to the general practitioners in the practice, with the request that the practice manager complete and return the questionnaire. Non-responders at the end of 4 weeks were sent another questionnaire and letter by post. All data were statistically analysed using version 12 SPSS. Comparisons were made between different practice profiles and AT introduction using Chi square testing, independent t test sampling, odds ratios and confidence intervals as appropriate.

Appointment systems
Managers from 56 (94.9%) practices completed questionnaires. Practices used a variety of appointment systems to manage patient access (see table 1). All of the practices in the area (n = 59) had applied for and received enhanced service access payments for meeting the AT. Some 52 practices (92.9%) kept computerised records of appointments, with four practices (7.1%) using paper records only.
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. The n = 32 practices reported how different appointment systems had changed since the introduction of AT (see  table 2). Practice managers rated how particular appointment systems had been affected in their own practice using a scale -1 to 1, where -1 = used less, 0 = no change and +1 = used more.
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.

Flexibility in booking appointments
Among the 54 practices which used appointment booking, 53 (98.1%) offered patients the option of booking appointments more than two days in advance. Despite this, a significant number of practices n = 32 (59.3%) restricted the time in advance that patients could make bookings (see table 3). This ranged from one to 15 weeks, with median and mean times each of four weeks. The other n = 22 (40.7%) did not restrict advance 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 ruralbased 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
Practice managers were generally satisfied with AT and the management of patient access within their practices (see table 4). The mean satisfaction score was 5.57 (SD = 4.28). Most practices n = 41 (74%) had receptionists who had received some training in appointment management and patient access. Nonetheless, 14 (25.5%) had not received any training. Only 3 (7.5%) practice managers reported that their receptionists had received training in appointment management or patient access outside the practice setting. The absence of training was not associated with different practice profiles or patient list size. *Practice managers were asked to rate change to individual appointment systems on a scale of -1 to 1.
-1 = appointment system used less or not used in the practice since AT introduction 0 = No change to how appointment system is used in the practice +1 = Appointment system used more or now used in the practice since AT introduction Practices that used nurses to see "extras" had smaller list sizes (Mean = 4088, SD 2699) than those that did not use their nurses in this way (Mean = 6507, SD 2982), mean difference 2419 (693 -4145), p = 0.007 (see table 5).
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  *Mean based on scale from -2 (Strongly disagree) to 2 (strongly agree).
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?

Conclusion
GPs in N. Ireland have been able to adjust to this government target by making changes to appointment systems and practice managers have been satisfied with its introduction. Factors relating to flexible appointment booking, receptionists' training and the development of the primary care nursing role were issues highlighted. Although this study has limitations, it is based in a standard primary care setting in N. Ireland and has a very high practice manager response rate. The data should contribute to the widening and continuing debate throughout the United Kingdom about the ease and speed of patient access to primary care, and the effect this might have on the rest of the NHS.

Competing interests
Both authors are practicing GPs. The research paper followed on from a thesis prepared for MSc in primary care, Faculty of Life & Health Sciences, University of Ulster, N. Ireland.

Ethics
The Office for Research Ethics Committee, Northern Ireland (OERCNI) independently ethically approved the study (REC reference number: 05/NIR02/66).