Wednesday, 2 January 2013

Opening the Doors

In November 2010 we took an important step as a practice. We opened our doors. We said, 'If you feel you need to see us, come down. If you feel you'd like a telephone call, ring us and we'll ring you back.'

Prior to November 2010 we had a GP on call, with patients phoning for urgent appointments. We would ring them back, usually ask them to come down depending on which GP was on call, and try to manage our workload and their problems. Phone calls and attendances would start at 3pm and finish at 6.30 at the earliest, often with visits in between, and there were extras in each routine clinic. Staff had the difficult job of managing demand amongst doctors, and we could see have up to 60-70 contacts in an afternoon for one GP.

To set some context, we are a large practice with 4 sites and over 27,000 patients. We have over 15,500 patients at our largest site, next to A&E but with high demand and high levels of social and medical morbidities. Over the last decade we had tried models such as nurse practitioner triage, GP telephone triage, minor illness clinics. We had recruited more doctors, more nurses, more reception staff due to a sustained rise in list size. How could we improve access for our patients?

So back to November 2010. The doors opened. Our Urgent Care Service was opened. We are very tight on space but we dedicated 3 clinical rooms to the service, built a separate entrance and allocated a separate waiting room and reception desk for registered patients with urgent, on the day, problems. No phone call needed. We employed nurse practitioners and an additional GP. We opened more routine appointments (no need for extras). We established a GP rota and ensured the Nurses and GPs worked as a team, with reception trained to ensure urgent problems such as chest pain or strokes were screened at the desk. Urgent and elective care was separated and access increased without contractual change or additional payment.

How do we judge if it has been successful? Patients think it is, and satisfaction surveys have been extremely positive. One patient judged the service as 8/10 because they'd 'had to wait 8 minutes', but the service has been extremely popular. We coped with a flu epidemic when we would have struggled, we can adapt the number of GPs and nurses per session as we can predict demand and routine surgeries now start and finish on time. Generally, patients are seen with 20 minutes, sometimes immediately, although at peak times it can be longer. Patients are learning when is best to attend. The doors open from 8.30 to 11.30 and 2.30 to 5.30. If there is a surge in demand GPs can help by seeing additional patients, but it is relatively rare. The 5.30-6.30 period is now relatively quiet.

In the last 12 months we have seen over 24,000 patients in our urgent care service. Most have been appropriate, and we have seen a small but significant reduction in A&E use during the day. Staff are not spending hours on the phone trying to get an urgent appointment for a patient, and visits seem to have reduced. Personally, I feel more confident having 'eyeballed' patients, and telephone calls are now genuinely for problems that can be dealt with on the phone. There are still some teething problems, some inappropriate attendances or days with longer waits, but we are getting there. We may have increased demand, but we provide a better service and we can't ask patients not to go to A&E if we don't provide an alternative.


  1. Wow. Well done. As a patient, this is exactly what I need - no more ringing the surgery repeatedly at 8.30am hoping to get through to book an 'urgent' appointment that isn't really urgent, but the system forces you to pretend it is - because you can't book an appointment in the next few days. You say you can predict demand. I think this is really interesting, Can you predict it by type and frequency? Or just volume?

  2. We can predict numbers on given days of the week now and staff accordingly. Epidemics become easier to spot. Have 2 years' data now which helps.