The King Canute GP appointment systemBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g7228 (Published 11 December 2014) Cite this as: BMJ 2014;349:g7228
- Ron Neville, general practitioner,
- Simon Austin, general practitioner
- Accepted 10 November 2014
Our practice, close to the North Sea, had a major access problem. After mergers and development of a large multidisciplinary team we found our prebooked general practitioner appointments were overbooked and we were reliant on adding extras to every surgery. This led to discontinuity of patient care, protracted telephone calls between patients and reception staff, and a practice culture of pressure and stress. We needed to make a change.
Recent major changes to the health service—the Quality Outcomes Framework1 and the Health and Social Care Act2—have been introduced without testing. We thought we might follow suit. However, we thought recent health secretaries, although dogmatic in imposing their will on the NHS, lacked the charisma of true leadership, and so we turned to an 11th century king for inspiration.
In AD 1028 King Canute tried to command the tide to turn back. History records that the king of all lands surrounding the North Sea got very cross, wet, and made a hasty retreat. Every day, in general practices across the country, dedicated practice teams get very cross when they are yet again unsuccessful at meeting the daily demand for appointments and the incoming tide of patient demand and expectation. What could we learn?
The big idea
King Canute could have kept his feet dry and his reputation intact if he had reflected for a moment, consulted with his courtiers, and moved his throne back up the beach to the high tide mark. From there he could have surveyed the North Sea every day and sat comfortably as the tide ebbed and flowed.
We decided to retreat to the “high water mark” of patient demand. In keeping with an aquatic metaphor we introduced “the pool.” What if we offered unrestricted appointment access to all patients who thought they needed to be seen that day? What if we created a daily appointment pool with no limit to capacity, and a guarantee to see every patient that morning, without fuss, argument, or negotiation while still providing enough prebooked appointments for patients who wished to plan ahead for scheduled care?
We formed a working group of two partners, reception manager, and senior practice nurse. We calculated the basic number of prebooked appointments needed for our eight partner urban teaching practice of 10 300 patients.3 We then calculated the maximum possible appointment requests that could occur on our busiest days, with daily demand completely cleared every working day. We floated the idea at a within practice training day and formed multidisciplinary groups to tease out some of the potential concerns and pitfalls. Key themes to emerge were the need to promote continuity of care and the need to balance patient demand with clinical need for urgent care.
The patient liaison group was supportive of the concept. Younger members grasped the opportunity this would give for concerned parents to have their children seen promptly, without protracted negotiation with reception or nurse triage. Older patients fondly remembered the days when they would be able to see their own GP, on the day, even if it meant a short wait. Our patients were supportive of the suggestion that in return for offering guaranteed immediate access we could ask each patient or parent to tell us, if they wished, what the clinical problem was and which doctor they usually saw. With increased rights comes responsibility. We outlined the proposed new system in our quarterly practice newsletter, widely read online and in the waiting room.
We went live. Our preplanned appointment slots with GPs remained in place but with each doctor being available for the daily pool session. In the morning all patients telephoning for soon, immediate, or urgent care were invited to attend at 10 30 am. Reception staff invited patients, if they wished, to state the clinical problem and which GP they normally saw. Patients were advised that they may have to wait a little longer than usual when attending for a pool appointment. When 20 patients had been booked at 10 30 am, patients were advised to come at 11 00 am, and then the next 20 at 11 30 am.
The first and most obvious effect of the pool was the effusive thanks from patients, particularly the parents of unwell children, that they could be seen promptly. Most patients were comfortable stating a simple summary of their reason for wishing to be seen that day—for example, possible urinary tract infection, suspected chest infection, headache. A few stated “personal problem” or requested a female doctor. Around half chose to state the name of their usual GP.
Within a few days the atmosphere at reception changed from one of stress to one of calm; calls were brief and the time for answering incoming calls was shorter. “Why didn’t we do this earlier?” was a voiced sentiment.
Many of our patients came slightly earlier than their appointed time. This meant we could take them early or within 10-20 minutes of their arrival. Patients were appreciative of being able to see their usual GP for management of flare-ups or acute changes to long term problems.
Nursing staff spent less time supporting receptionists trying to cope with patients wanting to be seen quickly. They also noticed that their work pattern became easier to plan, with fewer acute medical problems being added to their scheduled workload.
After a couple of months we held another staff training day to review the pool. Our reception manager appointed herself as pool attendant. Some patients were kept waiting more than 20 minutes if several patients had stated a preference for the same doctor. Others were not called because the patient had not checked in on arrival. In addition, she logged the patients who booked but did not attend and produced regular statistics of pool usage. Initially the car park was congested around 10 30 am, but this eventually resolved itself.
The behaviour of the doctors could be the subject of a psychology PhD. Our “innovative” partners convinced our “early adopter” to try the system and our “conservative” partners played the corporate team game to make the system work. Early on we had some competitive banter about who had seen the most pool patients each day. This then gave way to coffee room chat about who had seen the most challenging or complex pool patient, or perhaps the least appropriate.
Now we try to see ill children or distressed patients first, regardless of appointment order. Next we each see patients who have indicated a preference for a particular GP or indicated they have an ongoing problem being managed by a particular GP. If we have several requests for a female doctor, male partners make a point of trying to see any potentially difficult patients—for example, drug related presentations or patients with a history of aggression—to reciprocate. We have stopped counting how many patients each doctor has seen.
We have an unwritten understanding that if one or more doctor has several home visits scheduled they are encouraged to leave the pool early, letting the pool attendant know, and head off to start the visits.
Our registrars and attached medical students thrive on the training opportunities presented by the pool. Our more mature partners enjoy a refreshing mid-morning switch from preplanned care to acute care.
On some days we can have a few as four or five patients in the pool. On other days we can have 60. We always have a basic minimum of four doctors available for the pool but aim for six. It is rare for the pool not to be empty by midday.
A pleasant spin-off has been the ability to prove we meet whatever access target local or national bureaucrats throw at us. An unforeseen spin-off is that demand for our extended hours appointments is very low and we struggle to fill slots. Our demand for prebooked appointments with partners is unchanged. Now that the pool has settled down we are more liberal about allowing patients who need to see a particular doctor to book in for the pool a day or two ahead. We try to discourage this, but like King Canute, we have learnt we cannot control the tide.
Roll out to other practices
When our neighbouring practices heard about our new system it was greeted with gasps of incredulity that we could be naive enough to let patients manage appointment demand. We now offer them advice on how to implement the system. The key pool rules are:
Calculate the basic minimum demand for appointments with each GP and construct an appointment grid to cater for this
Ensure a basic minimum number of GPs are available every morning
Boil the kettle at 10 15 every morning and insist all doctors available for the pool meet, ready to start together at 10 30 am
Appoint a pool attendant to monitor the check-in, patient flow, and car park, and encourage GPs to leave the pool early if they have several house visits
Don’t count the number of patients each GP sees. It’s about quality
King Canute would have kept his feet dry if he had placed his throne at the high water mark, not the low tide point.
Evidence to support outcomes
In NHS Scotland’s Better Together patient experience survey in 2009-10 our score for patients seeing their preferred doctor was 74%. In the 2011-12 survey, after we introduced the pool, our score was 87%. This was 13 percentage points higher than the national average for practices of a comparable size. Our local emergency department says it does not have any problems with our patients using its service inappropriately, suggesting we are meeting demand for acute care well. Subjectively, our staff and our patients value and appreciate our team innovation. Objectively our statistics support this.
We did not quite manage an evaluation free radical NHS change, but we did try, and we kept our feet dry.
Cite this as: BMJ 2014;349:g7228
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.