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ADVANCED ACCESS IN PRIMARY CARE
by
Dr John Oldham








 John Oldham 2001


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Preface

I would like to thank the National Primary Care Development Team for their help in
preparing this booklet. Also, Mark Hunt, John Bibby and Tim Wilson for their scrutiny of
the text. Most of all I wish to express my gratitude for the energy and hard work of the
practices on the Primary Care Collaborative and those who generously donated their
stories, without whose experience this booklet would not be possible.

The origin of the principles on advanced access owes much to the pioneering work of my
friend Mark Murray. I have known Mark for a number of years, from when he was a
physician in Sacramento, California to his current role as international consultant (Murray,
Tantau and Associates, murraytant@email.msn.com). There are only a few individuals in
our lives who develop concepts that are globally applicable; Mark is one of those rare and
talented people - and a great guy!




John Oldham January 2001
Head of National Primary Care
Development Team
Gateway House
Piccadilly South
Manchester M60 7LP

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This booklet is intended to provide a guide on how to improve access to primary care for
the patients of a practice. To do this, various examples are provided of practical steps that
have resulted in improvements. The reaction of most people when there is mention of
“doing today’s work today” is “this is impossible, it will open the floodgates”. This is based
on the premise that attempting to prioritise demand from patients is the best means of
coping with high levels of demand in general practice. In reality, many of the systems that
we are used to operating simply deflect demand to another day, perhaps several days
away, in order to ‘protect’ today. This then blocks the future ability to deal with demand
and has a recurrent knock-on effect on access. It does not reduce demand and
paradoxically, is likely to increase it.

Why? Because patients have to build into their thinking the expected wait to see
someone. Their threshold is therefore lower - “I will book just in case it worsens”.
Secondly, people will game the system. They will access urgent appointments or out-of-
hours services to bypass the queue. Staff are placed in potentially adversarial
relationships with patients. Patients, staff and clinicians become frustrated. Worst of all,
the system may unwittingly restrict access to someone who needs to be seen.
Alternatively patients deflect themselves to A and E departments who will probably send
them back to the practice.

Releasing the artificial constraints on dealing with patient demand as a means of
improving access and easing staff pressures feels like the wrong thing to do. However,
demand is predictable according to list size and, contrary to popular thought, is finite.
There are now many sites that have moved towards the principle of “doing today’s work
today”. Their experience is that:

♦ Patient demand is smoothed and occasionally reduces, particularly for of hours (people
maximise self-help in the safe knowledge they can be seen when they want to be
seen).
♦ Patient satisfaction increases.
♦ Staff and clinician satisfaction increases.

The elements of this new system (advanced access) that achieves the results are:

♦ Understanding the demand for access to a specific practice
♦ Shaping that demand
♦ Matching the capacity of the practice to meet the demand
♦ Having contingency plans to sustain the system

These components are described in detail over the next few pages, along with examples
of practices currently operating various aspects of the system.


Introduction

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Case Study (1)




A six partner practice in a semi-rural area with 11,500 patients. Before the collaborative,
the waiting time for a routine appointment was 3-5 days with lots of gaming by patients and
staff to fill ‘urgent’ slots. They introduced all the components of advanced access;
segmenting demand using the telephone, altering how they handled demand on Mondays,
having contingency plans for staff absences and high demand. They can now ‘do today’s
work today’. Previously only 60% of patients were being seen when they wished to, now it
is 100%. Their DNA rate has dropped from 120/month to 20/month 'freeing up' 1000
minutes per month of GP time. Demand has not increased and staff and doctors find their
lives easier.



Characteristics of Access Models


Most practices in the UK will operate a traditional system with a number of urgent and non-
urgent appointments available, sometimes in combination with a system of open access,
where everyone who turns up is seen but has to wait a long time. In the traditional system
there are battles between patients and practice staff around what is or is not urgent;
patients game the system, receptionists and doctors apply the system differentially for
particular patients and the whole scenario can be stressful. This system also usually pays
little heed to the variation, which is predictable variation, in daily demand throughout a
typical week e.g. everyone knows Mondays are ‘busiest’.

If one day’s demand is put off until another day, there is a magnified effect on the queue
that develops for future availability. An analogy might be if a slow moving vehicle moves
into and blocks a space in the traffic on a motorway, an enormous queue builds up which
can, when the motorway is very busy, result in the vehicles at the back just crawling. We
have all been in that situation where there is no apparent reason for the slow down.
A traditional appointment system can work in the same way. Consider what a typical
week’s booking sheet might look like on a Monday. The numbers below are arbitrary and
for illustration only but the pattern is representative.

















Day


Mon
Tues Wed
Thurs Fri
Max. no. of

150
150
150
150
150
available appointments

Daily demand

175
150
125
150
150

Blocked urgent
for the day
Filled routine
Free routine
30 30
30 30 30
120
110
110
100 115
0
10
10
20 5
Blocked urgent
Filled routine
Free routine

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If the daily demand on a Monday is 175, then 30 people may find themselves, one way or
another, in the urgent slots – but there are 145 patients still not catered for. 45 can be
slotted into free routine appointments later in the week (10 + 10 + 20 + 5) but that blocks
the rest of the week, and even those more fortunate patients will still have to wait 3 – 4
days. The rest (100) are deferred into the free routine appointment slots the week after,
blocking that week’s capacity and repeating the pattern for subsequent weeks. This still
doesn’t account for those patients who really are urgent and also have to be added in. On
Tuesday, Wednesday, Thursday and Friday, the same sequence of events occurs with the
demand on each of those days (e.g. 150, 125, 115, 150) deferred to the future.

This deferred demand is what we call backlog, i.e. the number of days where there are no
free routine slots for an individual clinician.

Imagine now that you start the week with a blank sheet.









MON
TUES WED
THURS FRI
Daily Demand

175
150
125
150
150

Available non-

150
125
125
150
150
booked appts

(150-25) (150-25) 125
150
150

Carried over

25
25
0
0
0

By Wednesday you would be in a position to do ‘today’s work today’ with no carry over for
the subsequent week. The aim of advanced access is to get to that position. Note that the
demand, and therefore the workload, is unchanged.


Consider now that you seek to shape that demand by dealing with patients in safe,
different ways from face to face consultation. These efforts can dramatically reduce the
need for face to face appointments (see later) which releases “hidden capacity” in the
system. (Figure 1 illustrates schematically segmenting the demand in various ways.)

The balance can be achieved on each day. Capacity and demand is in equilibrium on a
daily basis. The distinction between “urgent” and routine with its rules and regulations and
battles, is no longer necessary.

Model for access

Figure 1


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Responding to demand
N HS D IR EC T
PH AR M A CY
OT H ER SO UR C E S
SEL F
H ELP
PA TIEN T
EL ECT R ON IC
A CC ESS
TE LE PH ON E
A CC ESS
P ER SO N A L
A TT E ND A NC E
W EB S ITE
IN FO RM A TIO N
E-M AIL Q U ER Y
D r
Q U ER Y
D N/H V
A PP OIN TM E N T P r NU R SE

M ID W IVES
IM M E D IAT E
A SS IS TA N CE
O T H ER


Preventing people booking an appointment when they wish to is no longer necessary.
This sounds crazy but is true. Why? Because you can be confident that your capacity can
meet your daily demand, because you have calculated it from gathering relevant data
beforehand.

So what about follow-ups? By definition, these should be treated as part of your daily
demand, and therefore part of the mathematical equation. In other words, the calculation
of daily demand is:

Daily demand = same day demand + follow-ups + other appointment types.

Daily demand is therefore a request for an appointment received on a specific day
whether it is requested for that day or not.

An essential element of moving to advanced access is to understand not simply the totality
of daily demand but the profile of that demand. This enables you to determine the
proportion of appointment slots that need to be available for ‘same day’ demand, and the
proportion of appointment slots that can be booked in advance. Evidence suggests that
this proportion will vary for each practice.

Understanding this allows you to ensure that on a busy day for demand (e.g. Mondays) the
system is not clogged with follow-ups, but equally that follow-ups are accounted for in the
week’s profile of the appointment system. Case study 2 illustrates how one practice did
this.


Case study (2)

Before starting advanced access, the practice had a high rate of DNAs, with surgeries fully booked 3-4 days
ahead. It had insufficient capacity to deal with acute appointments at the beginning and end of the week.
Problems around accessing the GP were causing some friction between patients and receptionists. GP
telephone consultations were undertaken, 10 minutes in the morning and 30 in the afternoon. The system
led to banking of calls, repeat calls and problems with accessing records on time.

Following the first Learning Workshop, two initiatives were undertaken. The first related to the appointments
system: daily demand was assessed over three weeks, determining that around 44 appointments were
required each week for follow-ups (the number varying on different days). The remaining appointments each
week were available appointments. Work was undertaken to remove the backlog. Since then, the third
available appointment (the measure used to determine wait time) has consistently been zero, there has been
a reduction in DNAs and cancellations, and patients are more satisfied. The number of follow-up
appointments needed is reviewed weekly to ensure that a bookable follow-up appointment is always

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available five working days in advance. The surgery introduced seven 5-minute booked telephone
consultations each day, where the GP would telephone the patient. The system was advertised in the
practice. Repeat calls and queuing no longer exist, notes are gathered in advance, and staff and patients
have received the new system well.


In order to move from the traditional model to advanced access there is a sequence of
events.



Step 1

Step 2

Step 3
Step 4

Step 5



dissatisfaction

understand

shape the
match capacity

put
with life as you

demand each

handling
to demand

contingency
know it


day of a typical

of demand
work down the

plans in place



week




backlog



What follow in the next few pages are practical tips on how to progress. The most
successful sites in improving access carefully understood the need to take account of
patient views, and planned their communication with patients about the system changes.

Quite a number of practices work hard to do the sums and effect improvements that
change the handling of demand, establish contingency plans and work down the backlog –
but remain nervous or unsure about how to handle demand for new appointments for the
future (as opposed to follow up). For example, a patient may ring and, because of their
personal circumstances, want to book an appointment in advance rather than the same
day. Some practices striving for advanced access have overcome this insecurity by
imposing new rules on the new system that insist patients ring again on the day they wish
to be seen. However, there is no need to do this. As mentioned, the calculation of daily
demand, which provides the basis for the mathematics (see next section), takes account of
all requests for an appointment whether for that day or not. The variation in patients
wishing to book in advance has already been accounted for, and if you have matched
capacity to predicted demand on a daily basis, then this should balance out correctly. The
only blocking off of appointments on a given day should be for the profile of follow-ups
previously calculated – what we might term “good” backlog. This is different from blocking
off the whole day until that day.

The advanced access appointment system would then look like this.

Day



Mon
Tues
Wed Thurs
Fri

Maximum number of
150
150
150
150
150
available appointments

Daily demand with adjusted 130
115
80
115
130
handling of demand

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You therefore can walk in to a Monday morning knowing the system has the capacity to do
today’s work today. Patients aren’t battling with staff and the system works more smoothly
for patients, doctors and staff. This is the experience of those who have adopted
advanced access (see table 1)
Free
appointments


Pre-bookable
follow-ups


Case Study (3)

Among the largest surgeries in the country this 10,000 patient practice in an
industrial town, with 11 partners and 2 associates has improved patient access
by using a number of techniques. These include freeing up GP time by
introducing nurse triage of visit requests and same day consultations, training
nurses to run chronic disease management clinics and introducing a Health
Visitor surgery for under 5s. A Duty Doctor system has also been introduced
so that GPs have undisturbed time in surgery. The practice reports positive
results: every patient can be seen the same day requested, empty slots are
appearing in surgeries and a senior receptionist remarked that she had
experienced the ‘happiest two weeks in the 15 years I’ve worked here’. The
third available appointment for GP’s has reduced from 4 days.


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Table 1: Characteristics of the various access models
(adapted from Murray)

Traditional Access

♦ Over full appointment schedules
♦ Work pushed forward from the past to “protect today”
♦ Urgent/routine appointment types
♦ Potential long waits for routine appointments
♦ High DNA rates
♦
Inequality of access
♦ Patients “game” the system
♦ High demand for out of hours services
♦ Backlog of routine work
♦ Considerable “noise” in the system from patients complaints
♦ Stressful environment for practice staff


Open Access

♦ Over full schedules
♦ Attempts to deal with demand on the day
♦ Capacity gained by working harder/longer
♦ Long waits for patients in the surgery
♦ Urgent/routine split
♦ Patients game the system to be seen as “urgent”
♦ Little control over workload
♦ Considerable noise in the system from patients complaints
♦ Stressful environment for practice staff


Advanced Access

♦ Handling demand altered and face to face consultations used more effectively
♦ Work pulled into today to “protect the future”
♦ No distinction between urgent and routine appointments
♦ Maximum control over workload
♦ No backlog (capacity and demand are in equilibrium each day)
♦ DNAs significantly reduced
♦ Greater equality of access
♦ No need for patients to “game” the system
♦ Less noise in the system
♦ Reduced demand for out of hours services
♦ High practice staff and patient satisfaction


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HOW TO PROGRESS


Understand the profile of demand


This has been referred to previously but is central to achieving advanced access, and is
therefore worthy of repetition.

• Understand the daily demand

Daily demand is a request made for appointment on a certain day whether for that day or
in the future (Appendix 1).

♦ Every day, record the total appointment requests in a practice (regardless of the
day to which the appointment is actually assigned). This should include telephone
requests; those made in person, and follow-ups. Do this for a week. Compare the
daily demand with appointments offered. Appendix 1 has a suggested tally sheet
for this.
♦ Analyse the volume and type of appointments over the week. Look for predictable
variation.
♦ Analyse how many appointments (%) each day are follow-ups (e.g. Monday 10%,
Tuesday 20%, Wednesday 30%, Thursday 30%, Friday 10%). This is important.

• Monitor follow-up ratios;

♦ Are guidelines being followed?
♦
Is there variance in follow-up ratios between clinicians? Does this indicate skill
needs?
♦ The highest daily demand is usually a Monday; eliminate wherever possible follow-
ups on Mondays; ask people to return in 8/9/10 days time etc.


Adjust the handling of demand

The aim here is to reduce the demand for face to face consultations and increase the
efficient use of face to face time.

•
Increase self-help

♦ Patient manned ‘desk’ with advice leaflets, video library, for drop-in,
(e.g. Hadfield Medical Centre Derbyshire)
♦ Consistent line on managing minor illness in the primary care team.
♦ Ask patients what they would like and mould advice material accordingly.
♦ Self care protocols (e.g. www.manorhousesurgery.co.uk )

• Web site

♦ Lots of opportunities for education, links with other sites e.g. NHS Direct decision
tree, bespoke minor illness advice. (e.g. Marple Cottage Surgery web site
www.marplecottage.co.uk).


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• E-mail

In our view, this means of communication will accelerate exponentially in the first few
years of this millennium. In one practice, which began e-mail requests for repeat
prescriptions, there was an increase from 5% of requests to 30% within 4 months. The
users were predominantly the retired. Tips are:

♦ Set up different e-mail addresses for Health Visitor/Community Nurse/Practice
Nurse/GPs/Receptionists. Note: patients’ use of e-mail to query receptionists is as
high as that for clinical staff. (Example: Dartmouth Hitchcock MC, Nashua, New
Hampshire, USA).
♦ Set up an access code for patients (e.g. their computer number) to facilitate
confidentiality.
♦ E-mail is used in some places by patients for:
- checking instructions at recent consultation
- checking results
- ordering repeat scripts
- advice
- admin functions e.g. checking appointment times, change of address
-
running e-mail ‘surgeries’ (Marple Cottage Surgery/ Dr A Midgley, Holmefields
Surgery, Exeter)
♦ E-mail is used by practices effectively for e-mail reminders for immunisation and
travel vaccination and could be used for call/re-call/follow-up. (Dr A Midgley,
Holmefields Surgery, Exeter).

• Creative telephone access

♦ Many practices have now used telephone consultation for dealing with same day
demand. This can be done either using a nurse (e.g. Girlington Practice, Bradford)
or a doctor (Dr Moyez Jiwa, Bridgegate Surgery, Retford; Dr Kevin Reynolds, St
Mary’s Surgery, Southampton; Dr Robin Sharman, Lockwood Surgery,
Huddersfield). In general, 40 – 50% reduction in the need for face to face
consultation is obtained.
♦ Other practices hold ‘telephone surgeries’ where a series of calls is timetabled into
the routine schedule. Patients are asked to call at a specific time or leave a
telephone number where they can be reached. This is particularly useful if there is
high demand for consultation for a particular clinician. That clinician can introduce
the caller to another team member to take forward an aspect of their care, creating
an alternative relationship. Using this for follow ups or medication reviews can
reduce the need for face to face consultation by 15-20% (Example Queensbury
Health Centre, Bradford).

Note: ‘Manage’ the initial contact point: apply the same standards to telephone, e-
mail use, personal attendance.
Aim for patients not to have to repeat information
Check frequently the views of patients and their understanding of the system

• Group consultations

♦ Some places have successfully managed high users of the service by bringing them
together for an hour’s session. People seem quite happy to discuss their issue
jointly. The clinician (nurse/doctor) is there for a half hour, another staff member for
the full hour.


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Match capacity to demand


Having changed the way demand is handled the next step is to balance the appointment
capacity with that demand by ensuring the daily appointment profile matches the demand
profile. When moving to this new system there will still be an overhang from the old
system of people waiting to be seen (“the backlog”).

As a result of experience, a sequence of events is recommended that eliminates the
backlog of appointments and achieves a ‘steady state’ for the practice where capacity and
demand are in equilibrium on a daily basis – Advanced Access.

• Reduce the backlog of appointments


1. Calculate the backlog. We define backlog as the number of days between today and
the earliest availability of an appointment. A useful measure of the backlog (which
helps to smooth out large day to day fluctuations) is the time a patient would have to
wait to access the third available appointment slot at the time of making the request.
Although this sounds clumsy it proves very useful information for planning e.g. if the
third available appointment with a doctor or nurse is in X days, and there are normally
Y appointments per day, then the backlog Z = X x Y. This means that Z appointments
need to be ‘worked through’ before the backlog will be cleared.

2. Set up some simple systems for shifting the demand quickly, as above, and a
contingency policy i.e. what happens automatically if someone is, off sick, on holiday,
or if there is an epidemic.

3. Match capacity of appointment system to predicted daily demand to ensure that after
working down the backlog you are in a stable state. Take into account the number of
follow up slots for each day. Eliminate the distinction between urgent and routine
appointments.

4. Set a date by which the backlog will be cleared. This will require hard work and need
short term additional capacity e.g. additional time each surgery or alternative shift
patterns. Once a stable state is reached, i.e. daily capacity = demand, then it becomes
easier to manage any day to day variations in the predicted demand for appointments.

• Anticipate associated needs

♦ Wherever feasible, maximise the interactions at a single visit to the practice e.g.
blood tests, medication reviews, routine BP/weight checks. Build this ability into the
system e.g. run a health visitor or nurse clinic alongside surgeries to enhance
capacity to deal with near-needs.

• Build in flexibility

♦ The most effective approaches to improve access decrease the number of
appointment types. This increases the flexibility for patients and decreased queues
created by multiple appointment types. In advanced access systems, there will be
no need for division between urgent and routine, and the follow-up is more
predictable. Check how you divide up your appointments, for example,
hypertension, diabetes, asthma, etc.


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• Maximise personal contact with clinician of patient choice

♦ This is difficult. We know however that re-visits reduce if people can check with
someone they trust. Think about alternative forms of access in this respect or a
patient’s favoured clinician ‘validating’ the patient seeing someone else e.g. health
visitor or nurse for chronic disease management. Telephone management of
consultation has proved effective in managing demand for a “popular” doctor.

• Match Team to Work

♦ The team can ask itself four questions:

What is the work
- e.g. follow up post MI patients
Who does it now
- e.g. GP
Who could do it
- e.g. Health Visitor or Practice Nurse, or both.
What is the next step - e.g. current staff assessment and training programme

There are many examples of expanding skills of individuals to change the process that a
patient experiences (Example: Health Visitor under five clinic - Adams Practice, Poole;
Receptionists as phlebotomists - Nelson Fold Practice, Salford East PCG). Understanding
the skill mix changes you need leads into determining training needs and the requirements
you wish to put in your Primary Care Development Plan.

NB: Don’t create delays in a process by adding steps/people to an existing one.


• Appraisal Systems

Many people already have appraisal systems in place. However, linking appraisal
firmly to a strategic plan (e.g. post MI care will be a nurse led service), identifying skill
needs and ambitions and mutually agreeing a programme has been found to be a key
success factor in small primary care organisations. Each staff member in these
organisations has a clear development plan to enhance their personal skills, which will
assist service improvement.

• Personal Development Plans for Clinicians

An example in one practice: each clinician fills out a skill assessment of every other
clinician, as well as themselves. In pairs, the self-assessment is compared to peer
assessment and development needs identified. The development needs may be linked
to new skills required to facilitate a strategic change in service delivery. (Example:
Carlisle PCG Transfer of Nursing Skills).

•
Involve Patients

Get patients involved in redesigning services: staffing help desks; providing support.
(Example: Hadfield Medical Centre, Derbyshire).

• Self Management

Choose a chronic disease programme to maximise self-management by patients e.g.
asthma, diabetes. Check on the educative input to patients by staff by testing their
understanding of the disease by questionnaire. (Example:
www.manorhousesurgery.co.uk)

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Contingency plans

Even though most demand can be predicted, unexpected situations will occur. It is better
to have automatic policies to meet overflow demand, and to place the decision to
implement that plan close to the patient e.g. receptionists. It is better to have a written
plan with clear criteria and involve all levels of staff in a group to create that plan.

The sorts of eventualities to be planned into the system (so that there is an automatic
response) are:

♦ Excess demand, certain unpredicted demand
♦ Holidays, education and other ‘planned’ absence
♦ Sickness and other ‘unplanned’ absence
♦ Seasonal variation (flu etc)

Example: Vine Surgery, Mendip PCG.

Measures

If we are to seek improvement, we need to know where we are and track progress with
reliable and simple measures. The ones we advocate are also a proxy for the alternative
forms of access and different team working we have suggested, since if these actions are
effective we know it will ease access for face to face consultation.

% patients seen by practice on day of their choice

This measure captures the ability of the practice to see patients when they want to be
seen, which may not be the same day.

How do I measure it? (see Appendix 1)

Use a small, random sample of patients (a minimum of 5 in the morning and 5 in the
afternoon) and, every day over the course of a week, ask this number of patients whether
they had an appointment on the day they requested. Make sure that patients are asked at
different times of the day. Count the number of patients who said they were able to get an
appointment on the day of their choice, and calculate this as a percentage of the total
number of people interviewed. You can either do this continuously to detect early
problems, or at greater frequency. The validity of such small samples comes from
measuring this over time.

3rd available appointment

Why should we measure 3rd available appointment for Doctors and for Nurses?

It will be clear by now that the strategy is to improve various forms of access and handling
of demand, which should increase the capacity of the appointment system for face to face
consultations. Therefore, measuring available appointments is a proxy for success in
those other areas, which will give a good indication of progress. However, we know that if
you just take the 1st or 2nd available appointment then this is highly subject to random
effect, e.g. a sudden cancellation. The 3rd available appointment is a much more

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successful measure of how the system is functioning. The following sounds complicated
but actually isn’t when you do it.

What is the 3rd available appointment?

If a patient requested an appointment with Nurse A or Dr B then the following routine
appointments may be available in chronological order:

1st appointment
4.00 p.m. today
2nd appointment
4.30 p.m. today
3rd appointment
8.45 a.m. tomorrow

The 3rd available appointment would be 8.45 am tomorrow and is recorded as 1 day. If the
3rd available appointment had been 8.45 a.m. the day after tomorrow it would have been
recorded as 2 days.

How do I measure it?

Experience with many practices has allowed a refinement of the method of measurement
to match more closely the working environment of most practices. To produce a summary
measure which will give a good indication of the availability of appointments during the
course of the month, we suggest using the median appointment time for GPs and for
nurses (see footnote on the median below).

There will be some practices for whom the median is not the most appropriate summary of
3rd available appointment (e.g. a two-partner practice where one of the partners is part-
time). In this case, it will be necessary to calculate a weighted average. An example of
how to do this is included in the “Note on measurements with weighted averages”
Appendix 2.

The measurement will be made as follows:

During one month, make the measure on one day in each week. This day will be referred
to as the “measurement day” (we advise rotating the day - e.g. Monday during week 1,
Tuesday during week 2 etc. - to give a better overall picture of the whole month’s activity).

At noon on the measurement day, use the practice appointment system to count how
many working days it would be until the third available routine appointment with a) each
GP and b) each nurse.

Take the median value (i.e. the middle value) for GPs and for nurses.

At the end of the month, there will be four median scores for GPs and four median scores
for nurses. Take the average of these for each professional group. These will be the
measures you can track.

An example

A practice has four GPs and three practice nurses. Information collected on one
measurement day will look like this:

Footnote: The median defined
The median is a statistic used to describe a series of numbers using a ‘typical’ value by taking the ‘middle’ value in a series. If a series
of scores for a measure are, for example: 3, 7, 6, 1, 1, 5, 3 - to calculate the median, rearrange the sequence of numbers into size order
(1, 1, 3, 3, 5, 6, 7), and count how many numbers there are (seven in total). The median will be the middle value, which will be the
fourth number: 3. If there are an even amount of numbers, take the average of the middle two.

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Days to 3rd available
appointment

Days to 3rd available
appointment
GP A
6
Nurse P
4
GP B
4
Nurse Q
3
GP C
1
Nurse R
8
GP D
3




Ordering the GP scores gives: 1, 3, 4, 6. The average of the two middle values is (3+4) ÷
2 = 3.5. This is the median for GPs for this day.

Similarly, ordering the scores for nurses gives: 3, 4, 8. The median here is 4.

There are 4 medians for GPs and 4 medians for nurses. For each group, take the simple
average (i.e. add these scores together and divide by 4). This gives the 3rd available
appointment measure for each of these two professional groups.

Do not include

♦ Any Doctor or Nurse who is on holiday during the measurement week unless they are
covered by a locum;
♦ Any appointments for urgent cases that may become reclassified later for routine cases
(these are not routine appointments at the time of measurement);
♦ Saturday or Sunday (i.e. when collecting data on a Friday, if the 3rd available
appointment is on Monday, this counts as one day).





The variety of ways in which practices operate and are organised poses difficulties for
developing ‘standard’ measures. The ones suggested have been refined through the
practical application of them to hundreds of practices. But we must also remember that
information should be useful, not necessarily perfect.

During use of the measure, a number of questions frequently arise. It may assist practices
to be aware of these queries and response.

How does the 3rd available appointment relate to the target of 90% of patients
accessing their health care professional the next working day?

“Access” in this context means a variety of things, including telephone contacts, electronic
mail and so on. If we tried to measure all of the different forms of access and whether they
wee available during the next working day, the measurement task would be enormous.
However, all the different forms of access have an impact on face-to-face appointments,
and face-to-face consultations are relatively easy to count. In this way the 3rd available
appointment is a proxy measure, meaning we can be confident we have reached the 90%
target if the 3rd available appointment is the next day for the practice.

Frequently asked questions on measures
Frequently asked questions on measures

2-8
Why measure the 3rd available appointment for all GPs and all nurses and combine
them - why not the 3rd available appointment with any clinician?

If the measure was of appointment availability with anyone in the practice, to get a true
picture the appointment would have to be something like the 6th or 7th available
appointment and adjusted for practice size. Most patients tend to consult the same GP or
nurse where possible. Therefore, to try to represent the total availability of routine
appointments in the way in which most patients will use the practice, it is suggested the
measurement is performed for each clinician then aggregated.

What about locum staff?

Treat the locum as if they are the GP that they are replacing.

What if we have a GP who’s very rarely in the practice?

If there is one member of the clinical staff who has very few clinical sessions and whose
figures would unfairly distort the summary measure for the practice, they can be excluded
from the figures.

What if our practice nurses don’t operate an appointment system like the GPs?

Practice nurse workloads may include a significant proportion of work for which there are
not ‘routine’ appointments (for example, chronic disease management clinics). If there are
‘routine’ practice nurse appointments for any other part of their work, then calculate the
measures for these. If there is no appointment system for practice nurses at all - i.e. there
is no part of their work where patients may book a routine appointment with a nurse - then
you will not be able to calculate the 3rd available appointment measure for this group.

What if we only have two GPs/practice nurses and one of them is part-time?

Calculating a median for two members of staff in this case would not give a good indication
of true waiting times. In this instance, it would be better to calculate an average, weighted
for the part-time proportion of staff time. Full details of how to do this are given in
Appendix 2.

Continuous monitoring

Once the system is stable, you should be able to switch to a different measure for
monitoring.

• Monitor % available appointment on a given day.
•
If this drops, check daily demand to see that there hasn’t been a change.

2-9
Appendix 1

Assessing Current Daily Demand

Practices need to measure the daily demand for appointments. This simply involves
counting the number of requests for appointments every day for one week and will enable
practices to:
♦ understand the scale of total demand for appointments;
♦
identify the variation that occurs on different days of the week.

Below is an example of a data collection tool to record appointment requests. Requests
are recorded for the different types of clinicians within the practice. This information
includes requests made on a particular day but for a future date. Record requests made
by telephone, those made in person, and follow-ups. Identify follow-ups separately.


Example tick sheet

Appointment
with/for

Monday
Tuesday
Wednesday Thursday Friday
Total for
week

Doctor


Follow-ups

////
////
///






Nurse
Practitioner

Follow-ups


///






Practice
Nurses

Follow-ups


////







Notes

Although many practices will have other people working in the team who see patients, their
work is part of the alternative route for dealing with demand and not measured as part of
this exercise.

2-10
Appendix 2

Note on measurements with weighted averages

Calculating weighted averages

If the practice has part-time clinicians, these need to be allowed for in the calculations,
otherwise the measure for the practice may be distorted - waiting times for part-time staff
may make the overall figures for the practice appear too long.

One of the ways adjustment for part-time clinicians can be made is by taking a weighted
average in the following way:

1) Record the number of days until the 3rd available appointment for each GP/Nurse
during the month as usual but do not calculate the median as described previously.
2) Calculate an average (mean) waiting time for each individual GP and nurse.
3) For each individual, multiply the average figure by their whole time equivalent figure
(e.g. as above).
4) add up the figures from these sums for all of the Doctors and all of the Nurses giving
one figure for all Doctors and one figure for all nurses;
5) Divide these numbers by the total whole-time equivalent figure for each group (e.g. a
full time nurse and a half-time nurse would be 1+0.5=1.5). These will be the weighted
average times.

Example calculation for Nurses





Staff

Whole time
equivalent fig
(WTE)

Number of days to
3rd appointment
(average for the
period)

WTE x
number of
days to 3rd
appointment




Weighted average:
Nurse A
(full time)
1
3
1 x 3 = 3
Nurse B
(half time)
0.5
4
0.5 x 4 = 2

Total:
1.5

5
5÷1.5 = 3.3 days

Nurses 3rd available appointment measure = 5 ÷ 1.5 = 3.3 days (round to one decimal
place).


2-1
CONCLUSION

Looking systematically at the weekly work of a practice is the starting point to improve
access. Gaining an understanding of both the totality of the demand as well as its shape
throughout a normal week is the building block for change.

This change involves altering how that demand is handled, maximising the use of self-
help, telephone and electronic communication. Part of the improvement includes
analysing who handles the demand, who could handle it and how to make that happen. A
sequence of simple things starts to unblock the old system, creating a balance between
demand and capacity. Ensuring this balance is maintained by having plans for absences
or unexpected high demand is the final piece of the jigsaw – the picture of Advanced
Access.

All changes are carefully measured, but in simple ways that allow the tracking of
improvement. So, what do those who have experienced Advanced Access think?

‘I’ve worked here for 15 years; the two weeks since we introduced advanced access have
been the best of my working life’. A Receptionist.

‘We’ve certainly seen a huge increase in clinician satisfaction. I myself have found
surgeries much more acceptable, I feel much less stressed, much less hassled, I feel I’m
actually giving much better patient care’. A General Practitioner.

‘Can I say how much better the new staff are than the old ones, I don’t have to fight to see
you, it is so reassuring’. A patient, commenting on an unchanged staff team.

As a clinician, improving access is not just about meeting targets; it is about improving
care for our patients. Seeing people when they want to be seen pre-empts problems and,
after all, is it not what we would want for ourselves or our own important people? As Paul
Batalden says, ‘every system delivers exactly the results it is designed to give’ – pushing
the old system harder won’t work, creating more of the old system won’t work, thinking
differently does.