Family Practice Advance Access originally published online on March 18, 2005
Family Practice 2005 22(3):266-268; doi:10.1093/fampra/cmi006
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Forty-eight hour access to primary care: practice factors predicting patients' perceptions
a Peninsula Medical School, Exeter, b Barts and the London, Queen Mary's School of Medicine and Dentistry, London E1 4NS, c Senior Lecturer in Medical Sociology, London School of Hygiene and Tropical Medicine, London and d Department of General Practice and Primary Care, GKT School of Medicine, Kings College, London, UK
Correspondence to Professor JL Campbell, Professor of General Practice and Primary Care, Peninsula Medical School, Exeter EX2 5DW, UK; Email: john.campbell{at}pms.ac.uk
Received 6 April 2004; Accepted 17 June 2004.
Campbell JL, Ramsay J, Green J and Harvey K. Forty-eight hour access to primary care: practice factors predicting patients' perceptions Family Practice 2005; 22: 266–268.
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Abstract |
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Background. The government has proposed a 48-hour target for GP availability. Although many practices are moving towards delivering that goal, recent national patient surveys have reported a deterioration in patients' reports of doctor availability. What practice factors contribute to patients' perceptions of doctor availability?
Method. A cross sectional patient survey (11 000 patients from 54 inner London practices, 7247 (66%) respondents) using the General Practice Assessment Survey. We asked patients how soon they could be seen in their practice following non-urgent consultation requests and related their aggregated responses to the characteristics of their practice.
Results. Three factors relating to practice administration and appointments systems operation independently predicted patients' reports of doctor availability. These were the proportion of patients asked to attend the surgery and wait to be seen, the proportion of patients seen using an emergency surgery arrangement, and the extent of practice computerization.
Conclusion. Some practices may have difficulty in meeting the target for GP availability. Meeting the target will involve careful review of practice administrative procedures.
Keywords. Access, administration, appointments, availability, General Practice Assessment Questionnaire, primary care, survey.
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Introduction |
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The UK government have determined that "By 2004, patients will be able to see a primary care professional within 24 hours, and a GP within 48 hours".1 A recent major national survey of NHS patients has suggested a deterioration in patients' perceptions of GP availability between 1998 and 20022 with an increase in the proportion of patients reporting they had to wait two or more days for an appointment with a GP of their choice (from 63% to 72%). This policy has been seen as contentious, and regarded by GPs' representatives as further fuelling already high expectations amongst the population3 with regard to the accessibility of primary care services. The NHS Plan calls for a greater role for the patient's voice in influencing the provision of services. Primary Care Trusts are increasingly using surveys of patients' opinions as a method for achieving this objective, in line with the new contractual arrangements for UK GPs.4 Smaller practices may have an advantage in regard to patients' perceptions of doctor availability over larger practices,5 but it is not known which features of practice structure might contribute to this perception. Many practices are now exploring alternative arrangements for providing access to their services,6 although it is not known how the introduction of such changes relates to the expectations of patients regarding primary care accessibility.3 The proposals outlined under the new contract for GPs7 tend to switch the emphasis from a clinician unit of care, to that of a practice. This study investigates practice factors determining the reported availability of GPs by patients in an inner city setting.
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Methods |
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As part of a study examining the accessibility of primary care,8 7247 consecutive patients (66% response rate) attending one of 54 volunteer inner London practices (from 202 approached) completed a questionnaire incorporating items from the General Practice Assessment Survey9 addressing perceived GP availability (median 138 questionnaires per practice, range 76–200). Subjects used an ordinal scale to report how quickly (on the basis of their previous experience) they were usually seen following a consultation request for which they were prepared to see any doctor in the practice (same day, next day, 2–3 days, 4–5 days, more than 5 days). Two measures of accessibility were determined for each practice: the proportion of respondents reporting that they were able to see a doctor (i) ‘the same or next day’, or (ii) ‘within 2–3 days’.
Practice characteristics were determined from a practice profile questionnaire. There was no practice clustering effect for the accessibility measures. Univariate associations between 16 variables from three broad areas of practice characteristic (size and staffing, appointment arrangements, population and environment) and the two measures of accessibility were calculated using Pearson's tests of correlation if one of the variables was normally distributed, or Spearman's if neither was normally distributed. For dichotomous variables, Mann–Whitney U was calculated (Table 1). Practices scored one each if reporting use of computer for: morbidity recording, routine consultations, acute prescribing, repeat prescribing, electronic links with health authority, call/recall programmes of care. A practice performance score (maximum possible score 6) was calculated for each practice (cervical cytology coverage amongst eligible women, immunisation rates at aged two and five years).8 Practice characteristic variables attaining a univariate significance of P 
0.1 were entered into stepwise multiple regression analyses with the measures of accessibility as dependant variables. Local ethics approval was obtained for the study.
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Results |
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Contributing practices were representative of practices in the two inner London Health Authority areas in respect of the number of whole time equivalent GPs providing care. Adult respondents were similar to non-respondents in respect of age, with females having a slightly higher response rate than men. Two out of three patients (66.9%, SE 2.8) reported that a doctor was available for consultation the same or next day following a consultation request with any doctor, compared with 89.3% (SE 1.6) reporting availability within 3 days of such a request. Two practice variables independently predicted the proportion of practice patients reporting that a doctor was available the same or next day following a consultation request: the proportion of patients asked to attend the surgery and wait to be seen (R2 change 0.25, P < 0.001) and the extent of practice computerisation (R2 change 0.10, P = 0.01). The proportion of patients reporting that a doctor was available within 3 days following a consultation request was independently predicted by the extent of practice computerization (R2 change 0.13, P = 0.011) and the proportion of patients seen using an emergency surgery arrangement (R2 change 0.08, P = 0.037).
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Discussion |
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Data collection was carried out using the General Practice Assessment Survey9 instrument, the precursor of the General Practice Assessment Questionnaire10—the latter being approved for use by practices in the new contract for GPs. Implementing a 48-hour target for GP availability is a challenging exercise.6 In this study, patients from more computerized practices, and practices seeing higher proportions of patients in emergency surgery arrangements had poorer perceptions of GP availability than patients from less computerized practices, and practices offering patients the possibility of turning up and waiting to be seen. It is not known whether these factors would predict patients' perceptions of access outside of London although the views expressed by the London patients seemed to relate to the more general concerns of patients reported in the NHS Plan.
Although there was an association between practice list size and patients' reports of the availability of a doctor the same or next day following a consultation request, this effect was not seen when the data were corrected for other variables using regression analysis. Findings from this present study add support to the earlier suggestion5 that practice administration and the operation of appointment systems may be of importance in influencing patients' perceptions of doctor availability. Further research is required to explore the observed association between the extent of computerization within practices and availability of services. It is not clear whether this reflects a difference in culture between practices, or whether practices with more extensive computerization have more efficient technical support for appointments systems arrangements.
If these patients' reports reflect actual GP availability, some practices may have difficulty meeting the proposed availability targets. Further work, probably of a qualitative nature, would be required to explore what factors contribute to patients' perceptions of doctor availability. Access arrangements in a primary care setting are changing rapidly with multiple points of access to NHS care, and care from a wider range of health professionals than previously. Meeting and maintaining the proposed target will not only involve review of the skill mix of the health professionals providing care, but also careful review of practice administrative structures and procedures.
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Declaration |
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Funding: the work was funded by the North Thames Region of the NHS Executive.
Ethical approval: local ethics approval was obtained for the study.
Conflicts of interest: none.
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Acknowledgments |
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We acknowledge the co-operation of staff from participating practices.
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References |
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1 NHS Executive. The NHS Plan. London: HMSO; 2000.
2 Boreham R, Airey C, Erens B, Tobin R. National Surveys of NHS Patients. General Practice. London: NHS Executive; 2002.
3 Bower P, Roland M, Campbell J, Mead N. Setting standards based on patients' views on access and continuity: secondary analysis of data from the general practice assessment survey. Br Med J 2003; 326: 258.
4 General Practitioners Committee of British Medical Association. Your Contract. Your Future. London: BMA; 2002.
5 Campbell JL. The reported availability of general practitioners and the influence of practice list size. Br J Gen Pract 1996; 46: 465–468.[Web of Science][Medline]
6 Oldham, J. Advanced Access in Primary Care. Manchester: National Primary Care Development Team; 2001.
7 British Medical Association and NHS Confederation. Investing in General Practice. The New General Medical Services Contract. London; 2003.
8 Campbell JL, Ramsay J, Green J. Practice size: impact on consultation length, workload, and patient assessment of care. Br J Gen Pract 2001; 51: 644–650.[Web of Science][Medline]
9 National Primary Care Research and Development Centre. General Practice Assessment Survey (GPAS) Manual. Manchester: University of Manchester; 1999.
10 National Primary Care Research and Development Centre. The General Practice Assessment Questionnaire; 2004. http://www.gpaq.info/
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