Today, we’re speaking to Dr Jamie Scuffell, GP and NIHR In Practice Fellow at King’s College London.

Title of paper: Patterns in GP Appointment Systems: a cluster analysis of 3480 English practices

Available at: https://doi.org/10.3399/BJGP.2024.0556

GP practices in the UK are using a wide range of different appointment systems to meet patient demand and improve access. This cluster analysis of NHS appointment data from 56 million appointments and 3480 English practices demonstrates two predominant models of primary care delivery. ‘Same day’ practices tend to fulfil appointments on the same day using GP telephone consultations. ‘Routine care’ practices tend to employ non-GP staff members offering face-to-face appointments and longer appointment wait times. ‘Same day’ care practices had younger and more urban populations.

Episode transcript

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A

00:00:00.640 - 00:00:54.360

Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate Editors of the bjgp. Thanks for listening to this podcast today. In today's episode, we're speaking to Dr.

Jamie Scuffle, who is a GP in South London and an NIHR In Practice Fellow at King's College London. We're here to talk about a really topical issue in his new paper here in the bjgp.

The paper is called Paper Patterns in GP Appointment A cluster analysis of 3,480 English practices.

So, hi, Jamie, it's really great to meet you and talk about this work, I guess, really just to start, as you point out in this paper, each practice has their own systems and strategies to manage appointment booking. But how do you think that this impacts on access and patient appointment booking in each practice?

Speaker B

00:00:55.000 - 00:02:17.300

Yeah, it's interesting because I think, as you say, appointment systems have developed even further, really, since COVID and we've ended up with this a quite interesting diverse range of implementing appointments across the country, across England at least.

And I suppose the things that have changed are, you know, if you phone up a practice now, actually, you might not even phone them up, you might submit an online consult, you might be triaged, you might see not a gp, but a range of other professionals as well. And also it might not be done face to face, it might be done by telephone or online.

In fact, there's a new appointment system range of things that have happened across England, and actually there's some evidence that that might relate to access in some ways. So we know lots of people who don't speak English struggle to navigate that system of getting an appointment, for example.

And we also know from the qualitative evidence that there's some digital exclusion as well with appointments. So, yeah, so I think there's lots of issues with access and how that relates to appointment systems.

And so far what we've done is looked at components of the appointment system and how that then affects access. But what we haven't really done much of is looking at the appointment system as a whole and how that might affect access.

Speaker A

00:02:18.180 - 00:02:33.200

Yeah.

So in this study, you wanted to look at patterns of primary care delivery in English GP practices, and you used this Appointments in General Practice data set. Can you tell us just briefly what's available in this data and what you were looking at here?

Speaker B

00:02:33.360 - 00:03:20.700

It's a tremendous data set and I think could be very useful. So every English GP practice for every day of the week publishes up to NHS England.

The appointments that have Happened for the day across lots of different categories, actually, so across whether they've been attended or not, or not attended, whether they're face to face or telephone or home visits or online also if they're GP or non GP appointments. And the sort of. The real clincher that is brand new is looking at appointment lead times as well.

Whether these appointments were booked same day or whether they were booked more in advance when the data is good enough, which is an. If it's a very, very useful data set.

Speaker A

00:03:20.780 - 00:03:43.720

Yeah, so you looked at data from about three and a half thousand practices this year. So as you mentioned, you weren't able to look at all practices due to quality issues.

But just talk us through what you were looking at here and I guess, yeah, just start us off with telling us what you found and perhaps we'll get into how you group the practices as well into clusters. But yeah, tell us a bit more about what you found here.

Speaker B

00:03:43.720 - 00:05:23.440

What we wanted to do was take a set of measures, I suppose, of an appointment book.

So for every practice we said, well, actually we might define their appointment book by the proportion of people who see a GP or the proportion of people who have a telephone consult, or the proportion of people who are booked same day and seen same day. And we kind of came up with actually about 12, in the end, 12 measures of an appointment book.

What we then wanted to do was kind of group together practices with similar characteristics and we picked two different types. I suppose these were the two poles at either end of the spectrum.

And the two poles are that there's a more traditional, what we've called a routine care group of practices, and this is about two thirds of the English practices that we included.

And the appointment characteristics they had were they are more likely to book in advance appointments rather than booked on the same day, more likely to be face to face appointments, interestingly, more likely to use not just GPs but also non GP appointments for delivering care. So they're the big categorization of the routine ones.

So longer wait times, more likely to use non gps and more likely to have face to face appointments.

And then I suppose there's the sort of the more the newer style of appointment system, which we've called the same day appointment system, and that's more likely to be led by GP telephone consults that happen and are booked on the same day. And in this case, same day appointment availability is quite substantially higher than the routine care practices.

Speaker A

00:05:23.600 - 00:05:34.560

And you found that actually there was quite a lot of difference within the practice population and where the practice was based on these two sort of clusters. So the routine and the same day practices as well.

Speaker B

00:05:34.960 - 00:06:59.980

Yeah.

It's absolutely fascinating that it's not just differences in the appointment systems, but actually there are underlying differences, not just in the practice populations, but also in the workforce associated with each of those practices. So the practices that were same day, much more likely to be in urban serving urban populations rather than rural populations.

Also, this might just be an account of. Because they're more likely to serve urban populations, they also serve more ethnically diverse populations.

Interestingly, no big differences between deprivation. And then also the same day practices have a very slightly younger population overall than the routine care practices.

List size is also slightly bigger with those same day practices compared to those that have a more routine approach. Also, differences in workforce.

The number of direct patient care staff, full time equivalents per 10,000 people on the practice books is a bit higher in the routine care cluster than the ones who are delivering same day care.

And the differences are that actually GP levels are pretty much the same, but the routine care cluster employs more nurses and more nurse practitioners and also employs slightly more administrative staff.

Speaker A

00:07:00.540 - 00:07:19.490

Yeah.

So you work as a GP and I just wonder from your own experiences whether what you found in this data reflects what you know or understand sort of on the ground and whether you had any insights from your own work, which might sort of explain why there are these differences, or if you had any thoughts about that.

Speaker B

00:07:19.650 - 00:08:44.140

I did a whole load of locoming when I finished training, actually. It was fascinating to go to a dozen practices over a period of time and look at how the appointment system was set up.

And I think when you're an individual GP behind a door, seeing patients, it's sometimes quite hard to anchor yourself in the wider picture of what's happening at other practices, even the one just down the road.

So I think it's quite interesting to think about how especially the slightly more bigger practices where I work in South London do tend to have had a more of a same day approach to delivering appointments and have also been a little bit more telephone, triage, telephone first in their approach for a longer period of time.

So I think the, I mean, one of the challenges of when you cluster these data is you can cluster into lots and lots of different clusters, but what you're trying to do is make it meaningful to and interpretable to people and practitioners. And I think those two very much.

I can, I can picture practices that operate in those two different ways, even though they actually have quite close in geography together. Quite close in geography.

And I suppose then it's interesting to think about not just how the appointment system is set up, but then kind of patient outcomes as well that might be associated with those two approaches.

Speaker A

00:08:44.620 - 00:09:13.990

One sort of interesting area that some papers have looked at is this sort of balance between quicker access and other outcomes. So, yeah, as you point out, same day access might allow quicker access, but might tend to be on the phone.

And whether that has impacts on other things in the practice, such as continuity of care. And what are your thoughts on that? And the balance shown in this data between sort of maybe quick access versus more routine type care.

Speaker B

00:09:14.310 - 00:10:12.150

I think it's so interesting with the potential opportunities to increase continuity of care are actually potentially higher with more of a same day approach, or at least a same day triaged approach.

I think depending on who you talk to, some people might say, well, actually if you are triaging patients, you could very well increase continuity of care.

But I think our general feeling is that we know same day appointment availability isn't necessarily associated with increased patient satisfaction in the GP patient surveys. And then we also know that patient satisfaction is in some way associated for some people with continuity of care.

So I think there's an argument for saying it could go either way with the same day approach either encouraging or discouraging continuity of care, depending on the context, which I have to say is difficult to get at with these data.

Speaker A

00:10:12.790 - 00:10:32.940

But yeah, another area I was interested in in your data was that the same day access was associated with more urban practices and also a younger population. And I suppose it's just sort of thinking about the patterns of why this might be occurring.

And do you think it's sort of patient driven or do you think it's practice driven?

Speaker B

00:10:33.500 - 00:12:18.490

That's really interesting. I mean, we know. I think it's probably a bit of both. Let's start with practice driven.

So we know that some of the ethnographic work demonstrates that practices organize appointment systems not just around clinical need, but also around demand. And they might not be the same.

And also there are other components, as we've said, you know, there are workforce differences between these two practices as well, which may have come about as a result of the differences in appointment systems, or it may just be necessity that there's lower employment of GPs in these more routine traditional type approaches and therefore there's employment differences there. So the appointment system may have come about as a result of those practice factors.

I think patient level factors are really interesting and I think that's where the work should go next. Although we know that the same day care type Practices do have a slightly younger population.

What we don't know from these data is who is consulting more, who is consulting less.

It might be that actually these same day practices do just as good a job or even better job at responding to clinical need once we take into account the consultation rates between two groups.

So I think it'll be really interesting to try and look at these patient level data and look at the experience of a single patient with a particular characteristic who's, who's subject to different types of appointment systems and then see if that does really affect outcomes. I think that's, that would be a really interesting thing to do next.

Speaker A

00:12:18.970 - 00:12:47.610

Yeah, so I guess that's sort of thinking about the impact of these different practice systems because we know that practices may decide to adjust their systems based, as you said, on their staffing or their patient population. But I guess as you mentioned, we don't really know what the impact is on for patient satisfaction.

Or do you think there's some way you could match this to the GP patient survey or the GPPS survey to sort of look at satisfaction as well?

Speaker B

00:12:48.250 - 00:14:04.400

Absolutely. Next step, I think is to try and do that. Yes. And if anyone's interested in any of this, I'm always really happy to speak to people, to collaborate.

We've had some, few really good papers recently looking at the association between appointment data and patient experience from single components. So looking at same day appointments particularly and demonstrating that increasing.

This is Patrick Birch, I think, and teams work in Manchester looking at the fact that if people have increased same day appointments that there might be a reduction in patient satisfaction and also scores of access and continuity in the patient survey.

What would be really interesting is to try and look at this a little bit more causally, I think, and ideally identify where practices have changed deployment system and then look at corresponding changes in satisfaction.

So I think one of the challenges is this is all ecological data and it's easy to draw strong conclusions from those data without really understanding the underlying mechanisms of what's happening. And as we've spoken about, there are lots of things going on in here.

Speaker A

00:14:04.400 - 00:14:07.800

Any other key findings you want to highlight from this, this paper?

Speaker B

00:14:08.120 - 00:14:47.090

Well, I suppose only just briefly to talk about the administrative differences between the two groups.

I think it's really interesting that even though there might be a whole mechanical change in the same day approach practices and you know, it demonstrates that these practices are, they've got a bigger list size but they've also got potentially some administrative economies of scale as well in managing, in managing the appointment load that's coming through.

There's a bit more work to understand what really is happening with the mechanics of these practices compared to the ones that have a more traditional approach.

Speaker A

00:14:47.650 - 00:15:07.460

So it sounds like, yeah, there's a lot of more that we could do in the future in terms of research to understand what's going on. But from this paper, do you think that there's any nuggets that practices on the ground could pull from this research?

And I think you've mentioned some of it just about sort of understanding their own appointment book and things. But do you have any thoughts about how this paper and the results could be used?

Speaker B

00:15:07.940 - 00:16:25.240

I think it's really interesting to see the diversity and the grounding of your practice versus other people's other practices. And so I think that's one piece is just really understanding where you sit compared to others.

I mean, the other real thing that would be great to understand a bit more is we spoke about the appointments in general practice data quality, and the data quality is limited really by the fact that when we look at our appointment books in gp, they're multicolored and all of the colours correspond to a particular category and those categories aren't well matched up to NHS England categories.

And although we did do some work to show that the practices we did include and didn't include looked much the same in terms of demographic characteristics and practice characteristics, it would be nice to be able to do a full census of appointment systems and if there is a spare five minutes for any practice manager listening, to be able to just categorize those few appointment types will just mean that we can then, you know, help feedback some of these data that are going up to NHS England back down to gps and help to understand a little bit more about, you know, what's happening on the ground and be able to understand these effects a bit more, I think.

Speaker A

00:16:25.320 - 00:16:50.240

And as you mentioned, I think you're absolutely right that at a national level and in terms of guiding policy, decision making and what the best sort of systems are, it's important to have a big picture look at the data. So I think that's really fascinating work, work that you've done here.

But yeah, I think that's been a really interesting conversation around this area and good luck with your future work, but it's been great to chat to you about it.

Speaker B

00:16:50.640 - 00:16:52.040

Thank you. It's been great to chat to you.

Speaker A

00:16:52.040 - 00:17:17.799

Too, and thank you all very much for your time here and thanks for listening to this BJGP podcast. Jamie's original research article can be found on bjgp.org and the show notes and podcast audio can be found at bjgplife. Com.

It's been great to talk again about some of the balancing between access, continuity and patient satisfaction, so do go back and take a read of Jamie's paper. Thanks again for listening and bye.