Access from the APCC point of view is about access to effective and **timely** care.
We will do the community an enormous service if we can increase the capacity of general practice to care for the health of that community.
If we are to demonstrate an improvement in ‘access’ to general practice, we need to be able to measure the relationship between the demand for service and our capacity to meet that demand.
As you know, we currently use the third available appointment (3AA), which is an international standard for measuring delay in a system. It measures the length of the ‘queue’ of people who have made an appt to see us – if the 3AA measure is 3 days, there are three days worth of people waiting to see us. In our practice that is a queue length of 75 people each.
However, I have recently spoken to a mother who was very concerned about her sick child but was unable to get him seen by anyone in her usual general practice (in-hours) for three days – even after she had spoken to the GP directly. Their only option was to present to their local hospital – which, as advocates of primary care, we would consider a less satisfactory outcome health-wise. Other patients tell similar stories.
In many cities and towns, people moving to a new area are unable to find practices with the capacity to take them on as new patients. Often the docs in a town (including mine) will tell me that they see all-comers, yet the patients tell us that they couldn’t get an appointment when they needed one. (I’m not sure how that happens.)
If the patient never actually makes an appointment, none of these scenarios are captured by the 3AA. It would be better if we had systems in place that would improve our capacity to see our patients when they are sick, and to increase the size of the ‘panel’ we can service, without making our job any more frantic – or getting us home later than we already do! Much of what we learn in the collaboratives is aimed at improved access to care, and many practices have made significant progress. Therefore for the next phase we are thinking about an additional measure for ‘access’ that would demonstrate an improvement in practice capacity – we tentatively call it ‘the John West’ measure.
The John West Measure
The John West measure is a measure of unmet demand. It is a tally over a week of how many people call with the intention of seeking an appointment , but do not end up making one.
This may be because
1) the practice is not taking on new patients (so they are rejected by the practice)
2) the practice has no vacant appointments at a time that fits the patient’s need (because, for example, they feel that they are too sick to wait three days, or because the doctor they want to see has a wait of two weeks and they are unwilling to accept an alternative appointment, or whatever reason) – so the patients ‘reject’ the practice)
Either way, mark a tally on clipboard each time – and count the ticks at the end of the week.
These patients are currently not picked up by the 3AA measure. They reflect some wasted opportunities for the practice and potential sub-optimal health outcomes. An improvement by the practice in capacity will be reflected by a decrease in the John West count.
It also acts as a balance to the 3AA measure. Some practices have a longish wait for routine appointments but serve the acute needs of their community well. You might improve your 3AA by seeing less acute patients – which is probably not a good thing - the John West measure will pick that up.
Collaborative practice have developed a number of strategies that may improve practice capacity – allowing us to deal with the same amount of patients in less time.
Such as -
- using other members of the team to do jobs normally done by the rate determining step – the doctor
- improving practice efficiency (less time looking for things, less time spent negotiating on the phone)
- using systematic care to reduce the need for visits by people with chronic illness
- increasing patient self management skills and thereby reducing unplanned appointments
These strategies, coupled with active management of our appointment scheduling, may free up some time to offer better acute services and to see new patients – and to go home earlier (especially if you live in Natimuk.)
We will measure this by an improvement in our John West count. Anyway, our latest practice PDSA is to test it out for a one week period each month for the next two months and see how practical and useful it appears to be.
I predict that there will be more John West rejects than I anticipate – which will inspire my colleagues and myself to do something about it!
Any other practices interested in having a trial are most welcome to give us feedback.
Any suggestions or comments?