Managing same day appointments in Australian general practice clinics is important, as demand for GP appointments is high and supply is limited.3 One of the aims of The Australian Primary Care Collaboratives Program was to improve access to general practice.4 While The Royal Australian College of General Practitioners (RACGP) requires practices to have flexible systems to accommodate urgent appointments,5 a recent survey found that 75% of people seeking urgent care reported seeing a GP on the same day that they needed the care, 13% saw the GP the next day, and 12% waited 2 or more days to see a GP.6 Thus, almost 600 000 Australian patients with urgent need over 1 year did not get a same day appointment. Assessment of clinical urgency requires a consistent approach to assessment and categorisation based on objective clinical criteria.7 In 2002, the New South Wales Court of Appeal ruled that ‘a doctor’s receptionist has a duty of care to assess a patient’s condition, determine the urgency of the case and make an appointment based on the urgency of the patient’s symptoms’.8 It also noted the need for policy and training to guide receptionists.
Most research about appointment making in the general practice setting has been conducted in the United Kingdom,2,9–17 and has not exclusively examined managing same day appointment requests. Relevant Australian research focuses only on nurse triage systems18 and suggestions for improving appointment scheduling.19 It is unclear how receptionists, GPs and other practice staff in Australian general practices manage requests for same day appointments.
General practitioners and general practice nurse committee members of VicReN, a Victorian general practice based research network, identified management of requests for same day appointments as an issue of concern in their practices, as demand for these appointments often outweighed capacity. The aim of this study was to examine the systems used in a range of general practices to manage requests for same day appointments, by exploring the experiences and perceptions of the responsible practice staff.
Methods
This study used a qualitative research design. Semi-structured, in depth interviews were conducted with clinic staff who had responsibility for managing requests for same day appointments at 10 general practice clinics (seven metropolitan and three regional) around Melbourne, Victoria. Participants were recruited through an e-mail bulletin of VicReN members, volunteer and snowball sampling,20 as well as purposive sampling to ensure diversity in practice characteristics (Table 1).
Table 1. Overview of participating clinics around Melbourne, Victoria
| Clinic | Location | Total number of reception staff employed at clinic (number on duty at one time) | Total number of nurses employed at the clinic | Total number of GPs employed at clinic | Staff interviewed* |
|---|
| A |
Outer urban |
7–8 (2) |
2 |
19 |
R n=2
GP n=1 |
| B |
Outer urban |
7 (3–4) |
2 |
11 |
PM n=1 |
| C |
Inner urban |
5 (2) |
5 |
4 |
PM n=1
R n=1 |
| D |
Central business district |
3 (3) |
0 |
6 |
GP n=1
R n=1 |
| E |
Rural/regional |
10 (3) |
11 |
12–14 |
R n=1
NUR n=1 |
| F |
Rural/regional |
7 (3) |
3 |
9 |
PM n=1
R n=1 |
| G |
Inner urban |
15 (3–5) |
3 |
15 |
R n=2 |
| H |
Rural/regional |
4 (4) |
12 |
10 |
PM n=1
R n=1 |
| I |
Inner urban |
4 (3) |
4 |
12 |
PM n=1
R n=1 |
| J |
Inner urban |
3 (1–2) |
1 |
4 |
PM n=1
R n=1 |
| * R = receptionist, GP = general practitioner, PM = practice/business manager, NUR = nurse |
Data collection
Twenty interviews were conducted by the first author, an experienced qualitative researcher, between December 2010 and April 2011. Participants self identified as having some responsibility for managing same day appointment requests, and included 11 receptionists, five practice managers, two GPs, a business manager and a practice nurse. Participants were interviewed in a private room at their clinic. Interviews lasted between 15 and 55 minutes (average length 36 minutes) and were audiorecorded. An interview schedule was used to initiate and guide discussion.
Data analysis
All interview data were transcribed and NVivo Version 9 was used for data management. The qualitative methods used in this study were based on a grounded theory approach21,22 where data were analysed with no preconceived categories and grouped into emerging themes using the method of constant comparison.21,23 Open coding was used initially where all data were examined for the potential for a code. Following this, codes were grouped into thematic categories. These themes were used as a guide for further coding and continued to be refined until data collection was complete and saturation was reached.21 To ensure credibility of interpretations, analyst triangulation23 was used, where data analysis was conducted independently by three qualitative researchers (BG, ED, MT-S) and then discussed with the research team to achieve consensus on common themes.
Results
All clinics had broadly similar policies and procedures regarding management of same day appointment requests (Table 2). Most had basic triage flow charts to guide receptionists. Some clinics offered receptionists training opportunities.
Table 2. Examples of types of policies used by clinics
- Have a prepared set of questions to ask patients when assessing their need to be seen that day
- ask who is the patient’s regular doctor, then ask if it is an emergency
- always ask the patient if the need is urgent for that day instead of just telling them there are no appointments left
- get patients to decide if their need is urgent and fit them in accordingly
- Always see children under the age of 12 years
- Patients must have an appointment if they want a prescription
- Have a set number of appointments set aside, or ‘saved’, for Mondays
- Use the nurse to triage the patient on the telephone or in the clinic
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Two types of systems were used in clinics: a carve out and a traditional system24 (Table 3). Some clinics reported experimenting with different systems (eg. moving from a ‘no appointments needed’ walk-in system to a carve out system). Irrespective of which booking system was used, demand for same day appointments usually exceeded each clinic’s capacity, and all clinics reported having to ‘squeeze in’ patients based on urgent need.
Table 3. Booking systems used in clinics
Carve out system
Clinics ‘carve out’ (or hold) a number of urgent care appointments and the remaining are booked in advance |
|---|
- Practice staff referred to these as ‘save for the day’ or ‘book on day’ appointments
- Seven clinics used this system
- Six clinics had nurses available to triage
- Saved appointments were either given to patients without negotiation (on a first in basis) or they were given based on urgent need
- The number of appointments set aside ranged from 4–10+ per GP (depending on size of clinic, patient demand and number of GPs). Some popular GPs in one practice had all appointments open, to be ‘booked on day’
|
Traditional system
All appointments are booked ahead of time and no urgent care appointments are set aside |
|---|
- Three clinics used this system
- Two clinics had nurses available to triage
- All requests for same day appointments had to be negotiated since there were generally no appointments available (unless a cancellation had been made)
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Policy versus practice
Clinic policies provided guidelines for receptionists when managing same day appointment requests.
‘I have got us a written protocol on triaging and there’s a set of questions to ask people to prompt responses. If they say this, then they need to be triaged or if they say this, they need to go to the hospital … We’ve had lectures on triaging … nurses have given them some talks on it.’ [Clinic C, practice manager]
Policies varied and were not always clear. Receptionists were generally aware that their clinic had processes; however, not all were aware of specific clinic policies, or chose to comply with them, eg. two receptionists from the same practice had different views on policy:
‘No [there’s no policy], it’s just your experience I suppose … you’ve just got to use your judgment.’ [Clinic G, receptionist 1]
‘We’ve got a policies and procedures manual … often they wouldn’t have the time to [look up the manual], so it really is up to the common sense of all.’ [Clinic G, receptionist 2]
Some policies were also disregarded, eg. practices using the carve out system had GPs and receptionists using ‘saved’ appointments ahead of time.
‘So as a general rule, we’ve always had that there’s got to be at least on a Monday, 70% of appointments free ... which very rarely happens. That policy isn’t adhered to or the doctors have said, “no, we want to see this patient for review” and therefore they use one of those appointments that are meant to be booked on the day only.’ [Clinic F, practice manager]
Receptionists sometimes used their own system if they felt it worked better, even if aware of a set protocol, eg. one receptionist kept her own list of patients who had urgent (but non-medical) needs on an informal waiting list and notified them if an appointment time became available for that day.
Experience is important
Most participants emphasised the importance of experience when juggling requests from patients when GPs were fully booked. Clinic policy and experience were necessary:
‘ … it’s all about experience and listening and learning.’ [Clinic F, receptionist]
‘It is a matter of feeling your way through the discussion with the patient and trying to be as helpful as possible. It does take some time, years of experience, to work your way through different scenarios with people and trying to accommodate them.’ [Clinic C, practice manager]
Some patients were reportedly willing to wait until the next available appointment; however, an experienced receptionist could establish if the patient did have medically urgent needs.
‘When you start enquiring, “well I had this pain through my chest and down my arm”. “How long have you had that?” “Since last night”, some of those things. Especially the elderly, they don’t want to worry people too much.’ [Clinic C, practice manager]
Active listening (on the telephone) and astute observation (in the clinic) emerged as an important part of the receptionist’s role:
‘You have to concentrate on what they’re telling you at the time … even though you’ve got a string of people in front of you when you’re on the phone ... it is a juggling act.’ [Clinic G, receptionist 2]
‘If a patient comes in sweating or … looking a bit grey, act straight away … don’t just sit there and, “oh yeah, take a seat” and not really look at the person. You physically have to stop, look at the person and go, “you really don’t look well”.’ [Clinic H, receptionist]
What counts as urgent and whose definition is used?
Differing perceptions of an ‘urgent’ need between patients and reception staff (and sometimes between receptionists, nurses and GPs) were common:
‘People’s understanding of an emergency can vary. Wanting scripts, people can think that’s an emergency. People who’ve just injured themselves, clearly you can see that’s an emergency.’ [Clinic A, receptionist 1]
‘… some [patients] just say, “look, I’ve got an urgent form that needs to be filled in” or “I’ve had a cold for a couple of days and I can’t put up with it anymore”. [Clinic I, receptionist]
‘… the patient’s telling you it’s urgent and sometimes they show up and they’re not really very urgent. But urgent is such an obscure word. It has so many different meanings for people.’ [Clinic E, nurse]
‘… we also find that urgent appointments tend to get filled up with things that are not urgent, that are just due to impetuous patients who think that their minor paperwork needs are actually deadly serious.’
[Clinic D, GP]
Five categories of patient-defined urgent needs were identified: medical, administrative, therapeutic, logistic and emotional (Table 4). Recognising a patient with urgent medical needs was typically straightforward for receptionists, who reported having flow charts available for reference and ready advice from other clinic staff. Some commented that prioritising patients with only medically urgent needs would likely assist to manage demand. Other ‘urgent’ needs were identified as burdensome and potentially avoidable.
Table 4. Types of urgent needs
| Need | Example |
|---|
| Medical |
Chest pain, breathing difficulty, severe headache, child with high temperature, vomiting, diarrhoea |
| Administrative |
Needing a new referral or paperwork for a medical certificate |
| Therapeutic |
Needing a repeat prescription – patient has run out of medication |
| Logistic |
When it’s convenient for the patient to see the GP at a certain time |
| Emotional |
When the patient needs to be reassured by the GP for some reason |
Negotiating for an appointment and managing it
Clinics always responded to urgent requests for same day appointments and would not turn away patients:
‘… if it’s urgent, they’re definitely seen.’ [Clinic E, receptionist]
‘… I just say, “look, just come in!” [laughter] That’s reality!’ [Clinic J, practice manager]
When there were no available appointments, one of the first questions receptionists typically asked of patients requesting a same day appointment was ‘Is it urgent for today?’ Given varied perception of what counts as urgent, receptionists would often engage in further discussion, and negotiation, with the patient to establish their need to be seen that day.
‘You really need to know how urgent that appointment is … If they indicate to me that it is rather urgent, well then I try to either triage and find out exactly what’s going on or if I don’t have any appointments, I ask the doctor.’ [Clinic C, receptionist]
Most clinic staff reported ‘squeezing in’, ‘squashing in’ or ‘fitting in’ patients. Sometimes GPs would briefly see a patient in a treatment room, or else staff double or triple booked the GP, who then provided a brief appointment in their consulting room.
‘… usually with most [GPs] we double book, probably only just one we don’t, but mostly we do double or triple book …’ [Clinic J, receptionist]
‘… the doctors have got a system in place. It’s called the fit in appointment … If there are no appointments … we just fit them in behind someone else’s time.’ [Clinic G, receptionist 1]
Once urgency was assessed, strategies were employed to efficiently ensure that only the ‘urgent need’ was tended to (Table 5).
Table 5. Responding to an ‘urgent’ appointment request
Options
- Give the patient an appointment with their GP (available appointment that day)
- Give the patient an appointment with another GP
- If no appointments left, ‘fit in’ or ‘squeeze in’ patient (may include GP seeing patient briefly in a nursing treatment room or a quick appointment in consultation room)
- Have the patient triaged by a nurse (either over the telephone or at the clinic)
- Call an ambulance for the patient or ask them to attend local emergency department
- Make an appointment for the next day (or next available appointment) if it is established the need can wait
Managing the appointment
- Not letting the patient into the consulting room (eg. GP may briefly see patient in nursing treatment room after patient has been seen by a nurse)
- Limiting the visit to the urgent problem only
- Having time set aside specifically for quick appointments
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‘… we’ll probably put them to see the nurse and then … the doctor to come out of his room to see the patient, rather than do a [room] consult … which will take twice as long, ‘cos they usually get onto more than one subject then!’ [Clinic B, practice manager]
‘We have right at the end of each morning … and afternoon clinic probably … an hour of squeeze ins where it’s going to be quick things.’ [Clinic H, receptionist]
Decisions to ‘squeeze in’ a patient never rested solely with the receptionist (Table 6). Ultimately, this decision was the GPs. If receptionists took the initiative to ‘squeeze in’ a patient, it was because there was an established agreement with the GPs. Clinic nurses were also perceived as a resource for receptionists if they were available to triage.
Table 6. Squeezing in patients – who decides?
When there are no available appointments, receptionists may:
- Give the patient an appointment when there is a cancellation
- Double or triple book GP based on the understanding that this is okay with the GP
- in some clinics the GPs tell receptionists at the start of each day if they are up for more or less ‘squeeze-ins’ that day
- some clinics have an established understanding whereby GPs have given receptionists general permission to double or triple book patients (in their reluctance to lose patients to another clinic)
- Ask the practice manager
- Ask the nurse (who may triage the patient – either by telephone or in person)
- Ask the GP
- some clinics require that all ‘squeeze-ins’ are approved by the relevant GP
- sometimes receptionists will advocate for patient ‘pushing’ to get them seen by GP
- sometimes patients will push receptionists to ‘ask the GP’
- receptionist may either telephone, email or speak in person to the GP, depending on perceived urgency
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‘If a [patient] comes in on the day … reception staff have to message the doctor first and see ‘will it to be okay for [this] patient to see you?’ … It’s put in the doctor’s court … whether yes or no.’ [Clinic I, practice manager]
‘So everyone’s covered. The receptionists are covered; we don’t make that final decision. The nurses do.’ [Clinic E, receptionist]
Responsibility was also placed back onto the patient.
‘And really we don’t want [receptionists] trying to decide … whether it’s an emergency or not, we want the patient to decide whether it’s an emergency or not.’ [Clinic A, GP]
Discussion
Differing perceptions of patients and clinic staff about what was considered urgent proved challenging to those managing urgent appointments. Clinics often found themselves ‘squeezing in’ patients with non-medically urgent needs. Additionally, clinic policies on managing same day appointment requests were not always adhered to, with clinic policy often supplemented by receptionists’ experience.
The RACGP standards5 for identifying patients with urgent medical matters were understood by receptionists, and they reported feeling supported in this role by nurses and GPs. Another strategy involved patients deciding the level of urgency.2 Consequently, some patients deemed their issue urgent when it was not, while others deferred a medically necessary appointment. The ‘less obvious’ emergencies (ie. those requiring further assessment by receptionists), highlighted the importance of active listening or systematic assessment of all requests. Less experienced receptionists may need clearer procedures to follow for determining ‘less obvious’ emergencies to reduce medicolegal risk.
The five categories of urgent needs identified in this study support previous research13 and provide clear delineation of the varying patient requests for same day appointments. Many urgent needs were potentially avoidable with better planning, particularly regarding ‘urgent’ prescription requests.
Additionally, some practice staff disregarded clinic policy, or were not aware it existed, requiring discussion about urgent appointment requests by the practice team. Policy and training are important for receptionists and other practice staff. Policies need to be specifically catered to individual clinics according to staffing ratios, appointment demand, and other clinic needs.
Confirming previous research, this study found that clinics struggled with high demand for GP appointments,3 and often had to ‘fit patients in’ to accommodate requests for ‘urgent’ same day appointments.2 Decisions about same day appointments were negotiated with patients and generally added to the demanding, stressful and complex nature of a receptionist’s role.1,2 Having nurses available to triage was beneficial.25
Most practices in this study used flexible systems5 to accommodate patients’ needs for urgent care. The carve out system worked particularly well, concurring with previous studies advocating a combined appointment system utilising book ahead and same day appointments.10,13 While some studies advocate an advanced access system for improving patient access to same day appointments,19,26,27 general practice clinics in this study did not use advanced access, as this is not yet commonly used in Australian general practice, in contrast to the United Kingdom and the United States.26
The most important results of this study were the differing perceptions by practice staff and patients on what was considered urgent, and the finding that requests for same day appointments could be readily classified into five different types of urgency. Previous research confirmed that patient demand for same day appointments could be driven by preference and convenience,9 which was reflected in this study where many requests were for non-medically urgent needs. This may partially explain why in a recent Australian survey,6 not all patients requesting a same day appointment for ‘urgent care’ received one. Managing same day appointments was not simply about attending to unavoidable, medically urgent matters. It also included responding to potentially avoidable administrative or logistical patient needs. It is possible that practice policies could be modified to address these requests in a manner best suited to individual clinics.
To our knowledge, this is the first study to examine the systems used in Australian general practices to manage requests for same day appointments from the perspective of practice staff. Interviewing a range of clinic staff, with varying degrees of responsibility for managing requests for same day appointments, enabled us to explore different viewpoints. The majority of our participants were receptionists who were in the frontline of receiving appointment requests from patients, and thus had both responsibility and power in this context, even if it were typically unsought and undesired.
This study was limited by a small sample size of 10 clinics in and around one large city. However, purposeful sampling enabled the study to be informed by the experiences of a range of practice types (varying in size, location and social demographics). More importantly, reaching saturation21 demonstrated internal validity of study findings. Future research would, however, benefit from gaining the perspective of patients and other clinic staff (particularly nurses).
Implications for general practice
Improving access to same day appointments is important4 but must be balanced with the need for chronic care and non-urgent appointments. Given the five types of urgent needs identified in this study, practices may need to develop clearer definitions of what is ‘urgent for today’ and improve patient understanding of this. In doing so, there is potential for practices to increase efficiency, decrease medicolegal risk, and improve patient care.
Competing interests: None.
Ethics approval: The University of Melbourne, Human Research Ethics Committee.
Funding: The RACGP Family Medical Care Education and Research Grant.
Provenance and peer review: Not commissioned; externally peer reviewed.
Acknowledgements
We would like to thank the practice managers who consented to their practice participating in our study, and the receptionists, practice managers and general practitioners who were interviewed. We also thank the VicReN committee members for their comments on earlier versions of this manuscript, in particular, Dr Hubert Van Doorn, Ms Judy Evans and Ms Lynne Walker.