Abstract
Sir: I have read with interest articles by Rooney 1 and Carlin 2 on this topical issue. It is quite clear that it is the plurality of options that will combine to improve access to clinical services, and these will vary in different settings. While 96% were offered appointments within 48 hours it is disappointing that only 72% accepted it in the clinic at King's Mill Hospital. 2 The reasons do need exploring further. Of those refusing, most would have accepted it in three days with a median of four days. There is no mention of the clinic opening hours. This is important, as half-day closures in some clinics a few times a week may restrict choice and attendance. Also, data on whether an alternative appointment was acceptable are restricted by small numbers (118). However, even in this group, no other alternative was acceptable to 43% of individuals, suggesting possibly restrictive appointments slots during the working week. A Saturday appointment would have been acceptable to 22%, but clearly this would have breached the 48-hour target. This adds to the importance of ‘walk-in’ clinics mentioned in a previous study by Mercer et al. 3
In our clinic, we reached figures of 100% offered and 90% seen within 48 hours in December 2007 and had maintained these when last monitored in March 2008. These were achieved after the work was carried out over several previous months. In essence, this was utilizing extra resources we obtained to offer a complete ‘walk-in’ service, increasing opening hours during the working week (no half-day closures on Tuesdays and Thursdays), nurse-led clinics before 9:00 h and during lunch hours, uninterrupted telephone receptionist cover including lunch times as well as extra manpower to answer telephone lines with increased phone capacity. We had been repeatedly told by service-users that they could not even access our clinics over the phone for days and weeks due to severe strain on the telephone systems. In addition, we modified our practice abandoning routine microscopy on people with no symptoms or signs and those who did not present as contacts of a sexually transmitted infection. However, our biggest problem had been staff shortages and freeze on recruitment in the Trust. The doctors would often stand in clinics waiting for patients to be seen as there were fewer nurses available (often caught up doing triage) and patients could not negotiate past or even get to receptionists on the phone. With consequent expansion in staff, we were able to make the necessary changes which included abolishing the triage service (shown to be an expensive use of resources in the past) 4 as well as set up outreach clinics. Initially, we were able to clear considerable backlog through the ‘walk-in’ facility, but soon it caused difficulties for those wanting appointments at fixed times of their choice. The slots were gradually made available for appointments in the latter half of clinics as the initial period was taken up by ‘walk-ins’. Hence, over a few weeks/months with close adjustments in available slots, we were able to achieve current access rates, which we have been able to maintain over the last four months.
It required a concerted effort across the health economy with close monitoring, willingness and active engagement of commissioners and employing Trust, availability of resources and flexibility of colleagues to make all these changes and improvements.