Access to genitourinary medicine clinics: how long does it take to book an appointment by telephone?

INTRODUCTION

The recent drive to modernize UK genitourinary (GU) medicine services has meant that many areas of traditional practice have come under scrutiny. Services have been required to demonstrate that they are accessible and have adequate capacity to deal with the needs of their local populations.

Auditing of the time patients must wait to be seen in a unit (Department of Health [DH] 48-hour target monitoring) allows some measure of accessibility but is only part of the picture. ^1,2 The process by which a patient makes a successful appointment is much more difficult to monitor and significant barriers may exist prior to appointment booking. Although new technology through messaging and Internet access offer great potential for the future, ³ the majority of patients seen in GU medicine departments through booked appointments will still have made contact with the clinic in person or by telephone. ^4–6 A positive patient experience has been identified as a key marker of health-service quality and patients specifically value confidentiality and an unthreatening and friendly atmosphere. ⁷ As such, GU medicine clinic receptions as the first point of contact are an important interface between services and the public and can project how the service is widely perceived. The aim of this study was to assess how long it takes for young persons to make appointments at UK GU medicine clinics and whether any specific difficulties in the process can be identified. This service evaluation was undertaken as part of a larger service evaluation of young persons’ access to GU medicine clinics in the UK.

METHODS

The telephone numbers and opening hours of all UK GU medicine services were obtained from the British Association for Sexual Health and HIV (BASHH) website, and verified with each clinic for accuracy. Of the 284 listed clinics, those open for less than two days a week were excluded leaving a remaining 222 clinics in the service evaluation. Health-care personnel posing as 16-year-old ‘patients’ telephoned the clinics during known opening hours, and requested an appointment to be seen. Each clinic was contacted with three set case studies within the known operating clinic times; a man and woman who complained of symptoms suggestive of genital chlamydia infection (dysuria and discharge, and breakthrough bleeding on long-term contraception, respectively), and an asymptomatic woman. The ‘patients’ reported an episode of unprotected sex and the presence of symptoms, or desire for asymptomatic screening if directly asked.

The researcher completed a standardized sheet to record the number of attempts needed to make a successful contact, how the call was dealt with, and the time taken for the call to be initially answered and then completed. A contact was considered successful where the call was answered within three minutes, and an arrangement to be seen within the clinic was offered. No actual appointments to attend were made. Set case scenarios were used to reduce bias, and to avoid sensitizing clinic staff no clinics were successfully called within a week.

Results were analysed for variation using the Mann-Whitney U and Kruskal Wallis tests using a SPSS package (SPSS Inc., Chicago, IL, USA).

RESULTS

A total of 222 clinics were included in the study. Overall, 1060 telephone call attempts were made in order to achieve 666 successful contacts. Overall 71.9% (479/666) of the telephone contacts were answered on the first attempt, but the range was 1–17 attempts, with 7% of clinics requiring four or more tries. Clinics in Wales, Scotland and Northern Ireland answered significantly fewer telephone calls on the first attempt when compared with English clinics (P = 0.02, range: 51.1–74.9%).

The mean length of time taken to answer a call was 10 seconds and the mean total length of the telephone call was two minutes, 35 seconds – with the range from 15 seconds to eight minutes, six seconds. The median length of the total call was one minute 51 seconds. The time taken to answer a call by an automated messaging system was significantly shorter than when answered by a receptionist (mean difference five seconds, P < 0.001), but the total length of a telephone call was a mean of 31 seconds longer (P < 0.001). There was no significance difference whether the female ‘patient’ was symptomatic or not; however, less than one-third of patients were asked about symptoms. Comparing the symptomatic male and female callers, 222 in each group, male callers took a mean of 40 seconds longer to complete a call (P < 0.001). Some clinics were more difficult to contact than others; of the 222 clinics, 35 required more than four attempts at contact for at least one scenario. Of these, five clinics took four or more attempts for two of the three scenarios but only one clinic was difficult to contact for all three scenarios. Nearly all these 35 clinics were full time (77%) and 57% are in ‘urban’ areas as defined by the Department of Environment, Food and Rural Affairs (Defra) classification. ⁸

DISCUSSION

Although this service evaluation is a snap shot of GU medicine clinic telephone interaction, it demonstrates a significant variation in the number of attempts and time taken for a patient to make an appointment at GU medicine clinics in the UK. Even if the patient is offered an appointment within 48 hours, they may have needed to ring many times and incur a wait. This represents a barrier to access; nearly 30% of clinics fail to answer a call at first attempt even when the clinic was confirmed to be open. In this study the researchers persisted in their contact of a clinic; however, in real life an individual might be less persistent.

Variability between UK countries and regions may reflect different resources and priorities in these areas. Although it may not be realistic to expect that all calls should be answered on the first attempt, variability in performance demonstrates some capacity for improvement. In 2006 the DH published 10 of ‘high-impact changes’ (HICs) that could be made to enhance 48-hour access to GU medicine services. ⁹ One HIC was to review access systems to make it easier for patients to access the service with a recommendation for a centralized booking services (CBS). One study where a CBS was introduced across three London clinics showed it increased the percentage of patients having a sexual health screen by 20%. ¹⁰ The development of a regional or national CBS could streamline sexual health services and standardize the process of access to clinics.

Of significance is the longer time it took a male ‘patient’ to book an appointment compared with a female ‘patient’. It is possible that the difference was due to the researchers themselves; the researchers were not in the target population and it is possible that in this evaluation the female researchers were able to interact more eloquently. However, the male researcher was asked a number of surplus questions by receptionists including whether he was homosexual. Such questions are sensitive in nature and are more suited to being asked by a health-care professional during a visit. This may identify another barrier to access in that invasive questioning may be off-putting, particularly for adolescents.

Although we found difficulties in accessing clinics on a third of first contacts, care must be taken to not over-interpret these results. Some clinics are addressing increased accessibility by allowing alternate methods of contact such as online booking methods and directing patients to walk-in services. However, as these methods were not assessed it is a limitation of the evaluation. In addition, although we did ensure clinics were advertised as open when we attempted to contact them, we made no allowance for peak times or day of the week when making our calls. Although it is arguable that telephone numbers should be adequately manned at all advertised times it is conceivable that our results would be substantially different if calls were made at different times of the day to poorly responsive services. The impact of such a bias is difficult to judge and may only be resolved through multiple assessments and averaging responsiveness.

To improve efficiencies many clinics are considering automated messaging services but it is of interest to note that although the telephone was answered faster by an automated messaging service, the whole phone call took significantly longer. Although we did not ask about ‘patient’ satisfaction with the booking service, this aspect should be considered when services are redeveloped. This evaluation specifically assessed accessibility of young people to GU medicine services; however, we believe it is generalizable to the wider population, as it was an assessment of how readily a telephone call was answered. As clinics work towards improving quality outcomes care should be taken to ensure that the first point of contact with a clinic is favourable.