An evaluation of Advanced Access in general practice

Full text

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An evaluation of Advanced
Access in general practice

Final Report
Report for the National Co-ordinating Centre
for NHS Service Delivery and Organisation
R & D (NCCSDO)

February 2007




Prepared by:
Chris Salisbury, Jon Banks, Stephen Goodall, Helen Baxter, Alan Montgomery,
Catherine Pope, Karen Gerard, Lucy Simons, Val Lattimer, Fiona Sampson,
Mark Pickin, Sarah Edwards, Helen Smith, Markella Boudioni

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Research team
Professor Chris Salisbury Professor of Primary Care1
Dr Jon Banks Research Associate1
Dr Stephen Goodall Research Associate1
Dr Helen Baxter Research Associate1
Dr Alan Montgomery Senior Lecturer1
Dr Catherine Pope Reader2
Dr Karen Gerard Reader2
Dr Lucy Simons Senior Research Fellow 2
Prof Val Lattimer Professor of Health Services Research2
Ms Fiona Sampson Research Fellow3
Dr Mark Pickin Clinical Senior Lecturer3
Dr Sarah Edwards Research Fellow4
Professor Helen Smith Head of Division of Primary Care
& Public Health4
Miss Markella Boudioni Senior Research Fellow5

1Academic Unit of Primary Care, Department of Community Based Medicine,
University of Bristol
2School of Nursing & Midwifery, University of Southampton
3School of Health and Related Research (ScHARR), University of Sheffield
4Brighton & Sussex Medical School, Department of Primary Care, University of
Brighton
5Faculty of Health and Social Care, London South Bank University
Contact Details
Professor Chris Salisbury
Professor of Primary Health Care
Academic Unit of Primary Health Care
University of Bristol
25-27 Belgrave Road
Bristol BS8 2A
Tel 0117 3313865 Email: c.salisbury@bristol.ac.uk

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Acknowledgements
We would very much like to thank:
All those patients who participated in the research
The staff in the 48 practices who hosted the research, particularly the 8 case
study practices who allowed us to observe their work in detail
Mary Wallace, the project secretary/administrator
The Advisory Group: John Campbell (chair), Meera Kulkami, Nick Goodwin,
Val Burrowes, Yealand Kalfayan, Cherie Mahoney, Mark Hunt, Sally Wyke,
Jeremy Dale, Emma Maclellan-Smith, Melanie Lawless
The members of the service user advisory group
Sir John Oldham, for his advice in the planning stage for the research
Steve George, for his contribution to the research proposal
Deborah Street, for her advice about the discrete choice experimental design
Susan Hamilton for the analysis of census data
Andrew Wagner for providing data about general practices’ characteristics
Bruce Guthrie for help and advice with the measurement of continuity of care
The anonymous reviewers for their constructive comments on the draft
report.

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Table of contents

Acknowledgements .....................................................................2
Executive Summary................................................... 8
Section 1 Background............................................. 18
1.1 The importance of access to primary health care....................18
1.2 What do we mean by ‘access’?.............................................19
1.3 What problems do people have with accessing care?...............20
1.3.1 Barriers to accessing primary health care .....................20
1.3.2 Which groups face particular difficulties with access? .....21
1.4 Policy initiatives to improve access .......................................22
1.4.1 Primary Care Access Fund...........................................22
1.4.2 GP Contract ...............................................................24
1.5 The National Primary Care Collaborative and the National Primary Care
Development Team .............................................................24
1.5.1 Applying the improvement model to access to primary care25
1.5.2 Problems with GP appointment systems .......................26
1.6 Advanced Access................................................................27
1.6.1 What is Advanced Access? ..........................................27
1.6.2 Advanced Access and continuity of care........................29
1.6.3 Seeing patients on the same day and embargoing of
appointments ............................................................30
1.6.4 What benefits are claimed from Advanced Access?.........31
1.6.5 What concerns have been expressed about Advanced Access?
...............................................................................32
1.7 What evidence is available about Advanced Access? ...............33
1.8 The need for research.........................................................35
Section 2 Aims and objectives ................................ 36
2.1 Aims.................................................................................36
2.2 Objectives .........................................................................36
Section 3 Methods .................................................. 37
3.1 Plan of investigation ...........................................................37
3.2 Modification to the original plan............................................37
3.3 Research components.........................................................38
3.4 The use of mixed methods...................................................41
3.5 Service user involvement ....................................................42
3.6 Ethical approval .................................................................42
Section 4 Recruitment of PCTs and practices: the practice
survey...................................................................... 43
4.1 Introduction and aims.........................................................43
4.1.1 Objectives ................................................................43
4.2 Methods............................................................................44
4.2.1 Recruitment of PCTs...................................................44
4.2.2 Analysis....................................................................45
4.3 Results...............................................................................45
4.3.1 Advanced Access .......................................................47
4.3.2 Practice characteristics...............................................47
4.3.3 Matching capacity with demand...................................49
4.3.4 Interventions to improve access ..................................49

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4.3.5 Appointment availability .............................................52
4.3.6 Implementation of Advanced Access principles..............54
4.4 Selection and recruitment of practices for the main evaluation.55
4.4.1 Characteristics of practices recruited for main study.......57
4.4.2 Terminology..............................................................58
Section 5 Activity.................................................... 59
5.1 Introduction and aim ..........................................................59
5.2 Research questions.............................................................59
5.3 Method .............................................................................59
5.3.1 Overview of method...................................................59
5.3.2 Data Collection..........................................................59
5.3.3 Definitions and concepts used in the analysis ................61
5.3.4 Analysis....................................................................62
5.3.5 Sample size and power of the study.............................62
5.4 Results..............................................................................63
5.4.1 Description of data.....................................................63
5.4.2 Skill mix ...................................................................63
5.4.3 Capacity...................................................................63
5.4.4 Unplanned work ........................................................64
5.4.5 Workload..................................................................64
5.4.6 Did not attend (DNA) rate...........................................64
5.4.6 Alternatives to face to face consultations......................65
Section 6 Continuity of care.................................... 68
6.1 Introduction and aim ..........................................................68
6.2 Research questions.............................................................68
6.3 Method .............................................................................68
6.3.1 Overview of method...................................................68
6.3.2 Data Collection..........................................................71
6.3.3 Sampling..................................................................71
6.3.4 Inclusion and exclusion criteria....................................72
6.3.5 Analysis....................................................................73
6.4 Results..............................................................................73
6.4.1 Description of sample.................................................73
Number of consultations in the analysis.................................74
6.4.3 Continuity of care ......................................................74
6.4.3 Continuity of care for different age groups....................75
6.4.5 Clustering by practice.................................................78
Section 7 Making an appointment........................... 79
7.1 Introduction and aims.........................................................79
7.2 Objectives:........................................................................79
7.3 Method .............................................................................79
7.3.1 Overview of method...................................................79
7.3.2 Anonymity................................................................80
7.3.3 Randomisation ..........................................................80
7.3.4 Contacting the practice...............................................81
7.3.5 Script used by researchers to request an appointment ...81
7.3.6 Disclosure of identity..................................................82
7.3.7 Details of appointment offered ....................................82
7.3.8 Analysis....................................................................82
7.4 Results...............................................................................84
7.4.1 Flow of calls..............................................................84
7.4.2 Making contact with a receptionist ...............................85

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7.4.2 Mean length of time that it took to obtain an appointment86
7.4.4 Making an appointment with any doctor or a specific doctor 86
7.4.6 Length of wait for first available appointment with any doctor or
a specific doctor ........................................................88
7.4.6 Length of wait for third available appointment with any doctor or
a specific doctor ........................................................89
7.4.7 Disclosure of the researchers identity...........................90
Section 8 Survey of patients attending the practice 91
8.1 Introduction and aim ..........................................................91
8.2 Research questions.............................................................91
8.3 Method .............................................................................92
8.3.1 Overview of method...................................................92
8.3.2 Questionnaire design..................................................92
8.3.3 Survey administration ................................................93
8.3.4 Sample size ..............................................................94
8.3.5 QOF reports..............................................................95
8.3.6 Analysis....................................................................95
8.4 Results..............................................................................95
8.4.1 Response rates..........................................................95
8.4.2 Comparison between responders and non-responders ....96
8.4.3 Characteristics of respondents.....................................97
8.4.4 How long has the patient had the problem....................97
8.4.5 How long did it take to get an appointment? ...............100
8.4.6 Previous consultations about the same problem and frequency of
consultations with health service providers in the last 12 months
.............................................................................101
8.4.7 Importance to people of various factors when making
appointments ..........................................................102
8.4.8 The type of appointment obtained .............................108
8.4.9 The type of appointment received in relation to issues which
were important to particular patients..........................110
8.4.10 Evaluation questions based on GPAQ........................111
8.4.11 Satisfaction with receptionists .................................111
8.4.12 Opening hours.......................................................112
8.4.12 Seeing a particular doctor.......................................112
8.4.13 Seeing any doctor..................................................114
8.4.15 Urgent access to see a GP.......................................116
8.4.16 Waiting times in the surgery ...................................117
8.4.17 Contacting the practice by telephone........................118
8.4.18 Continuity of care ..................................................120
8.4.19 Communication .....................................................122
8.4.20 Enablement...........................................................122
8.4.21 Overall satisfaction with the appointment system.......123
8.4.22 Overall satisfaction with the practice ........................125
8.4.23 GPAQ scales..........................................................125
8.4.24 Clustering by practice.............................................127
Section 9 Survey of non users............................... 128
9.1 Introduction and aim ........................................................128
9.2 Research questions...........................................................128
9.3 Method ...........................................................................128
9.3.1 Overview and questionnaire design............................128
9.3.2 Survey administration ..............................................128
9.4 Analysis ..........................................................................129
9.5 Results............................................................................130

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9.5.1 Response rates.........................................................130
9.5.2 Comparison between responders and non-responders ...130
9.5.3 Characteristics of respondents....................................132
9.5.4 Characteristics of case study practices ........................133
9.5.5 What factors are most important to patients intending to make
an appointment at their primary care practice .............133
9.5.6 Difficulties in making an appointment..........................135
9.5.7 Wanting to make appointment but not trying to make one136
Section 10 Discrete choice experiment ................. 141
10.1 Introduction and aim .......................................................141
10.2 Research questions..........................................................142
10.3 Method...........................................................................142
10.3.1 Overview of method................................................142
10.3.2 Identification of attributes and assignment of levels ....143
10.3.3 Specification of preference (utility) function ...............145
10.3.4 Experimental design................................................147
10.3.5 Questionnaire instrument.........................................147
10.3.6 Survey administration .............................................151
10.3.7 Sample size ...........................................................151
10.3.8 Analysis and interpretation.......................................152
10.4 Results...........................................................................154
10.4.1 Response rates.......................................................154
10.4.2 Comparison between responders and non-responders .154
10.4.3 Characteristics of respondents..................................155
10.4.4 Validity checks .......................................................156
10.4.5 Basic models..........................................................157
10.4.6 Trade-offs (or marginal rates of substitution) .............162
10.4.7 Sub-group analysis .................................................162
10.5 Predicting utility scores ....................................................165
Section 11 Survey of staff..................................... 167
11.1 Introduction and aims......................................................167
11.2 Research questions..........................................................167
11.3 Methods .........................................................................167
11.3.1 Sample frame.........................................................167
11.3.2 Questionnaire design...............................................168
11.3.3 Survey administration .............................................169
11.3.4 Analysis.................................................................169
11.4 Results...........................................................................170
11.4.1 Response rates.......................................................170
11.4.2 Stress ...................................................................171
11.4.3 Individual questions which make up the scales of the Team
Climate Inventory....................................................175
11.4.4 Job satisfaction.......................................................177
11.4.5 Overall satisfaction with job .....................................180
11.4.6 Overall satisfaction with the appointments system ......182
Section 12 Qualitative case studies ...................... 184
12.1 Research questions..........................................................184
12.2 The case studies..............................................................185
12.2.1 Sampling ...............................................................185
12.2.2 Data collection........................................................186
12.2.3 Analysis.................................................................187
12.2.4 Definitions .............................................................188
12.2.5 Description of each site ...........................................189

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12.3 Managing access .............................................................202
12.3.1 Managing access - the Advanced Access practices.......202
12.3.2 Managing access – the control practices ....................213
12.3.3 Summary – managing access...................................218
12.4 Continuity of care............................................................218
12.4.1 Continuity – the Advanced Access practices ...............218
12.4.2 Continuity of care - Control practices.........................222
12.4.3 Continuity – summary .............................................224
12.5 Patient experience of the access system.............................224
12.5.1 Patient experience – Advanced Access practices .........224
12.5.2 Patient experience – control practices........................226
12.5.3 Patient experience – summary .................................228
12.6 The practice experience....................................................228
12.6.1 The practice experience – Advanced Access practices..228
12.6.2 The practice experience – control practices ................233
12.6.3 The practice experience – summary ..........................235
Section 13 Access facilitators ............................... 236
13.1 Access Facilitators – qualitative interviews..........................236
13.2 Research questions..........................................................236
13.3 Methods .........................................................................236
13.4 Results...........................................................................237
13.4.1 Access facilitators – Roles and Responsibilities............237
13.4.2 Measuring demand and capacity ...............................237
13.4.3 The Collaborative method ........................................238
13.4.4 Two models of Advanced Access ...............................239
13.4.5 The Impact of DESA targets on the introduction of Advanced
Access....................................................................240
Section 14 Discussion........................................... 242
14.1 Synthesis of findings in relation to research objectives.........242
14.2 Strengths, limitations and methodological issues.................251
14.2.1 Overall Strengths....................................................251
14.2.2 Overall limitations...................................................252
14.2.3 Strengths and limitations of each sub-study...............254
14.3 Other research about Advanced Access ..............................258
14.3.1 The original work of Murray in the USA......................259
14.3.2 Recent studies from the USA....................................259
14.3.3 Studies from the UK................................................260
14.3.4 Case studies in the USA and Australia .......................260
14.4 Implications of the results of this research..........................262
14.4.1 How should we interpret the findings? .......................262
14.4.2 Implications for patients ..........................................263
14.4.3 Implications for practice activity ...............................264
14.4.4 Implications for practice staff ...................................265
14.4.5 Implications for policy .............................................265
14.4.6 Implications for future research................................272
Recommendations ..................................................................273
14.5.1 Local – recommendations for practices ......................273
14.5.2 National.................................................................273
14.6 Conclusion......................................................................274
References............................................................. 275
Appendices ............................................................ 287

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Executive Summary
Introduction
Improving access to services is a central aim of the NHS Plan. In order to
achieve this, the government has implemented a number of initiatives. The
NHS Plan introduced a target that patients should be offered an appointment
within two working days, each Primary Care Trust (PCT) was given funds to
employ a primary care access facilitator supported by the National Primary
Care Development Team (NPDT) and financial incentives were introduced for
practices to improve access through their contracts and through a Directed
Enhanced Service (DES) on Access.
The organisational model strongly promoted by the NPDT is that of ‘Advanced
Access’. This is based on the principle of ‘doing today’s work today’ by
ensuring that there is sufficient capacity to meet peoples’ demands so that
they can be seen on the day of their choice. There are several underlying
steps in this approach including understanding demand, shaping the handling
of demand by providing alternatives to face-to-face consultations, matching
capacity to demand and developing contingency plans (Murray & Tantau,
2000). Practices use rapid ‘Plan-Do-Study-Act’ cycles to implement these
changes (Murray & Berwick, 2003b). By working with a Primary Care
Collaborative, the aim is that practices will learn generic quality improvement
skills which will enable them to achieve sustainable improvement within any
area of patient care.
Many of the first wave of practices working with the Primary Care
Collaborative reported marked improvements in the wait for an appointment
and patient satisfaction. (However, other commentators have expressed
concerns that increasing access in this way may lead to a reduction in
personal continuity of care, may increase total demand on general practice,
and may not meet the needs of particular groups of patients (Murray, 2000).
Considering the size of the investment in Advanced Access, the radical claims
made for its benefits, and the strength with which it is being promoted by
PCTs, it is remarkable that very little rigorous evaluation of this model has
been undertaken. Advanced Access is arguably one of the most important
organisational changes in general practice in recent years, and there is a
pressing need for comprehensive evaluation of this initiative.
Aims
To evaluate ‘Advanced Access’ in general practice, and assess its impact on
patients, practice organisation, activity, and staff.
Objectives
To describe the range of strategies that general practices have employed to
improve access to care
To determine the impact of Advanced Access on the wait for an appointment,
continuity of care, practice workload, and demand on other NHS services.

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To explore the perceptions of different groups of patients, including both
users and non-users of services, about the accessibility of care and their
satisfaction with access to care in relation to different models of organisation.
To explore the trade-offs that patients make between speed of access,
continuity of care and other factors when making an appointment in general
practice.
To explore the perceptions of general practitioners and receptionists about
working with the NPDT and implementing changes to practice arrangements
to improve access.
To assess the impact of the above changes in practice organisation on staff
job satisfaction and team climate.
Method and results
This research was based on a comparison of 48 general practices, half of
which operated Advanced Access appointment systems and half of which did
not (designated ‘control’ practices). These practices were recruited from 12
representative Primary Care Trusts (PCTs). From within these 48 practices,
eight (four Advanced Access and four control) were selected for in-depth case
study using an ethnographic approach.
The research was comprised of several component studies. These included:
•
A survey of all practices in 12 PCTs. Based on this we recruited the 24
Advanced Access and 24 control practices and the 8 case study practices.
•
An assessment of appointments available and patients seen, based on
appointments records
•
An assessment of continuity of care based on patients’ records
•
Random phone calls to practices to assess ability to make an appointment
by telephone
•
A questionnaire survey of patients attending the practices
•
A postal survey of patients who had not attended the surgery in the
previous 12 months
•
A discrete choice experiment to explore trade-offs patients make between
access and other factors
•
A survey of practice staff
•
Qualitative case studies in 8 practices
•
Interviews with PCT access facilitators
The methods and results for each of these studies are described below, in
relation to each of the research objectives.

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The range of strategies that general practices have
employed to improve access to care
Survey of practices and selection of study sites:
A postal questionnaire survey was conducted amongst all 391 practices in 12
PCTs which were representative of the English population. A response rate of
63% was achieved. The majority of practices had adopted at least some
elements of the Advanced Access approach. A wide range of innovative
measures was being implemented by practices, whether or not they operated
Advanced Access.
Although 67% of practices claimed to operate Advanced Access, fewer than
half of these appeared to be following the central principles of this approach.
Conversely, many of the practices which did not describe themselves as
operating Advanced Access used some of the same ideas. Advanced Access
practices embargoed a higher proportion of doctors’ appointments until the
same day than non-Advanced Access practices, but offered a similar number
of appointments in total.
The findings from the practice survey were used to identify and recruit the 24
‘Advanced Access’ and 24 control practices for the main evaluation, and also
to select eight case study practices for more in-depth qualitative research.
Observation of case study practices:
Eight practices (four Advanced Access and four control) were purposefully
selected as case studies. Patients and staff in these practices were
interviewed and access to care was studied using direct observation.
The defining characteristic of Advanced Access for most practices (both for
those which introduced it and the control practices that did not) was that
appointments were made on the same day, rather than that patients should
be seen when they wished. The staff in both Advanced Access and control
practices appeared to assume that demand would exceed supply and so had
to be capped, in contrast to the assumption of the Advanced Access model
that access was predictable and manageable.
The systems in both types of practice appeared to be designed to control
access. In the case of control practices this was achieved by a disincentive -
the wait for an appointment. In Advanced Access practices demand was
limited by the pressure to telephone the practice early in the day, and by the
lack of flexibility in when appointments could be made.
There were important contextual factors which influenced whether and how
practices organised their appointment systems. There was a sense that
practices designed systems that they felt worked for them. These included
factors to do with the local population, the building or the local geography and
history.
Receptionists in both Advanced Access and control practices used a variety of
strategies to overcome the problems they experienced when unable to offer
patients suitable appointments, and it was evident that this was a process of
negotiation with patients that allowed receptionists considerable discretion.

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Some patients also appeared to use various strategies in order to ‘game’
systems which did not meet their perceived needs.
Patients expressed different sources of satisfaction and frustration with the
appointment systems in Advanced Access and control practices. In Advanced
Access practices, patients complained about the inflexibility and apparent
illogicality of the system, but appreciated the speed of access. In control
practices, patients expressed frustration with the wait for an appointment.
The impact of Advanced Access on the wait for an
appointment, continuity of care, practice workload, and
demand on other NHS services
Wait for an appointment:
Attempts were made to contact each practice by telephone, posing as a
patient wishing to make an appointment, on 11 occasions at monthly intervals
and at different times. If the practice was engaged or did not answer, up to
five further calls were made at two minute intervals in an attempt to make
telephone contact. It was possible to make telephone contact with practices
within six phone calls on 97% of these monthly attempts, but the researcher
was more likely to be able to contact Advanced Access practices within 6 calls
(99% of occasions) than control practices (95% of occasions). There was no
difference in the length of time spent telephoning to obtain an appointment
(median 3 minutes at both types of practice). On 15% of occasions the
researcher was not able to book an appointment, with no difference between
Advanced Access and control practices. When appointments were made,
Advanced Access practices offered an appointment with any doctor sooner
than control practices (median wait 0 days and 1 day respectively). The
median wait for the third available appointment was one day and two days
respectively. Both types of practice failed to achieve the NHS Plan access
target of offering patients a routine appointment with a GP within two working
days; Advanced Access practices met this target on 73% of occasions and
control practices on 65% of occasions. The median length of wait for a first
appointment with a particular doctor was the same (two days) in Advanced
Access and control practices.
We also addressed the issue of access through a patient survey. Consecutive
patients consulting in 47 practices were invited to complete a questionnaire
(response rate 84% (10821/12825)). Patients in Advanced Access practices
were more likely than those in control practices to be seen on the same day
as they contacted the surgery. In Advanced Access practices, 57% of patients
reported being seen the same day, and 75% being seen within two days. In
control practices 32% of patients were seen the same day and 57% within
two days. Overall, patients in Advanced Access practices were seen sooner
than those in control practices.
Continuity of care:
Data were collected about 114,675 consultations conducted with 5541
patients in 47 practices. There was no evidence of any difference between
Advanced Access and control practices in continuity of care, either for surgery

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consultations with GPs or if all type of consultations with doctors or nurses
were considered.
Further information about continuity of care came from the qualitative case
studies, where continuity of care was a common theme in interviews with
both patients and staff. Many patients commentated on the importance to
them of an enduring doctor-patient relationship, but for others this was not
important at all. Staff highlighted concerns that an excessive emphasis on
speed of access could have a detrimental effect on continuity of care. Both
patients and staff treated speed of access and continuity of care as values
which could be traded off against each other, and the outcome of this trade-
off would depend on the nature and seriousness of the problem.
The discrepancy between the quantitative and qualitative research with regard
to continuity of care is considered in the discussion section.
Workload:
Data was collected from practice appointment records about appointments
available for booking and attendances with different types of health
professional and in different types of consultation. The total number of
appointments available and the total number of patients seen increased
considerably in both Advanced Access and control practices over the period
during which Advanced Access systems were introduced. There was no
evidence of difference between the two groups, but wide variability between
individual practices. There was no evidence of difference between Advanced
Access practices and control practices in the proportion of appointments which
were not attended by patients (DNA rates).
Demand on other NHS services:
There was no evidence from the survey of patient consulting of any difference
between the two types of practice in patients’ use of other NHS services. In a
postal survey of people who had not consulted recently in general practice
there was some evidence that people registered with Advanced Access
practices were more likely to have consulted an NHS walk-in centre, an A&E
department, a pharmacy or another general practice than those registered
with control practices. However the numbers of respondents indicating these
consultations were small and confidence intervals for these estimates were
very wide so these findings should be interpreted with caution.
The perceptions of different groups of patients, including
both users and non-users of services, about the
accessibility of care and their satisfaction with access to
care
Survey of patients consulting:
In this survey it was notable that most consultations were not for acute
problems, with 70% of people having had their problem for at least a few
weeks.

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The most important factors for patients in making an appointment appeared
to be being able to choose to book an appointment on a day of their choice,
followed by being able to book as soon as possible, being able to see a doctor
rather than a nurse and being able to see a particular doctor. However these
preferences varied considerably for different patient groups, such as the
elderly, those with chronic illnesses, men and women and those in or out of
employment.
Patients in Advanced Access practices were no more likely than those in
control practices to say that they had obtained their current appointment on
the day of their choice or to say they were seen as soon as they wished, and
they were less likely to say they had been able to book the appointment in
advance. However, when asked about their usual experience of making
appointments, patients in Advanced Access practices had more positive
experiences of how long they had to wait to see any doctor, see a particular
doctor and see a doctor urgently than those in control practices. There were
no differences between the experiences of patients in Advanced Access or
control practices in satisfaction with the receptionists, waiting times in the
surgery, getting through on the telephone, speaking to a doctor on the
telephone, continuity of care, or satisfaction with the appointment system.
Non-user survey:
A postal survey was conducted to seek the views and experiences of patients
in the case study practices who had not had a consultation with a member of
their general practice team in the previous 12 months. The response rate was
47% (735/1564). A minority of patients had wanted to make an appointment
in general practice but had not been able to, or had not tried to make an
appointment because they thought this would be difficult. Patients in
Advanced Access practices were more likely than those in control practices to
have experienced or anticipated difficulties in contacting the surgery or in
getting an appointment at a convenient time. Patients in control practices
were more likely to have experienced or anticipated difficulties in getting an
appointment within a reasonable length of time.
Trade-offs that patients make between speed of access, continuity of
care and other factors when making an appointment in general
practice
We conducted a discrete choice experiment (DCE) amongst 1200 patients
consulting in the eight case study practices (response rate 94%). The DCE
was designed to elicit preferences for key, generic, components (attributes) of
general practice appointment systems, quantify trade-offs and predict
respondent’s choices from a range of alternatives specified. Respondents were
presented with making trade-offs between different levels of attributes for
two, hypothetical yet realistic health conditions; an acute, low worry and an
ongoing, high worry condition. For both conditions the four key components of
appointment systems that were of value were, in order of importance, being
offered: choice of doctor; a convenient time of day; a doctor rather than a
nurse; and an appointment sooner rather than later. In addition, respondents
valued duration of the appointment (preferring 20 minute appointments) if
the appointment was for an ongoing, high worry condition. It followed that

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Evaluation of Advanced Access in general practice
© NCCSDO 2007 14
respondents’ were willing to wait an extra 3.5 days (acute, low worry
problem) or an extra 5 days (ongoing, high worry problem) for an
appointment to see a doctor of their choice; an extra 2.2/2.6 days,
respectively, for a convenient time of day for the appointment and an 1.6/1.8
extra days, respectively, for an appointment to see any doctor rather than a
nurse.
The perceptions of general practitioners and receptionists
about the experience of working with the NPDT and
implementing changes to practice arrangements designed
to improve access
Qualitative case studies:
Based on interviews and observation conducted within the qualitative case
study practices, it appeared that the Primary Care Collaborative and the PCT
access facilitators had some influence during the introduction of Advanced
Access but their involvement in shaping practice policy was significantly
reduced once the new appointment system was up and running. There was
only limited evidence of quality improvement approaches such as regular
monitoring of supply and demand or the use of PDSA cycles, and little to
suggest that the introduction of Advanced Access was associated with learning
an approach to quality improvement which would benefit other aspects of
practice organisation in the way envisaged by the NPDT.
Interviews with access facilitators:
Six PCT access facilitators were interviewed about their perceptions of helping
practices implement Advanced Access. Their reflections tended to reinforce
our observations at the case study practices about the confusion between the
Advanced Access model, the access targets, and the appropriateness of
embargoing appointments. They also experienced difficulties in getting
doctors to fully engage with the collaborative process, and felt that practices
tended to take some ideas from Advanced Access but failed to embrace the
complete model. On the other hand, although these issues were all
challenges, the facilitators remained generally enthusiastic about Advanced
Access and positive about their experience of working with practices to
introduce change.
The impact of Advanced Access on staff job satisfaction
and team climate
A survey was conducted amongst the doctors, nurses, receptionists and
administrative staff in 46 practices (85% (817/960) response rate). There
were few differences between Advanced Access and control practices in the
perceptions of stress experienced by any of the groups of staff. Doctors and
receptionists expressed more positive team climate scores in Advanced Access
practices compared with control practices, whereas nurses reported lower
scores. Doctors in Advanced Access practices had slightly greater job