General Practitioner Appointment Systems, Patient Satisfaction, and use of Accident and Emergency Services--a Study in One Geographical Area

This study examines the relationship between (i) measures ofhow appointment systems work; (ii) patients' views of the arrangementsfor seeing their general practitioner; and (iii) practice self-referralrates to accident and emergency departments (A&E). Nineteengeneral practices and one district general hospital A&Edepartment in West Lothian, Scotland formed the setting fora prospective study employing analyses of computerized hospitalrecords, of patients surveys, and of data collected by practicesduring an 8-week study period in 1993. Principal outcome measureswere: (i) measures of appointment system operation correctedfor practice list size [number of unbooked (‘available’)appointments, appointment provision, proportion of patientsseen as ‘extras’]; (ii) patient views on practiceappointment systems (reported dissatisfaction with arrangementsfor being seen, proportion of patients reporting they normallywait in excess of 15 minutes when attending to be seen, theperceived availability of a doctor to deal with (a) urgent and(b) non urgent problems); (iii) practice self-referral ratesto local A&E department. Practices varied widely in theirrate of provision of appointments, in the proportion of appointmentswhich were unbooked at the start of the working day and in theproportion of patients identified as ‘extras’ byreception staff. These measures of appointment system operationcorrelated with patient dissatisfaction with the arrangementsof seeing a doctor in their practice and with the perceivedavailability of a doctor to deal with non urgent problems. Themeasures did not, however, correlate with A&E self-referralrates after they had been corrected for distance between practiceand hospital, or with the perceived availability of a doctorto deal with urgent problems. The proportion of patients seenas extras was related to the proportion of patients reportingthey normally waited in excess of 15 minutes to be seen whenattending their practice. Practices with small list sizes hadfewer respondents reporting dissatisfaction with the arrangementsfor seeing a doctor than had larger practices. Patients attendingA&E reported higher levels of dissatisfaction with the arrangementsfor seeing their general practitioner than did a sample of patientsattending their general practitioner. This finding persistedafter attempting to control for case mix, and was true whetherpatients were referred to A&E by their doctor or self-referred.The crow fly distance between a practice and the hospital isconfirmed as an important predictor of use of A&E servicesby patients who self-refer to such departments. This paper identifiesthree predictors of patient dissatisfaction with access arrangementsfor seeing a doctor. These are patients' perceptions of generalpractitioner availability to deal with non-urgent problems,practice list size, and measures of appointment system operation[the proportion of unbooked (‘available’) appointments,the rate of provision of appointments, and the proportion ofpatients identified as ‘extras’ by reception staff].Distance between practice and hospital is confirmed as an importantpredictor of a practice's self-referral rate to A&E. Thereis no evidence from this study that the variation amongst practicesin A&E serf-referral rates is related to the operation ofgeneral practitioner appointment systems.