Physiotherapy Outpatient booking - same day appointments and direct access

Background

The system of same day appointments was developed by physiotherapists at Eastbourne hospital and has been running there for three years, maintaining no waiting list and with “did not attend” (DNA) rate at less than 1%. To see if this system could be replicated it was introduced into the Torbay Hospital Physiotherapy Department in March 2006.

Direct access was added to same day appointments in October 2006 as a pilot project. Patients now no longer need to be referred into the service – they telephone in and self refer.

What is the problem you are trying to solve?

To make more effective use of staff time by reducing wasted time from DNA (17% for first and follow up appointments), thereby increasing capacity for patient treatment without additional staffing. Also giving choice to patient – to have treatment on a day and at a time that suits them.

Direct access reduced the need for GPs to provide referral information, reducing administrative workload for them.

What local organisations are involved?

South Devon Healthcare NHS Foundation Trust and Torquay GP practices in Torbay Care Trust

How many people are running this project and who are they?

Head of physiotherapy – Fiona Jenkins; team lead physiotherapist, outpatients Torbay Hospital – Frances Hunt

What local population are you targeting?

Torquay residents, approximately 60 000

How many people are you targeting?

Approximately 100 patients per week

Interventions

What interventions are you using to address the problem?

Patients are given the number of the dedicated telephone booking line at Torbay Hospital Physiotherapy Department. They are asked to ring in on the day they want treatment and book an appointment. Follow-up treatments are booked the same way.

Is the project design based on evidence? If so, please state reference.

There is evidence from the Eastbourne service that same day appointments dramatically reduces DNA rate and provides additional capacity.

Evidence from several sources ^{1 2} about the effectiveness of direct access physiotherapy suggests that direct access could save a five person GP practice one month of consulting time each year.

Outcome

What outcomes or planned outcomes are you measuring?

• Waiting time for treatment;
• DNA rate;
• Ratio of first to follow up appointments;
• Complaints regarding waiting time;
• Patient satisfaction; and
• GP satisfaction.

Do you have any outcomes or results yet? If so, what are they?

• DNA rate reduced from 17% to less than 1% in the first six months;
• No complaints regarding waiting times;
• Ratio of first to follow up appointments changed from 1:4 to 1:1.6;
• Good patient satisfaction, with adjustments made where possible to incorporate suggestions for improvement; and
• Excellent feedback from GPs, with adjustments made where possible to incorporate suggestions for improvement.

Is your project relevant to a government target or guideline?

The Musculoskeletal Services Framework ³ and the target set out in The NHS Improvement Plan: By 2008 no one will wait longer than 18 weeks from GP referral to hospital treatment ⁴ .

Feedback

What obstacles did you have to overcome to set up this project?

We needed to get staff on board - the pilot meant a significant change to working practice. The telephone system needs to be updated to indicate to patients that they are held in a queue.

We were approached by GPs from their local Practice Based Commissioning group, asking to add direct access to the same day appointments system. However, commissioners want further extension of the pilot before a decision is made regarding roll out to other physiotherapy departments.

What have you learned about the project so far?

Our system is very effective at reducing wasted time by DNA. Getting patients to contact the department for follow-up reduces DNA further.

Any type of pre-booking leads to DNA, even if booked 24 hours in advance. However, there needs to be a balance between keeping zero DNA and meeting some patients’ need to pre-book. We now allow pre-booking of early morning slots 48 hours in advance.

Commissioners were concerned that direct access may be difficult to commission due to the volume of patients self referring. However, we haven’t found a significant increase in numbers.

What would you do differently?

We would have made agreements with the commissioners regarding roll out of same day appointments before Primary Care Trust reconfiguration. When the service was introduced, physiotherapy was provided uniformly across primary and secondary care. Since 2004 there have been different employment arrangements for each organisation which has made roll out more difficult in the timeframe planned.

References:

1. Holdsworth L, Webster V. Patient Self Referral: A guide for therapists. Radcliffe Publishing. 2006.
2. The Chartered Society of Physiotherapy. Self-referral to physiotherapy services. 2004. http://www.csp.org.uk/uploads/documents/csp_self_referral_briefing.pdf (accessed 27 April 2007).
3. Department of Health. The Musculoskeletal Services Framework. 2006. www.dh.gov.uk (search for 6857, accessed 27 April 2007).
4. Department of Health. The NHS Improvement Plan: Putting people at the heart of public services. 2004. www.dh.gov.uk (search for 3398, accessed 27 April 2007).