Interacting with patients and managing appointments
A key function of the receptionist’s role is to allocate patient appointments. At the time of the study, there was political pressure and financial incentive for practices in the UK to ensure that patients could obtain an appointment with a GP within 48 hours. Appointment systems varied widely from practice to practice, some had a number of drop-in clinics, whereas others had bookable appointments for all clinics. Online appointment booking was not available at any of the practices and no GPs had individual patient lists.
In all practices a common distinction was made between routine and urgent appointments. As such, it was part of the receptionist’s role to ascertain the level of urgency of patients’ needs in order to prioritise them. Yet, this was not always a straightforward task. Negotiation with patients over the level of urgency was commonly observed, as illustrated here in a typical exchange between a receptionist and a patient:
A woman (white with fluent English) came to the desk wanting to see a specific GP:
Receptionist (R): ‘It’ll be next week.’
Woman (W): ‘What time?’
R: ‘It may not even be next week…’
W: ‘Oh, eh, come on love …’ [slightly aggressive]
R: ‘Well what’s the problem?’
W: ‘My stomach’s swollen, really sore.’
R: ‘Oh … yeah, right, well I have a cancellation at 5.10 but you’ll have to wait.’
W: ‘Yeah, fine … what do you think’s wrong?’
R: ‘Oh I don’t know, I’m not a doctor.’
The woman sits down with her friend who also has an appointment.
Receptionist (to researcher): ‘Her stomach does look swollen. And she really kicks off that one — comes in and wants to be seen immediately.’ Practice B
Within a framework where receptionists are assumed to be powerful and patients vulnerable, it is perhaps tempting to view this exchange as yet another example of a receptionist acting as a powerful gatekeeper. However, this interpretation, although it might mirror the experience of the patient, overlooks the subtleties of the work involved for the receptionist, who had to assess the urgency of the patient’s need but had little information to go on aside from her knowledge of the patient and her physical appearance. It also suggests that the woman’s past history of aggressive behaviour may have influenced the receptionist’s decision making and, therefore, her access to a doctor.
Contrary to the notion of receptionists as obstructive gatekeepers, numerous examples of receptionists altering their position at different times to take on the role of patient advocates were witnessed. Receptionists would often go to great lengths to help certain patients navigate the system, ensuring they obtained urgent appointments even if they had not been requested directly:
‘Two people asked about new registrations. Jane [receptionist] told one of these, a lady who wanted to see a doctor straight away, to phone after 6pm and ask for an emergency appointment.’ Practice E
Furthermore, in some cases, receptionists’ concern for the wellbeing of patients extended to feelings of clinical responsibility:
‘At the end of the day, I don’t want someone leaving the practice without diabetic medication and have that be on my head. Or if it’s an asthma attack or something …’. Practice B
Whether or not a patient was deemed a candidate for advocacy related to receptionists’ perceptions of certain groups of patients. Although some were seen as vulnerable, others were regarded as trying to ‘play’ the system. Receptionists considered protecting the system, and by extension the vulnerable patients, from those attempting to take advantage of it to be one of their central responsibilities. Patients suspected of being players were those who attempted to gain access to an urgent appointment by exaggerating the severity of their complaint or not turning up for booked appointments that had been arranged at short notice, having claimed their needs to be urgent:
‘They know how the system works so they miss one and then phone in the morning and book one for that day/next day. The ones that don’t know how the system works are the ones that need to.’ Practice F
‘Fiona [receptionist] [says] “Doesn’t it amaze you that patients that have booked appointments this morning haven’t turned up?” Paula [receptionist] and I say that we’ve just been talking about this. It’s always the same ones.’ Practice B
Among practice staff, it tended to be non-clinical staff that were most likely to live in the practice area and be familiar with the living environment and individuals within it. This is of relevance to the linkage role that receptionists fulfil between patients and clinicians in the communities they serve. It has the potential to cause anxiety about confidentiality among patients, although the study did not observe this. However, other examples of the implications of living within the community were evident, notably multilingualism, which was a feature of a number of telephone conversations, and other, more unexpected issues:
‘There was some discussion about the person who had been shot dead and how he was related to someone they knew, called Tim.’ Practice A
‘Clare [receptionist] lived in the area and knew a lot of the patients personally, which meant that she didn’t have to check many people’s addresses as proof of their identity. She told me that she thought it was good for the patients to have someone that they know, but finds that sometimes people ask her about scripts and other work matters on her days off.’ Practice G
‘… He’s twitchy, pacing, seems on edge, and then he leaves. Dawn says something about being glad that they found the script. I get the impression that he’s got angry with someone before. Jane says he wouldn’t flip out at her because she’s known him since before she worked here, since they were kids.’ Practice B
Negotiating practice rules and policies
Practice rules and policies had various impacts on the negotiation of urgency and receptionists’ relationships with patients. Some policies were helpful for reducing the complexity and made it easier to prioritise patient appointments:
‘… I asked more about these “judgments”. Fiona [receptionist] gave an example: if a patient said they had chest pain, they would ask them how long they had had it — if they had had it less than 24 hours, they would tell them to phone an ambulance, if they had if for longer, they would give them an emergency appointment.’ Practice B
Appealing to certain rules during encounters with patients could be useful because it was a source of legitimacy and helped justify the receptionist’s position on a particular issue:
‘Paula [receptionist] explained why she couldn’t give her a prescription without her seeing a doctor and that there was nothing she could do. The woman was getting visibly worked up and took a somewhat confrontational tone. At this point, Paula looked over to Fiona who was sitting at the mid-desk in order to bring her in to the conversation. Fiona spoke loudly and quite sternly to the woman from halfway across the office. “It’s not our decision, it’s a government decision,” she said. “You’ll have to go on the telephone list and then the doctor will give you a call. I’ll put you on now.” The woman, while still not happy, seemed to accept this and left the reception.’ Practice B
In practice B, at the request of a senior GP, receptionists were required to ask every patient their presenting complaint and note it on the booking system. Following this rule put receptionists further into the clinical realm and brought hostility from patients. Tracy, a receptionist, reported a strategy for lessening her discomfort at having to ask and the likelihood of objection from the patient:
‘I ask Tracy [receptionist] how she feels about asking people to give a reason for their appointment. She doesn’t like doing it. “What’s it like?” [to Mary]. Mary [receptionist] doesn’t like it — they think that everyone [all receptionists] has a problem with it. Some people [patients] get angry and refuse to tell them. Sometimes Tracy gives people a set of very general options (Is it your leg? Back? Chest?). A couple of times she’s left it blank and Dr Doepfer [GP] has come and shouted at her.’ Practice B
In some situations, rules were effectively unworkable due to language and literacy barriers. In practice D, anyone collecting prescriptions on behalf of someone else had to sign their own name, as well as writing the name of the patient. However, some couldn’t write English and most receptionists couldn’t read Urdu, which was a common written language among the patient group. Some patients weren’t able to write at all and using a thumbprint was not sufficient. Receptionists reported being tempted to break the rules by writing the patient’s name themselves.
Staff interactions and practice culture
Practices varied in terms of the interaction level between receptionists and health professionals, the dynamics of these relationships, and attitudes towards roles and responsibilities. An incident in practice B illustrated how it can be particularly undermining for a receptionist if a health professional (in this case a practice nurse) contradicts the receptionists’ actions when dealing with a patient:
‘… a patient expecting to be fitted in for a blood test that morning — receptionists explained it wasn’t possible, but then nurse walked into reception and the patient asked them directly. Receptionists tried to explain to nurse what had been said but nurse cut them short and agreed to see the patient. [Receptionist was visibly upset by this].’ Practice C
Other incidents could be a source of pride for receptionists, such as when one doctor publicly demonstrated his faith in their abilities. The following example shows how uncertainties in receptionists’ work can create both vulnerabilities and opportunities for positive support:
‘Fiona [receptionist] recounted a story about a female patient coming to the practice and complaining loudly about some kind of appointment mix up. Dr Doepfer [GP] had come over to the woman and asked her to explain what the problem was. He listened to her and said, “My girls wouldn’t make that kind of mistake,” which had appeased the woman.’ Practice B
In practice A, on the basis of receptionists’ recommendations, open clinics were introduced once a week, and subsequently increased to four times per week. Receptionists were happier with more open clinics because they could suggest a patient attend the open clinic when no timely appointments were available. More open clinics usually meant that patients could be seen at an earlier date but would usually spend longer in the waiting room. This alleviated pressure on receptionists by giving them more room for manoeuvre with appointment allocation. However, receptionists reported that having four open clinics per week was gruelling for clinicians, who were less satisfied with the arrangement.
Previous research has identified that the practice environment is an important factor when considering communication among practice staff.11 Practices A and E were comparable in size and in the patient group served. They also had a similar building layout; in both, the reception was on the ground floor and the consulting rooms and common room on the first floor. In practice E, the distance between doctors and reception staff was stark. Doctors were rarely seen at reception and several receptionists reported feeling apathetic towards the practice and underappreciated by the doctors. In practice A, there was a book in the reception area for signing in and out, which all staff used. Doctors were frequently seen at reception and receptionists took advantage of their presence by, for example, asking them to sign scripts. In practice E, receptionists reported that the doctors did not like to be interrupted between patients and had made complaints about receptionists querying their instructions. The contrast between practices A and E illustrates that the practice’s built environment was not a primary factor in determining whether the relationships between receptionists and doctors were fraught, and likewise did not shape the culture of the practice.
