The COVID-19 pandemic has placed unprecedented demands on general practice in a variety of forms: first, to provide a variety of clinical services specifically designed to combat the pandemic; second, to adapt to remote ways of working facilitated by digital technologies; and, third, to maintain ‘everyday’ general practice under immense patient demands, a fatiguing workforce, and increasing staff shortages. A seemingly unintended by-product of these adaptations is the significant shift towards providing general practice appointments that take place on the same day as or 1 day after their booking.
Data from NHS Digital reveal that, before the COVID-19 pandemic (data available from June 2019–March 2020), 68.3% of total monthly general practice appointments in England took place on the same day or 1 day after their booking on average. This figure increased by 14.8% to 78.4% after the pandemic (data from April 2020 to November 2021), reflecting 1 285 498 more appointments of this type per month on average (average monthly total appointments of this type before and after the pandemic were 12 385 232 and 13 670 730, respectively).1
The improved access to same-day or following-day appointments since the onset of the pandemic is associated with an improvement in the proportion of general practice appointments that were booked but not attended (‘did not attend’, or ‘DNA’) across this period. Before the pandemic (data available from June 2019–March 2020), 5.1% of total monthly general practice appointments in England were recorded as DNA on average. This figure decreased by 23.5% to 3.9% after the pandemic (data from April 2020–November 2021), reflecting 330 258 fewer missed appointments per month on average (average monthly total missed appointments before and after the pandemic were 1 285 461 and 955 203, respectively).1
While the total monthly appointments undertaken in primary care has increased since the onset of the pandemic (the average monthly number of appointments in June 2021 to November 2021 [27 527 272] was 8.4% greater than the corresponding figure in June 2019–March 2020 [25 392 012]),1 this does not explain the entirety of the increase in same-day and following-day appointments.
Before the pandemic (data available from June 2019–March 2020), 31.6% of total monthly general practice appointments in England were booked 8 or more days in advance on average. This figure reduced by 32.0% to 21.5% after the pandemic (data from April 2020 to November 2021), reflecting 2 730 403 fewer appointments of this type per month on average (average monthly total appointments of this type before and after the pandemic were 8 034 858 and 5 304 455, respectively).1
These data reveal that a substantial proportion of appointments undertaken in general practice has shifted from those planned at least 8 days in advance to those taking place on the same day or day following their booking.
While patients may value an improvement in the availability of same-day or day-following appointments, this metric represents only one element of quality care in general practice. In fact, in a previous study of 12 825 patients across 47 practices, it was found that a 10% increase in the proportion of same-day appointments was associated with an 8% reduction in the proportion of patients satisfied,2 while other work showed that speed of access is of limited importance to patients, and for many this is superseded by various other factors including choice of clinician or convenience of appointment.3
ACCESS TO GENERAL PRACTICE AND TRADE-OFFS
This shift from planned in advance to same-day and following-day appointments suggests general practice is increasingly providing reactive care at the expense of preventive interventions, long-term management, and continuity of care between patients and clinicians with whom they have established rapport. These elements of general practice are known to be highly valued by patients and clinicians, and valuable for health outcomes,4 reaffirming that speed of access is not the only relevant variable.
Accordingly, the degree to which access to planned-in-advance appointments should be traded off against access to same-day appointments requires an open debate that considers patient preferences, general practice infrastructure, the demands of the pandemic, and population health targets. Absent this debate, any shift in appointment proportions will be determined by alternative factors that are unlikely to result in better patient care. It has been suggested that the recently observed shift towards same-day appointments has been driven and facilitated by the widespread uptake of digital technology-enabled remote consultations.5 While these technologies provide clear benefits to GPs and their patients, they must not be allowed to dictate how patient care is delivered. Instead, their power should be harnessed to help deliver the optimum balance of same-day and planned appointments, once this balance has been defined.
Footnotes
This article was first posted on BJGP Life on 20 Jan 2022; https://bjgplife.com/shift
- © British Journal of General Practice 2022
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