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

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Abstract
This study examines the relationship between (i) measures of how appointment systems work; (ii) patients' views of the arrangements for seeing their general practitioner; and (iii) practice self-referral rates to accident and emergency departments (A&E). Nineteen general practices and one district general hospital A&E department in West Lothian, Scotland formed the setting for a prospective study employing analyses of computerized hospital records, of patients surveys, and of data collected by practices during an 8-week study period in 1993. Principal outcome measures were: (i) measures of appointment system operation corrected for practice list size [number of unbooked (‘available’) appointments, appointment provision, proportion of patients seen as ‘extras’]; (ii) patient views on practice appointment systems (reported dissatisfaction with arrangements for being seen, proportion of patients reporting they normally wait in excess of 15 minutes when attending to be seen, the perceived availability of a doctor to deal with (a) urgent and (b) non urgent problems); (iii) practice self-referral rates to local A&E department. Practices varied widely in their rate of provision of appointments, in the proportion of appointments which were unbooked at the start of the working day and in the proportion of patients identified as ‘extras’ by reception staff. These measures of appointment system operation correlated with patient dissatisfaction with the arrangements of seeing a doctor in their practice and with the perceived availability of a doctor to deal with non urgent problems. The measures did not, however, correlate with A&E self-referral rates after they had been corrected for distance between practice and hospital, or with the perceived availability of a doctor to deal with urgent problems. The proportion of patients seen as extras was related to the proportion of patients reporting they normally waited in excess of 15 minutes to be seen when attending their practice. Practices with small list sizes had fewer respondents reporting dissatisfaction with the arrangements for seeing a doctor than had larger practices. Patients attending A&E reported higher levels of dissatisfaction with the arrangements for seeing their general practitioner than did a sample of patients attending their general practitioner. This finding persisted after attempting to control for case mix, and was true whether patients were referred to A&E by their doctor or self-referred. The crow fly distance between a practice and the hospital is confirmed as an important predictor of use of A&E services by patients who self-refer to such departments. This paper identifies three predictors of patient dissatisfaction with access arrangements for seeing a doctor. These are patients' perceptions of general practitioner 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 of patients identified as ‘extras’ by reception staff]. Distance between practice and hospital is confirmed as an important predictor of a practice's self-referral rate to A&E. There is no evidence from this study that the variation amongst practices in A&E serf-referral rates is related to the operation of general practitioner appointment systems.

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