Actual availability of general practice appointments for mildly ill children

There are concerns that there may be shortages in the Australian primary care workforce, especially in rural and regional areas. However, some have suggested that a shortage of general practitioners is also a problem in metropolitan areas.1 In some outer suburbs of Melbourne, residents have reported significant difficulty in acquiring a medical certificate for sick leave in a timely manner, and that waiting 2 weeks for a doctor’s appointment is common.2 Similarly, some GPs in Melbourne have reported having to close their books due to excessive demand, with one doctor stating he had to turn patients away for 2 years3. Even in some inner-city Melbourne practices, doctors have reported having to close their books, and hearing from patients that they have had to telephone four or five clinics just to obtain an appointment.4

An actual or perceived lack of availability of primary care appointments may contribute to the increased rates of attendances at hospital emergency departments (EDs), as patients seek alternative ways to reach health care providers. Attendances at EDs are increasing at a rate exceeding population growth, and there is a perception among hospital staff that a significant portion of attendances are for conditions that do not require the urgent or specialised services that such departments provide.5,6 While some ED visits are for serious acute conditions some of which result in hospitalisation, a large number could be treated in a primary care setting.6-8

Many hospital EDs are experiencing a severe strain on their limited resources, as evidenced by chronic overcrowding and long waiting periods.9,10 Thus, ensuring that primary care practitioners are sufficiently available and accessible in the community is essential for both individuals and the health system as a whole. This would help patients with urgent conditions receive more timely treatment in hospitals by reducing demand for ED services, while those who do not require emergency treatment would benefit from the continuity of care and preventive services available in the community.11

Understanding the true availability of the primary care workforce for the population is necessary to determine whether a shortage actually exists. Projected models of supply and demand for the primary care workforce do indicate a possible shortage of practitioners.12 However, beyond head counts of providers, there are few data that provide more than anecdotal reporting of primary care workforce supply and demand in Australia. For example, in 2009 the Australian Bureau of Statistics found that, in 1 year, about 937 800 people reported they had been unable to access health services when they needed them. Of the 82% who were attempting to access general practice services, 47% cited long waiting periods or a lack of available appointments as the main reason for lack of access.13 A study of an outer metropolitan region in Western Australia found that 59% of people had reported difficulty in obtaining GP appointments, citing lack of appointments, long waiting periods and inconvenient hours.14 Although indicative, such data are of limited use in assessing the actual availability and accessibility of services, given their focus on modelled data or on patient recall of health service access. No previous studies have provided a real-time assessment of GP availability or appointment charges from the patient’s perspective.

The lack of such data hinders adequate policy responses to ensure that the needs of the population are met. We undertook this study specifically to help fill this gap. We focused particularly on children because previous studies have shown a decrease in the proportion of GP visits specifically provided to children over the past 2 decades.15

Methods

We used “secret shopper” techniques, a well known and often-used method to determine the actual versus reported availability of physician appointments.16 This involved having research assistants pose as parents and telephoning general practice clinics seeking treatment for children with non-urgent, low-acuity conditions. The study was conducted between 1 August and 30 September 2014.

Sample

The sampling frame included all GPs working within the catchment areas of three Medicare Locals in the greater Melbourne metropolitan area. The Medicare Local catchments included urban, suburban and regional areas. Each Medicare Local provided contact details of all GPs within their catchment areas. A random sample of 225 practices were contacted, 75 from each Medicare Local list.

Data collection and analysis

Same-day appointments were sought for paediatric patients based on one of two clinical scenarios, each of which was designed to present non-urgent, low-severity conditions appropriate for general practice. The scenarios were developed with the help of two clerical staff from two general practice clinics and two GPs from other practices. The scenarios were:

• a 3-year-old child with an earache and a mild fever; and

• an 8-month-old with a slight cough, runny nose and mild fever.

Research assistants telephoned clinics between 9:00 am and 12:00 pm on weekdays to maximise the likelihood of same-day appointment availability.

Attempts were made to make an appointment with a specific, randomly selected GP in the practice. If a same-day appointment with that GP was not available, a request was made for a same-day appointment with any GP in the clinic. Same-day appointments offered with other GPs within the clinic were classified as an available appointment. Data were recorded on whether an appointment was unavailable, available with the requested practitioner, or available with another practitioner within the clinic. Where same-day appointments were available, the time between making the call and the next available appointment was recorded. Bulk-billing status of the clinic was a binary variable (yes/no). Where clinics did not bulk bill, both the upfront cost of an appointment and the final out-of-pocket cost (upfront cost minus the Medicare rebate amount) was recorded. Where the receptionist stated the cost of an appointment was likely to vary on length of appointment, a minimum and maximum cost provided by the practice were recorded.

Where an appointment was offered, the appointment itself was not accepted. Receptionists were told by the research assistant that they would call back if an appointment was actually needed and if the time offered was acceptable. No appointments were actually booked in any practice. The call process was developed and pilot-tested with medical reception staff from GP clinics to ensure that it did not have a significant impact on the administration of the clinics.

The study received ethics clearance from the University of Melbourne Human Research Ethics Committee. This committee required that, after the data were collected, letters be sent to clinics that had been selected within the catchment areas alerting them to the possibility of having been contacted by the research team and describing the nature of the study.

Statistical analysis

All data were analysed using Stata, version 13 (StataCorp). Analyses primarily involved the use of descriptive statistics, with the ?2 test used to investigate potential associations between appointment availability and the availability of bulk-billing in clinics.

Results

Appointment availability

Overall, same-day appointments to see any doctor were offered by 78% of clinics (175/225). Appointment availability between the three Medicare Local catchment areas varied only slightly, from 72% to 81%. However, availability to see a specific doctor in the practice was more limited (Box 1).

Time until available appointments ranged from less than 1 hour in 15% of practices to over 8 hours in a single practice (Box 2). About half of the clinics contacted (111; 49%) were able to offer an appointment within 4 hours. A further 9% offered walk-in appointments, for which a waiting time could not accurately be determined (Box 2).

Appointment cost

About three-quarters of the clinics contacted (168; 75%) offered bulk-billing for paediatric patients. Actual proportions varied between 72% and 80% in the three Medicare Local catchment areas (Box 3).

Box 4 provides a comparison of appointment availability by clinic billing practices. Appointments were more likely to be available in clinics that provided bulk-billing for paediatric appointments, with 82% of those able to offer an appointment compared with 67% of private-billing clinics (P = 0.01). Mean out-of-pocket costs were lower at clinics in which appointments were available than at those in which no appointment was offered. In clinics that did not bulk bill, the minimum out-of-pocket costs cited by reception staff ranged from $2 to $75.65, with a mean of $32.18. Maximum out-of-pocket costs ranged from $12 to $94.30, with a mean of $34.67.

Discussion

Among the most important findings from this study is that there is significant same-day GP appointment availability for children with low urgency, low-acuity conditions in the areas we studied. Further, about three-quarters of clinics with same-day appointment availability offered bulk-billing for paediatric patients, suggesting that financial constraints are unlikely to be a significant barrier to accessibility of primary care appointments. With 78% of clinics able to offer a same-day appointment and with there being multiple GPs practising within the postcodes of our catchment areas, it seems likely that most people attempting to procure such an appointment would be able to do so, and with no out-of-pocket cost. In addition, a high proportion (almost 60%) of appointments were offered either within 4 hours of contacting the clinic or on a same-day walk-in basis.

Our results indicate that increasing attendances for children at EDs are unlikely to be driven primarily by a lack of availability of appointments in general practice. It is possible that a perceived lack of primary care appointment availability may be a contributing factor in some ED presentations. Parents and guardians may simply be assuming a lack of availability of GP appointments, and believe they are more likely to be provided with timely care in an ED. If this is the case, public information campaigns based on our findings may help to change the behaviour of patients in seeking acute care for low urgency conditions at their general practice clinic. Although not all GPs had same-day appointments available, there were multiple GPs able to see patients for non-urgent conditions in a timely manner. This is in contrast to the picture presented in some media reports.2-4

Our findings on the high proportion of clinics that bulk bill for paediatric care (75%), and the higher availability of appointments in these clinics compared with private-billing clinics is important. The perceived cost of appointments may be influencing the behaviour of parents seeking care for children with non-urgent conditions.17 A study of patients 15 years and older found that over a million Australians reported that they had not seen, or had delayed seeing, a doctor due to cost in a given year; another study found that 24.5% of those living in an outer metropolitan suburb cited financial matters as a barrier to visiting a GP.13,14 Publicising the availability and accessibility of same-day appointments for children in bulk-billing clinics may allay concerns over the cost of appointments.

A previous study has shown that if parents are unable to obtain appointments with a practitioner that they know and trust, they may instead seek treatment in an ED.18 Although parents may wish to see the same GP for all of their child’s health care needs, that appears to be an increasingly unrealistic goal. Trends in GP practices indicate that the number of GPs working in larger practices (of four or more partners) is increasing, while only about 11% work in solo practices.19-21 Frequently, patients are seen by several members of a practice.

A limitation of our study is that that the distribution of GPs may differ between metropolitan, regional and rural areas across the country, so our findings may not be generalisable to other parts of Australia. Further research would be required to assess the availability of same-day GP appointments in other areas. Further, we collected our data on weekday mornings — a time likely to maximise appointment availability. A similar audit conducted nearer closing time may produce different results.

This study provides an accurate and current real-time assessment of availability and accessibility of general practice appointments for children with non-urgent conditions from the patient’s perspective. We found high availability of appointments in GP practices, although not necessarily with a specific doctor in the practice. Additionally, the high availability of appointments in bulk-billing clinics indicates a lack of economic barriers to available care. We believe this information can aid in developing data-driven policy approaches for ensuring the availability of the primary care workforce and the use of paediatric ED services for non-urgent conditions. Further, the public should be made aware of the ready availability of GP appointments.