You implemented the triage-first access model in October 2025. The online consultation platform is live, the SOPs are written, and the contract requirements are technically met. Now you need to verify it's actually working safely and fairly.
This systematic audit plan shows you how to benchmark your access performance against peer practices, identify safety risks and equity failures, and fix the gaps before the GP Patient Survey results are published in July 2026.
This is proactive quality assurance that demonstrates governance maturity to CQC inspectors, protects your practice from safety incidents, and ensures you're competitive with neighboring practices.
Implementation timeframe: 6-8 weeks for full audit cycle; immediate actions on critical findings
Why This Matters
For Your Practice
The GP Patient Survey fieldwork runs January–March 2026, with results published in July. Access questions dominate the overall rating—if patients feel they can access care when needed, your scores rise; if they don't, satisfaction collapses regardless of clinical quality.
October 2025 reset the competitive landscape. Some practices implemented Total Triage effectively—same-day triage responses, fair clinical-need prioritization, high patient satisfaction. Others are struggling with backlogs, silent system closures, or two-tier access where the old 8am phone rush still wins.
The performance variance between peers is now massive. If you were mid-table on access in 2024, you could drop to bottom quartile by 2026—or jump to top quartile—based entirely on execution quality. You need to know where you stand before Survey results lock in your reputation for the next year.
Concrete benefits:
Patient safety: Catch missed red flags before they become serious incidents. Verify triage decisions are clinically appropriate and safety-netting is adequate.
Regulatory compliance: Demonstrate CQC Regulation 17 (Good Governance) through systematic quality assurance. Show proactive risk management.
Competitive positioning: Know where you rank against peers. Fix problems while you still have time before Survey fieldwork closes in March.
Efficiency gains: Identify capacity mismatches and workflow bottlenecks. Stop wasting GP time on preventable "ping-pong" triage requests.
Risk reduction: Find equity failures, safeguarding gaps, and availability breaches before complaints or incidents force action.
For Your Professional Development
By leading this audit and implementing evidence-based improvements, you'll demonstrate:
Quality improvement leadership: Systematic performance review using peer benchmarking, data analysis, and behavioral observation. Proactive rather than reactive management.
Clinical governance expertise: Understanding of triage safety, decision fatigue patterns, and safeguarding in digital contexts. Ability to work with Clinical Lead on quality assurance.
Data-driven decision making: Using comparative analytics, timestamp analysis, and outcome metrics to identify problems and measure improvement.
Change management skills: Addressing "shadow systems" (unofficial workarounds), retraining staff on equity principles, managing service model transitions.
Strategic planning: Connecting operational performance to Survey outcomes and competitive positioning.
Add these achievements to your year-end evaluation: "Led comprehensive access audit identifying [X] safety improvements and [Y]% equity improvement. Repositioned practice from [Xth] to [Yth] percentile in peer group access rankings through evidence-based optimization."
Prerequisites and Preparation
What You Need Before Starting
Approvals: Practice Manager authority to conduct audit; Clinical Lead engagement for safety reviews; Partner approval if audit reveals need for additional capacity investment.
Data access: Admin access to online consultation platform (to extract timestamp and outcome data); appointment system reporting access; telephone system statistics.
Stakeholders: Clinical Lead (for triage quality review), Safeguarding Lead (for written disclosure review), Reception Team Lead (for behavioral observation and training).
Baseline data: Last 2-3 months of triage activity (request volumes, response times, outcomes); recent patient feedback or complaints themes related to access.
Optional but useful: Peer benchmarking data showing your practice's access ranking compared to statistical peers can help set improvement targets and identify high performers to learn from.
Throughout this plan: You can use My Practice Manager tools (email assistant, document generators, task tracking) to speed up template creation and compliance tracking, or create documents manually. All approaches are viable—tools just save time.
Estimated Time Investment
Total audit and improvement cycle: 6-8 weeks (audit 2-3 weeks, fixes 3-4 weeks, verification 1 week)
Your time per week: 4-6 hours during audit phase (data gathering, meetings, observation); 2-3 hours during fix phase (training coordination, monitoring)
Clinical Lead time: 3-4 hours for triage quality review (one-off); 1 hour monthly for ongoing spot-checks
Safeguarding Lead time: 2 hours for written disclosure review (one-off)
Reception Team Lead time: 2 hours for behavioral observation; 4 hours for retraining delivery if needed
Staff training time: 2-4 hours if refresher training required (care navigation scripts, triage information quality, equity principles)
The Implementation Plan
Phase 1: Know Where You Stand (Week 1)
Before auditing your internal systems, establish your baseline and competitive context.
Meeting 1: Kick-Off and Audit Scope
Attendees: Practice Manager, Clinical Lead, Reception Team Lead, Senior Partner
Duration: 60 minutes
Agenda:
Review the competitive reality—October 2025 created performance variance between practices
Identify audit objectives—what are we most concerned about? (Safety, equity, capacity, compliance)
Set audit scope and timeline—what systems will we audit over the next 6-8 weeks?
Assign data-gathering responsibilities and set deadlines
Define "good enough" vs "needs improvement" thresholds for key metrics
Outputs:
Project charter: objectives (safety, equity, competitive positioning), scope (all access channels), timeline (6-8 weeks)
Data request list: platform logs, appointment journey times, telephone stats, recent complaints
Success criteria: what does "good" look like for our practice?
Quick document creation: Need an audit project charter template or data request memo? Email mypm@automate.mypracticemanager.co.uk with: "Create an access audit project charter for [Practice Name]. Objectives: safety, equity, competitive positioning. Timeline: 6-8 weeks." Response in 1-2 minutes. Alternatively, create manually using standard project management templates.
Action: Gather Your Baseline Data
Request these datasets from your systems (cover last 60-90 days):
From online consultation platform:
Daily availability logs (timestamps when platform was open/closed)
Request volumes by day and hour
Request-to-response timestamps (for SLA analysis)
Triage outcomes (urgent/routine appointment, advice only, signposted, etc.)
Vague description count (requests with minimal clinical detail)
From appointment system:
Phone booking timestamps (call received → appointment booked)
Online booking timestamps (form submitted → appointment allocated)
DNA rates and follow-up documentation
Same-day appointment availability tracking
From telephone system:
Call answer times and abandonment rates
Peak demand patterns
Queue lengths during busy periods
From complaints/feedback log:
Access-related complaints in last 3 months
Themes: delays, unfairness, difficulty contacting, confusion about process
Output: Raw data pack ready for Phase 2 analysis
Optional: Benchmark Against Statistical Peers
If you want to understand how you compare to similar practices, you can:
Manually review last GP Patient Survey results for similar-sized practices in your area
Use peer benchmarking tools (e.g., GP Survey Health Check) to identify your statistical peer group and see where you rank
Contact high-performing practices to learn what they did differently post-October 2025
This gives you a competitive target: are you protecting a top-quartile position, or catching up from mid/bottom quartile?
Phase 2: The Data Audit (Week 2-3)
Analyze your data to find technical failures: availability breaches, capacity mismatches, equity failures, decision fatigue patterns.
The "Silent Closure" Audit (Availability Compliance)
Question: Is your online consultation actually open during contractual core hours (8am–6:30pm), or is it being turned off early?
Method:
Review platform availability logs—timestamp analysis of open/closed status
Count days with early closure (before 6:30pm) or late opening (after 8am)
Identify patterns: Specific days worse? Winter months? Staff shortage days?
Assessment Criteria:
Compliant: Platform open >98% of required hours; any closures have documented business continuity reason
Partially Compliant: Occasional early closures (5-10% of days); usually capacity-related
Non-Compliant: Frequent closures (>10% of days); staff routinely turning off forms due to overwhelm
Red Flag: Forms disabled before 6:30pm on >10% of days = contract breach + hidden capacity failure requiring immediate escalation to partners.
Evidence Location: Platform availability report; document for CQC inspection preparation
The "Queue & Flow" Audit (Capacity & SLA Performance)
Question: Are triage responses meeting SLAs (urgent cases <2 hours, routine cases <24 hours within working days)?
Method:
Extract request-to-response timestamps for all cases in review period
Calculate SLA compliance rates:
Urgent: % responded to within 2 hours
Routine: % responded to within 24 working hours
Identify worst-performing days and times
Analyze backlog patterns: Does queue clear daily, or does backlog accumulate?
Assessment Criteria:
Compliant: >95% urgent cases <2h; >90% routine cases <24h; daily queue clearance
Partially Compliant: 85-95% urgent compliance; occasional backlog (cleared within 48h)
Non-Compliant: <85% urgent compliance; persistent backlog; some cases waiting multiple days
Red Flag: >20% of urgent cases exceed 2 hours, or routine cases regularly hitting 48h+ = capacity crisis requiring immediate intervention.
Evidence Location: Triage performance dashboard; escalate to Clinical Lead and partners if non-compliant
The "Two-Tier Access" Audit (Equity Compliance)
Question: Are phone patients getting faster access than online patients? (This indicates you haven't truly shifted to triage-first; the old 8am rush system is still operating in parallel.)
Method:
Sample 50 phone-based access requests and 50 online consultation requests (same time period)
Calculate "request to appointment booked" time for each channel
Compare median and mean journey times
Check for consistent patterns favoring one channel
Assessment Criteria:
Compliant: Phone and online journey times within 15% of each other; allocation based on clinical need, not channel
Partially Compliant: Some variance (15-30%) but explainable by case mix; no systematic bias
Non-Compliant: Phone consistently 50%+ faster; evidence of "8am rush still works" informal system
Red Flag: Phone patients consistently get same-day appointments while online patients wait 2-3 days for equivalent clinical need = equity failure and incomplete triage-first implementation.
Evidence Location: Comparative access analysis report; present to Clinical Lead for allocation protocol review
The "Decision Fatigue" Audit (Clinical Quality Over Time)
Question: Are triage outcomes consistent throughout the day, or degrading by late afternoon? (Decision fatigue causes GPs to "book everyone" rather than think critically about each case.)
Method:
Group triage outcomes by time of day: 8-10am, 10am-12pm, 12-2pm, 2-4pm, 4-6pm
Calculate "booking rate" (% of requests resulting in appointment) for each time block
Look for escalating pattern (higher booking rates later in day)
Check variance between different triage clinicians (some may cope better with volume)
Assessment Criteria:
Compliant: Booking rates vary <10% across day; consistent clinical decision-making; variation explained by case mix
Partially Compliant: Modest increase (10-20%) in afternoon; still within acceptable clinical judgment range
Non-Compliant: Dramatic increase (20%+ higher booking rate by 5pm); suggests decision fatigue or time pressure
Red Flag: 40% booking rate at 9am rising to 70% at 5pm = clinician decision fatigue requiring rota redesign or workload reduction.
Evidence Location: Triage outcome analysis by time; Clinical Lead review
Phase 3: The Clinical Safety Audit (Week 3)
This is where you find the missed red flags—the cases that could have resulted in patient harm.
Action: The "Missed Red Flags" Review
Clinical Lead conducts structured review of sample cases:
Sampling Method:
Pull 20-50 random triage cases coded as "Admin" or "Routine" (last 30 days)
Include mix of online consultation submissions and phone triage records
Ensure sample covers different triage staff and times of day
Clinical Lead assesses each case:
Was the triage decision clinically appropriate? (Did "routine" actually need urgent attention?)
Were red flags recognized? (Chest pain, stroke symptoms, sepsis indicators, safeguarding concerns)
Was safety-netting adequate? ("Call back if symptoms worsen" clearly documented)
Were complex cases appropriately escalated? (Uncertain diagnosis, multiple comorbidities, vulnerable patients)
Scoring:
Safe: Appropriate triage decision, red flags recognized, adequate safety-netting
Learning Point: Decision defensible but could be improved; opportunity for training
Unsafe: Missed red flag or inappropriate delay that could have caused harm
Outputs:
Triage quality audit report with findings and severity ratings
List of specific learning points for training
Identification of any cases requiring immediate clinical follow-up
Recommendations for SOP updates or training enhancements
Action: The Safeguarding Audit (Written Disclosure Risk)
Safeguarding Lead conducts specialized review:
Sampling Method:
Pull 10-15 online consultation submissions flagged as "complex", "social issues", or involving vulnerable patients
Include cases where triage staff raised concerns or requested advice
Ensure sample covers children, adults at risk, and domestic situations
Safeguarding Lead assesses:
Were safeguarding indicators recognized in written text? (Disclosure language, coercion signs, inconsistent histories, child welfare concerns)
Was same-day escalation to Safeguarding Lead documented? (Did triage staff follow escalation protocol?)
Were patients offered verbal alternatives when needed? (Some concerns cannot be safely disclosed in writing)
Was appropriate action taken? (Referrals made, risk assessments completed, multi-agency coordination)
Was the consultation protected from Proxy Access? (If patient disclosed abuse and has proxy access enabled for partner/relative, was the sensitive consultation redacted from online view to prevent abuser seeing the disclosure?)
Assessment Criteria:
Compliant: All indicators recognized; same-day escalation documented; appropriate action taken; patient offered verbal alternatives; sensitive consultations redacted from proxy access where applicable
Partially Compliant: Most cases handled well but some delays, missed escalations, or proxy access oversights
Non-Compliant: Safeguarding concerns missed or significantly delayed (>48 hours); no evidence of verbal alternative offering; sensitive disclosures visible to proxy access holders
Red Flag: Safeguarding disclosure missed for 48+ hours, or sensitive disclosure visible to proxy access holder = immediate case review, staff retraining, incident reporting if harm or risk of harm occurred.
Outputs:
Safeguarding audit report with case-by-case findings
Identification of training gaps (written disclosure recognition, escalation protocols, proxy access protection)
Recommendations for patient-facing messaging ("If you cannot safely write about concerns, please call")
Proxy access policy review if redaction procedures not consistently followed
Action: The "Information Quality" Audit
Question: Are reception staff capturing enough clinical detail for safe triage decisions, or are GPs "flying blind" with vague descriptions?
Method:
Review online consultation submissions and phone triage notes for descriptive quality
Count "vague descriptions": one-word reasons ("unwell", "pain", "review"), missing key information, no context
Calculate vague description rate as % of total requests
Identify specific staff members with higher vague description rates (training target)
Assessment Criteria:
Compliant: <10% vague descriptions; clear clinical detail including symptom onset, severity, impact on daily life, red flag questions answered
Partially Compliant: 10-30% vague; mostly adequate detail but inconsistent quality
Non-Compliant: >30% vague; GPs frequently have to send requests back for clarification ("ping-pong")
Red Flag: >30% vague descriptions = care navigation training needed; GPs wasting time on preventable information-gathering loops.
Outputs:
Information quality report with vague description rate and examples
Identification of staff needing care navigation training
Recommendations for structured capture scripts
Phase 4: The Behavioral Audit (Week 4)
Data tells you what happened. Observation tells you how it happened. This phase finds the "shadow systems"—unofficial workarounds staff have invented to cope with workload.
Action: The "Floor Walk"
Practice Manager conducts direct observation:
Schedule: 30-60 minutes during busy period (Monday morning, post-weekend surge)
What to observe:
Batching behavior: Are staff letting online requests accumulate for 1-2 hours to "process them all at once"? (This creates dangerous lags for urgent cases mixed into the batch)
"Nice Patient" bypass: Are receptionists bypassing triage for "regular" patients or those who are polite/persistent? (Creates hidden two-tier system)
Fear-based upgrading: Are staff marking everything "Urgent" to avoid responsibility? (This floods GP capacity and defeats triage purpose)
Assisted completion reality: When a patient struggles, what actually happens? Is it offered proactively and delivered compassionately, or is it seen as a burden?
Listen for language:
Defensive: "I have to ask these questions..." (suggests staff feel procedure is bureaucratic, not helpful)
Empowering: "I'll get this to the right clinician for you..." (suggests staff understand value and feel confident)
Assessment Criteria:
Strong: Consistent process adherence; proactive patient support; staff confident explaining triage rationale
Developing: Mostly consistent but some workarounds; staff competent but not always confident
Weak: Significant workarounds; staff defensive or overwhelmed; patient experience suffers
Outputs:
Behavioral observation notes with specific examples
Identification of training needs (scripts, confidence-building, workload management)
Recommendations for process simplification or capacity adjustment
Action: The "Ping-Pong" Check
Question: How often do GPs have to send triage requests back to reception for missing information? (This measures care navigation quality.)
Method (choose based on your systems):
Option 1: Manual tracking (if GPs have capacity):
For 1 week, GPs tally "bounce backs"—requests they cannot triage due to insufficient information
Calculate bounce-back rate as % of total triage requests
Identify common missing information
Option 2: Automated/semi-automated (more practical for busy GPs):
Search GP task/message outbox for phrases like: "Please can you provide...", "more info needed", "need clarification", "can you ask the patient..."
If your clinical system supports it, check for administration notes or specific SNOMED codes used when requesting more information
Count these over representative 1-week period; calculate as % of total triage requests
Sample the messages to identify common missing information themes
Assessment Criteria:
Compliant: <10% bounce-back rate; care navigation capturing information efficiently
Partially Compliant: 10-20% bounce-back; room for improvement but manageable
Non-Compliant: >20% bounce-back; significant GP time wasted on preventable loops
Red Flag: >20% bounce-back rate = structured capture scripts needed; care navigation training priority.
Outputs:
Bounce-back rate and common missing information themes
Recommendations for structured capture tools (templates, prompts, checklists)
Phase 5: Fix the Gaps (Week 4-6)
Based on audit findings, implement targeted improvements. Prioritize safety, then equity, then efficiency.
If Safety Gaps Found
Meeting 2: Clinical Lead Safety Review
Attendees: Clinical Lead, Practice Manager, Safeguarding Lead
Duration: 90 minutes
Agenda: Review missed red flag cases, identify root causes, develop immediate actions, plan ongoing quality assurance
Actions:
Update Triage SOP with clearer red-flag escalation rules:
Add specific red-flag checklist (chest pain, stroke symptoms, sepsis indicators, safeguarding concerns)
Clarify "when in doubt, escalate" principle
Document safety-netting requirements (what to tell patients about worsening symptoms)
Add proxy access protection procedures (redact sensitive safeguarding consultations from online view)
Deliver refresher training using real audit cases (anonymized):
Scenario-based learning: "How would you triage this?"
Red flag recognition practice
Safety-netting language examples
Q&A on escalation thresholds
Implement monthly triage spot-checks going forward:
Clinical Lead reviews 10-15 cases per month
Positive feedback loop (celebrate good decisions, not just critique errors)
Learning points shared at team meetings
Embed in governance calendar (standing agenda item)
Outputs: Updated SOP, training delivery record, monthly spot-check schedule
Quick SOP updates: Need to revise your Triage SOP with red-flag checklists? Email mypm@automate.mypracticemanager.co.uk with: "Update our Triage SOP for [Practice Name]. Add red-flag checklist for chest pain, stroke, sepsis, safeguarding. Include safety-netting requirements and proxy access protection." Get revised document in 1-2 minutes. Or use AI Document Tools for visual editing.
If Capacity Mismatch Found
Action: Recalculate triage FTE needed and present business case to partners.
Method:
Use actual demand data from audit (daily OC volume, phone triage volume)
Apply time standards: 10-15 min per online consultation, 5-10 min per phone triage
Calculate total daily triage time required
Compare to current triage FTE allocated
Account for leave, training, admin time (availability factor ~0.85)
Formula:
Triage FTE needed = (Daily demand × Average time per case) ÷ (Clinical hours per FTE × 0.85)
Options if capacity insufficient:
Add triage staff: Recruit or redeploy ANP/experienced nurse with triage competency
Extend triage hours: Spread workload across more clinicians (shorter shifts each)
Accept longer SLAs: Document trade-off (e.g., routine cases within 48h instead of 24h); communicate to patients and commissioners
Reduce demand: Better care navigation to pharmacy, self-care, NHS 111 where appropriate
Outputs: Triage capacity analysis report, business case for partners with options and costs, implementation plan for chosen option
Need capacity analysis support? Email mypm@automate.mypracticemanager.co.uk with: "Create triage capacity business case for [Practice Name]. Current demand: [X] daily requests, current FTE: [Y], SLA targets: urgent <2h, routine <24h. Calculate FTE needed and present options." Get analysis in 1-2 minutes. Or calculate manually using formula above.
If "Silent Closure" Found
Action: Implement daily availability monitoring and staff briefing on contractual requirements.
Immediate fixes:
Daily availability check: Staff task to test online consultation form submission at 8:05am and 6:25pm; log results
Staff briefing: Explain contract requirement (8am-6:30pm) and patient fairness principle (keeping all channels open)
Contingency planning: If overwhelmed, escalate to PM for capacity adjustment; don't close form without PM authorization
Medium-term fixes:
Automated uptime monitoring: Request from platform provider if available; set up alerts for unexpected closure
Capacity forecasting: Use demand patterns to predict busy days; arrange additional triage cover in advance
Communication templates: If legitimate closure needed (system failure, emergency), have pre-drafted patient communications (website banner, SMS)
Outputs: Daily availability monitoring log, staff briefing notes, contingency plan
If Equity/Two-Tier Access Found
Action: Retrain staff on clinical-need prioritization and audit allocation patterns.
Meeting 3: Equity Training Session
Attendees: All reception and triage staff
Duration: 90 minutes
Content:
The principle: Clinical-need prioritization, not first-come-first-served
Why it matters: Fairness (everyone gets prioritized by urgency, not phone skill); safety (sickest patients seen first)
The old system's problems: 8am rush favors phone-savvy/flexible patients; penalizes workers, disabled, digitally excluded
The new expectation: All channels processed equally; allocation by clinical need; no "hidden fast track"
Monitoring: Weekly equity metrics; team accountability for fairness
Actions:
Audit appointment allocation for 2 weeks post-training:
Compare phone vs online journey times weekly
Verify clinical-need prioritization working
Address any persistent bias immediately
Update patient communications:
Website FAQ: "How are appointments allocated?"
Reception script: "We prioritize by clinical need, not time of contact. Urgent cases are seen same-day, routine cases within [X] days."
Outputs: Equity training delivery record, post-training allocation audit results, updated patient communications materials
If "Poor Information Quality" Found
Action: Create structured capture scripts and monitor vague description rate weekly.
Structured Script Example:
"I need to ask a few quick questions to make sure we get you the right help:
What's the main symptom or concern?
When did it start? Is it getting worse?
How is it affecting you—can you work, sleep, look after yourself?
Have you tried anything so far?
Any red flag symptoms I should know about: chest pain, difficulty breathing, sudden weakness, blood, severe pain?"
Actions:
Train staff on why information matters: GPs need this to triage safely; better info = faster resolution for patient
Provide prompts/templates: Built into online consultation platform where possible; cheat-sheet for phone triage
Monitor vague description rate weekly: Track % improvement; celebrate when <10% achieved
Outputs: Structured care navigation scripts, training delivery record, weekly vague description rate tracking
If Decision Fatigue Detected
Action: Rota redesign and clinical support mechanisms.
Options:
Shorter triage shifts: Break 8-hour triage duty into 2-hour blocks with breaks; rotate clinicians
Triage buddy system: Pair less experienced triage staff with senior clinician for quick advice
Clear escalation pathway: "Uncertain? Escalate to senior clinician. You will never be criticized for choosing safety."
Workload caps: Maximum 80-100 triage decisions per day per clinician; if exceeded, defer non-urgent to next day
Clinical Lead monitors:
Monthly review of time-of-day outcome variance
Staff feedback on workload sustainability
Incident reporting for triage-related safety concerns
Outputs: Revised triage rota with decision fatigue mitigation, clinical support protocol for uncertain cases, monthly monitoring dashboard
Phase 6: Verify and Maintain (Week 7-8)
Meeting 4: Verification and Next Steps
When: 2-3 weeks after implementing fixes
Attendees: Implementation team plus frontline staff representatives
Agenda:
Review improvement metrics: Has performance improved since fixes implemented?
Staff feedback: What's working? What still needs adjustment?
Patient feedback: Any change in complaints or compliments?
Embed for long term: Set up monthly/quarterly review schedule
Prepare for Survey: Brief check on patient-facing communications—do patients understand the system?
Outputs: Verification report showing before/after metrics, ongoing monitoring schedule, recommendations for patient communications if needed (simple FAQ or poster explaining how triage works)
Set up ongoing monitoring: Use Task Management to create recurring tasks:
Monthly: Triage quality spot-checks, equity metrics review, vague description rate tracking
Quarterly: Comprehensive equity audit, capacity review, staff training needs assessment
Annually: Full triage safety audit, safeguarding audit, GP Survey analysis
This ensures nothing gets forgotten and provides an audit trail for CQC. No pre-built templates—create custom tasks specific to your practice needs (quick and easy).
Common Problems and Solutions
Problem 1: "Online consultation form being turned off at 3pm because staff overwhelmed"
Why this happens: Inadequate capacity planning when system was implemented; triage workload exceeds available FTE; no backup for sick leave or surge demand; staff fear falling behind and close form to "catch up."
How to address it:
Immediate: Authorize form to stay open; PM or senior partner to monitor and escalate capacity concerns rather than allowing closure
Short-term: Capacity recalculation using audit data; temporary locum triage support if gap significant
Medium-term: Permanent capacity increase (recruit/redeploy triage-competent staff) or accept longer SLAs and communicate to patients
Long-term: Monthly demand forecasting; adjust capacity seasonally (winter surge planning)
Prevention: Quarterly capacity reviews aligned with demand trends; surge capacity planning for winter, post-holiday periods; clear escalation protocol ("if overwhelmed, contact PM—don't close form").
Problem 2: "Phone patients getting same-day appointments, online patients wait 3 days"
Why this happens: Practice hasn't truly shifted from 8am rush to triage-first; dual system operating (old "first-come" for phone, new "triage" for online); staff informally telling patients "call at 8am for faster access"; no monitoring of equity metrics.
How to address it:
Immediate: Audit appointment allocation patterns (phone vs online journey times); present data to team showing the inequity
Short-term: Retrain all staff on clinical-need prioritization (not first-come-first-served); equity principle ("fair access for all, regardless of contact method")
Medium-term: Weekly equity metrics monitoring; team accountability for fairness; address persistent bias immediately
Long-term: Patient communication explaining fairness principle; staff confidence in defending the system to persistent patients
Prevention: Weekly equity metrics (phone vs online journey times tracked); team meetings with fairness as standing agenda item; patient surveys asking "did you feel treated fairly?"; PPG involvement in monitoring equity.
Problem 3: "Safeguarding disclosure in online consultation missed for 48 hours"
Why this happens: Triage staff not trained to recognize safeguarding indicators in written text (different skill than verbal disclosure); no same-day escalation protocol; pressure to "get through the queue" discourages careful reading; unclear responsibility for safeguarding vigilance in written submissions.
How to address it:
Immediate: Safeguarding Lead reviews case; makes referral if appropriate; assesses risk to patient or others; check if patient has proxy access enabled and whether sensitive disclosure was visible to proxy holder
Short-term: Enhanced triage training with written disclosure scenarios (domestic abuse language, coercion indicators, child welfare concerns); same-day escalation protocol ("any safeguarding concern → Safeguarding Lead notified same day"); proxy access redaction procedures (sensitive consultations hidden from online view)
Medium-term: Patient-facing messaging ("If you have concerns you cannot safely write about, please call us"); monthly safeguarding-specific audit (sample complex cases including proxy access checks)
Long-term: Safeguarding as core competency for triage staff; annual refresher training; clear escalation pathway and response standards
Prevention: Safeguarding scenarios in triage training (including proxy access risks); monthly audit of complex cases for missed indicators and proxy access oversights; clear messaging to patients about verbal alternatives; Safeguarding Lead oversight of triage quality.
Success Criteria and Evidence
You'll Know You've Succeeded When:
Patient complaints about access decrease by 30%+; GP Patient Survey 2026 shows improvement
Zero missed red flags in triage spot-checks; >90% "Safe" audit ratings; no triage-related safety incidents
Platform available 100% of core hours; >95% SLA compliance (urgent <2h, routine <24h)
Phone vs online journey times within 15%; fairness perception improving
Vague description rate <10%; bounce-back rate <10%; staff confidence >4.0/5.0
You're confident defending your access model to CQC inspectors
Evidence You Can Show to CQC:
Availability logs (core hours compliance), triage quality audit reports (findings + actions), equity analysis (phone vs online data)
Safeguarding audit report (written disclosure review), training records (triage competency, red flags, equity)
Updated SOPs (Triage SOP with red-flag checklist), meeting minutes (Clinical Lead and partner engagement)
Monthly spot-check schedule, SLA compliance dashboard, incident reporting, improvement trends
Maintaining the Improvement
Monthly: Triage spot-checks (10-15 cases), equity metrics, vague description rate, staff/patient feedback
Quarterly: Capacity review, comprehensive equity audit, staff training needs, PPG consultation, partners briefing
Annually: Full triage safety audit, safeguarding audit, GP Survey analysis, policy/SOP review, competency refresher
Embed the change: New starter induction, standing team meeting agenda item, celebrate success stories, continuous improvement mindset.
Additional Resources
My Practice Manager Tools
Email Assistant (Fastest) Email mypm@automate.mypracticemanager.co.uk with audit template requests, capacity analysis memos, patient FAQ creation. Response in 1-2 minutes. No login required.
AI Document Tools Generate audit templates, triage SOPs, patient communications in ~1 minute. Visual editing interface ensures quality and customization.
Task Management Set up recurring audit tasks: monthly triage spot-checks, weekly equity metrics, quarterly capacity reviews. Never miss a quality assurance deadline.
Compliance Library Browse referenced documents: Digital Services Operations Policy, Appointment and Access Management Policy, Triage Quality Audit Checklist, Workforce Capacity Planning Template, Patient Safety Incident Response Policy.
Related Improvement Plans
Strategic Admin Workforce Planning — capacity planning methodology
Improving Controlled Drugs Management — quality audit approach applicable to triage audits
Regulatory Guidance and Standards
GP Contract 2025/26:
NHS England: Changes to the GP Contract in 2025/26 — online consultation core hours requirement, patient charter, GP Connect
BMA Resources:
Online Consultation Tools: Managing Patient Care Safely — safety considerations and safeguards
CQC Guidance:
CQC Single Assessment Framework — Responsive.1 (people can access services when needed), Safe.2 (learning from incidents)
Regulation 9: Person-centred care
Regulation 17: Good governance (includes systematic quality assurance)
NHS England Patient Safety:
Patient Safety Incident Response Framework (PSIRF) — learning from triage incidents
Learning from Patient Safety Events (LFPSE) — incident reporting and national learning
Getting Help
Questions about this improvement plan? Email contact@mypracticemanager.co.uk
This improvement plan is provided as practical guidance for GP practice managers. While based on current regulatory requirements and peer practice analysis, you should exercise professional judgment and adapt recommendations to your practice's specific circumstances. For clinical advice or practice-specific risk assessments, consult appropriate clinical and governance professionals.