The MEPRA model explained

What does a “demand-led” GP surgery really look like?

The idea is simple – but often misunderstood.

Patient demand for help from the healthcare system is highly predictable, meaning that the GP surgery can plan to meet it and offer same-day access.

No one is told to come back tomorrow, or next week, or go to a walk-in centre because all slots are full.

They all get the help they need.

This is radically different from the traditional system, where what matters is not how many patients need appointments, but how many slots are available (“supply-led”).

Once that fixed number of slots is filled – usually within minutes of phone lines opening – patients are rebuffed or redirected. For the rest of the day, practices do not respond to demand but instead try to divert it.

Most attempts to reform our supply-led system have focused on turning the patient away from the professional they really want to see or talk to – their GP – and sending them to a pharmacist or nurse instead. In many cases patients end up self-referring to A&E, or giving up altogether on seeking medical attention.

Demand itself is poorly understood. While most surgeries know that there is a rush of phone calls every morning, particularly on Monday, they probably can’t explain how it ebbs and flows the rest of the week.

The result is a rigid system, where GPs struggle to fit their patients into 10-minute slots, treating them in the same time frame no matter how serious or complex their symptoms.

This supply-led framework goes back to 1948, when access to a GP was dependent on means and the obvious solution was to provide more GPs. But it never evolved into understanding demand or into a system sufficiently flexible to handle the inexorable growth today.

Yet both are easy to do.

In reality, patient demand for GP services is completely, utterly, boringly stable and predictable.

After four weeks of monitoring, the surgeries we’ve worked with can tell within a range of 10% how many patients are going to phone every single day.  Even hourly rates are predictable.

That’s right: If you ask how many phone calls the receptionists will field on Tuesday at 11am or Thursday at 4pm, they can provide a reliable working estimate.

The surgeries that have successfully become demand-led record and then harness the data to organise themselves far more efficiently, ensuring there is a good fit between demand (patients requesting appointments), and the number of staff on hand to help them.

The model they follow  is ‘MEPRA’: Measure, Predict, Respond and Adjust.


1.  Measure - First we need the data to measure when and what type of requests come in. Extracting remotely from the clinical system means this is not a chore, but produces all the information we need, by day, hour, even minutes, and it’s effortlessly updated.

2.  Predict - With just a few weeks of data, it becomes easy to predict demand on any given day so that capacity can be planned around it.  Did you know that in a typical practice, 28% of demand is on a Monday?  There may be local differences, but this means adjusting the rota for receptionists and GPs - perfect for part-timers.

3.  Respond – As demand comes in on the day, the surgery staff must handle it rapidly and appropriately.

The key here is to give GPs the tools to treat patients differently, according to their needs. Not everyone needs the same amount of care and attention. Not everyone needs a 10-minute, face-to-face slot.  With a more flexible system in place – see here for details – doctors can help a far larger number of patients quickly.

4.   Adjust – Over time the surgery will learn valuable lessons about how demand fluctuates and how best to meet it, and be able to optimise the way they work.  As the surgery responds better to demand, so demand will shift again. Once patients learn that they do not have to call at 8.30am in order to see their doctor that day or that they do not need to book slots two weeks ahead just in case their cold hasn’t gone away, they stop doing it. Patient behaviour changes as anxiety demand falls and the supply arrangements must change as well.

That’s why MEPRA is a continuous cycle of improvement.

This does not mean the surgery’s staffing arrangements are constantly in flux. As response to demand improves, generally demand smooths, regularises and is easier to manage.

Indeed, although MEPRA may appear daunting at first, practices we have worked with tell us it is ultimately far less work for everyone in the surgery.

Finally, doctors are in control of their schedules – instead of constantly battling a backlog.

Dr Sara Cowell is author of Enabling Demand-Led General Practice: How GPs Can Solve Their Capacity Problem, Improve Patient Care, and Rediscover the Joy In Their Work.

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