SunnyBank Medical Centre Moving Towards Advanced Access Dr Graham Hillary & Susan Dawrant

Dr Graham Hillary & Susan Dawrant Organisation at April 2000 6 Doctors 4 Full Time 2 Part Time Locum Cover 4 Practice Nurses (2.3wte) Recruiting: Treatment Room Nurse HCA Phlebotomist List Size 9400 + increasing Clinical Appointments 10minutes Full Time GP 21.75 hours surgery per week 24.25 hours surgery per week at holiday time Fully Computerised Paperless Dr Graham Hillary & Susan Dawrant

Dr Graham Hillary & Susan Dawrant Demands on Time 8 Weeks Holiday 2 weeks Study leave No Bank holiday work Closed Wednesday Lunchtime In-house Diabetic Clinic Outreach Diabetic Session ENT Outreach Minor Surgery Sessions Undergraduate Teaching Training Acupuncture PCT Meetings Collaborative Core Training Session Management Meeting Dr Graham Hillary & Susan Dawrant

Dr Graham Hillary & Susan Dawrant April 2000 Appointments booked up to 8weeks ahead Held appointments (Routine/Reserved/Urgent) Long queue for routine appointments 3rd Available appointment - Average 9days Up to 160 - 200 DNA’s per month Low staff morale - constant pressure for limited availability Patient satisfaction poor Duty Doctor always very pressured Duty GP always coping with demand in excess of availability. Average 3rd available appointment measured at 12noon was 9 days - more popular GPs booked up several weeks in advance for routine bookings/reviews Dr Graham Hillary & Susan Dawrant

Matching Capacity to Demand Understand Daily Demand Measure requests for Appointments over a one week period. Tally Sheet. Analyse results Average of 20% - 30% shortfall Tally sheet - Staff asked to record every request for an appointment for either a GP or PN. Daily record over a one week period compared against actual appointments available. 20 - 30% shortfall dependant on day. Monday 30% shortfall Dr Graham Hillary & Susan Dawrant

Review Workload/Systems PDSA Cycles Maximise manpower on days of high demand. Monitor follow-up Delegate to the most appropriately trained clinical member of the team. Length of appointments/type of consultation Reduce DNA rate All GPs available on Monday to maximise capacity available. Monitor reviews - frequency - could review be delegated to another member of the team - telephone consultation. Review appointment timings - clinic sessions to ensure maximising use. Interchange routine appointments/telephone consultation slots as required DNA - patient contacted by phone day before appointment to remind/confirm attendance when booking for longer than 10mins. Dr Graham Hillary & Susan Dawrant

Working Smarter not Harder Match the Team to the work Expand the role of the Nursing Team Nurse led Specialist Clinics Treatment Room Nurse HCA’s Phlebotomist Salaried GP Locum Cover Locum to cover GP absences Salaried GP to cover workload - due to GP taking clinical sessions from timetable due to outside commitment. Dr Graham Hillary & Susan Dawrant

Increasing alternative forms of Access Telephone Consultation Trialing the System (PDSA Cycles) Evaluation & Review Implement & Trial New System Re-Evaluate Monitor Dr Graham Hillary & Susan Dawrant

Increasing alternative forms of Access Telephone Consultation. Routing patient to other healthcare professional where appropriate Group Consultation (Smoking Cessation Clinics). Outside Agencies Clinics - Benefit Advice/Cancer Support Team NHS Direct Self-help - other agencies Video/Leaflets/Booklets for patient use. Dr Graham Hillary & Susan Dawrant

Appointment System for GP Bookings Highest Demand/Maximum Capacity Monday - No pre-bookable appointments. Tuesday - Friday 50% of appointments are bookable up to 3 working days in advance. A GP can override the booking policy Telephone Consultations Duty GP would triage request for appointment once availability exceeded. Dr Graham Hillary & Susan Dawrant

Advertising the Changes Communication Across the Team Reception Team inform patient when taking appointments. Practice Leaflet Handouts available in reception Flyer included in routine correspondence Call Display Dr Graham Hillary & Susan Dawrant

Unblock Future Capacity Commenced New Appointment Booking System from Jan2001. Diary Planned and New Appointment System implemented. Existing Diary not extended beyond Christmas. Over Christmas & New Year no prebookable appointments for any GP. Dr Graham Hillary & Susan Dawrant

Evaluation - PDSA Cycle Initially no appointments may be booked more than 3 days in advance. Concerned about creating an artificial backlog. Evaluate after a 6 month period Increase the booking time to 7 days in advance. Unequal spread of demand across clinicians Dr Graham Hillary & Susan Dawrant

Appointment Availability 2001 March-Spare Capacity in the System 92% of the time. September-Spare Capacity in the System 97.5% of the time Spare availability not always utilised patients’ preferred time option choice of clinician timeframe available to book appointments Initially a small number of appointments weren’t booked due to booking timeframe. However, as the patient have become familiar with the appointment booking system unbooked appointment due to booking time frame are virtually nil. Occasionally unequal demand spread across GPs. Popular GPs never have any free appointment slots. Dr Graham Hillary & Susan Dawrant

Organisation at October 2001 6 Doctors 4 Full Time 2 Part Time 1 Salaried GP 8 Sessions per week Long-Term Locum 4 Sessions per week 6 Practice Nurses (3wte) 3 G Grade 2 F Grade 1 D Grade 2 HCA (1.5wte) Phlebotomist (Extended Role of Receptionists) Training Reception Members to undertake HCA Role List Size 9600 + increasing Clinical Appointments 10minutes Full Time GP 18 hours surgery per week 21 hours surgery per week at holiday time Fully Computerised Paperless Dr Graham Hillary & Susan Dawrant

DNA’s Previously 160 - 200 per month March 38 29% GP Booked Reviews 26% booked on same day 5% booked 1 day in advance 24% booked 2 days in advance 16% booked 3 days in advance September 40 8% GP Booked Reviews 53% booked on same day 13% booked 1 day in advance 6% booked 2 days in advance 3% booked 3 days in advance 6% booked 6 days in advance 20% booked 7 days in advance Dr Graham Hillary & Susan Dawrant

Dr Graham Hillary & Susan Dawrant Conclusion It Works Match manpower to demand (holiday/sickness) Routing the patient to the most appropriate member of the team. Increased accessibility Reduced DNA’s Less harassed staff Patients have stopped playing the system Positive feedback from patients/staff/clinical team Empty slots Increased Capacity but a restriction on patient choice DNA’s same day appointment - increased New problem Complacency - unbooked slots appearing in routine surgeries Duty GP can become grumpy when underworked/overworked Dr Graham Hillary & Susan Dawrant

Dr Graham Hillary & Susan Dawrant Sunnybank Medical Centre 01274 424111 E-mail sdawrant@bradford-ha.nhs.uk National Primary Care Development Team E-mail npcdt@manchester.nwest.nhs.uk Dr Graham Hillary & Susan Dawrant