Reedyford Health Care What is it like to be a patient? Meena Modi

“How are we going to help all our patients, all day, every day?” Consensus Preparation Staff survey Patient survey Data capture Training System setup Whole team New deal for patients Feedback wall Test & learn Build confidence Launch day Routine Review Evidence: New measures New staff survey New patient survey Your decision Yes. Pledge to each other and to patients Launch programme 12 weeks to a different practice

What do patients think of our service? Administrative staff views – Lack of appointments to offer to patients – Great clinical service, but poor appointment service – Patients complain about lack of appts Clinical staff views – Good practice reputation but poor access – Easier to get an audience with the Queen, than an appt with me – Patients feel they are being ‘fobbed off’ – Struggle to get appt with Dr of choice on the day – patients don’t like phoning in the morning to be told no appts available

My daily work at present Administrative staff views – phones are very busy in the mornings esp at 8.30 am – Feel positive when we have appts to offer to patients. Feel really bad when we don’t – Can get lot of abuse from patients when no appts to offer Clinical staff views – Get to work 30 mins earlier to fit in admin – Working at full pace all day – Dealing with various queries all day, sometimes worry that may have missed something – Lots of pressures to meet targets and meet patient needs – Never have enough time, always running late due to lack of time – No time for lunch

Outside a traditional surgery People waiting on the phone, the same, unseen

The traditional model Reception takes call GP sees patient 10 min slot GP sees patient 10 min slot Problem solved 70% “routine” 30% “urgent” “All gone. Call back tomorrow” 3 week wait, high DNAs, repeat booking See any GP/locum Poor continuity, repeat booking Patient pressure

My ideal work Administrative staff views – Stagger opening of appts so patients don’t have to ring at 8.30 am – Be able to book appt for patient with Dr of choice. This would cut down repeat phone calls and I would feel more positive about picking up the phone! – Steady phone calls all day – Enough appts to meet demand Clinical staff views – Being able to assign slots of different lengths to patients with different categories of problems, but then it is difficult for some of them to know what is serious and what is not. – Reception staff to take better note of patient screen alerts which ask for double appointment slots for patients who are known to take up time. – Better service, more appts – would like to be able to run on time, have enough appointments, not see patients who are wasting time, encourage patients to take responsibility in looking after themselves where appropriate

My ideal work - Clinical staff views (cont) – Being able to devote the time needed to more complex patients - includes a lot of the diabetic patients I see. – Having time to process post and lab links the day they arrive. – Also having satisfied patients that I don't have to spend valuable minutes in the consultation apologising for their difficulty getting an appt

Fear losses if changes are made? Administrative staff views – fear of losing job – It can only be better if patients offered more appts – Changes may be made without proper planning or consultation Clinical staff views – It can only get better! – Role of the triage nurse could change – if GPs on triage all the time – Open to change but sceptical after 25 years of change as have tried other systems before – worry more patients will be brought in to be seen anyway due to the threat of litigation. There will be an inequality of patients wishing to see certain GPs; the threat to continuity

Why do patients call? 65% of calls are for a GP, others for nurse, a few admin

92% of demand is by phone. A good place to start

GP demand much higher on Monday

GPs: days similar, few on Thursday?

But is everyone really sick only at 8am?

30% of requests for clinician not met, of which 11% told to call back. This creates rework

Examples of comments show more rework Chasing x-ray referral, asked to ring back in morn to speak to secretary Appt canx and rebooked Pt chasing phone call from GP, Advised will be this afternoon sometime Requested female GP, none available, advice phone call from nurse booked Visit request, phone call arranged from triage nurse Requested female, could not find a female gp that was convenient for her, plenty of male appts though! Patient wanted to change appointment but decided to keep original Didn't specify how long he wanted to wait to see requested GP Patient only wanted to see Dr Ashworth next Fri or Mon, non available, she will try back later

Vast majority want to be seen today, some a week away, even though (inset) clinically 78% routine, just 22% urgent

But 62% acute or exacerbations, ie best dealt with now.

40% request a named GP, 60% don’t mind. Typical, and useful thinking of new system.

GPs’ view, continuity matters for just 30%. A little lower than most?

64 telephone consults, just 15% of total.

Of the telephone consults, 89% resolved over the phone.

GPs’ view, only about 15% “face to face not needed” Amazing how this changes (day 1 Derbyshire practice 30%)

The traditional model Reception takes call GP sees patient 10 min slot GP sees patient 10 min slot Problem solved 70% “routine” 30% “urgent” “All gone. Call back tomorrow” 3 week wait, high DNAs, repeat booking See any GP/locum Poor continuity, repeat booking Patient pressure

A practice in the Patient Access community looks a little different Monday morning 8.30, Busy day, going full tilt. All carefully worked out. Dr Chris Barlow of Quorn, one of the earliest pioneers in 2000

The traditional view of general practice, every problem requires 10 minutes face to face with the GP One tiny problem Perfect service

We help all our patients, all day, every day The Patient Access method makes this a reality. A new principle is at work

Magic 1: Over half need only the call Call fulfils demandSee doctor See nurse Two practices, 8,000 patients, 9 months to May 2011

Magic 2: The call takes about 4 minutes Four practices, 17,000 patients, 9 months to May 2011 Traditionally, all patients take ten minutes. Why?

A whole new system, all work in a new way PA Navigator measures the flows, which vary by GP & practice. Reception takes call GP phones patient Problem solved Come and see GP Admin question Come and see nurse 20% 10% 30% 60%

Measurement is crucial to good performance – patient service PA Navigator measures the flows, which vary by GP & practice. Reception takes call GP phones patient Problem solved Come and see GP Admin question Come and see nurse 20% 10% 30% 60% Prompt answer Rapid response critical, often also choice of GP. Always offer same day, 80% choose this

Measurement is crucial to good performance – working efficiently PA Navigator measures the flows, which vary by GP & practice. Reception takes call GP phones patient Problem solved Come and see GP Admin question Come and see nurse 20% 10% 30% 60% Predict demand volume & timing to plan supply High solve rate saves GP time Adequate nurse capacity for balanced workload Below 50% saves no time. Maximum safe level? Consult durations flexible, appropriate

Clarendon Practice, Salford, turns round Dr Jeremy Tankel, GP Principal Harry Longman, Patient Access

Average days wait to see a GP falls off a cliff. All data from Clarendon, charts by PA Navigator

They now measure the wait in minutes. Median is about 30. All data from Clarendon, charts by PA Navigator

Patients are more likely to see the same doctor. Continuity, so precious to both, is up 15% This means that on multiple consultations, a patient has about 85% chance of same GP All data from Clarendon, charts by PA Navigator

Clarendon, a deprived population of 10,000, 3 partners, 3 sal GPs Why change and for what? Before Rising demand – falling morale Waiting room stress Grumbling patients All pre-books gone Mad rush on phones at 8am After Demand high but stable A “no-waiting” room Free slots in most sessions Patients love it No need for 8am rush

A training and teaching practice, with a new NP. Previously drowning in demand, now feeling on top of workload Before Frustrated, stressed doctors Miserable reception staff Unhappy patients Reputational issues List size effect After Reduced stress! Abuse of reception staff gone All pts who need it are seen Saving one clinical session

They know when the patients are going to call, by day, by hour, and the GPs are ready All data from Clarendon, charts by PA Navigator

Rock steady 90% of patients are seen the same day – the other 10% chose to wait for their own convenience. All data from Clarendon, charts by PA Navigator

As response has improved over time, the proportion of patients saying the service is “better” has risen to 76%, while those saying “worse” are now 8%. All data from Clarendon, charts by PA Navigator

Work on the whole practice system with the whole team Change is hard. We make the process easy and fast 5 stages over 12 weeks, knowing how you are doing Every practice differs. You make the decisions You lead. We guide you through the change