Parkside Surgery What is it like to be a patient Parkside Surgery What is it like to be a patient? Harry Longman, Patient Access harry.longman@patient-access.org.uk

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

What do patients think of our service? Administrative staff views Some patients get frustrated that they can’t have what they want Mainly seen on the day they request...if ring before 11.00 will get in the same morning with a GP A few patients don’t like...new systems, and have booked appts earlier so they have a time and date Some patients don’t like to volunteer information Clinical staff views Appreciate being able to see the docs quickly...surprised to be offered an "on the day" appointment. Easy to get in when wanted but not always with the GP they want Appointments waiting time recently 4/52 "Like the continuity “ (provided they get it of course) Like ease of access...flexibility We are generally liked personally and patients seem to appreciate that we try to get things right. Reception held in very high regard by patients (some that have transferred from other practices.)

My daily work at present Administrative staff views My (phone) duties are...often non stop! Stresses are generated from the number of patients the GPs need to see every day to keep on top of the workload. Clinical staff views 30-45 patients, some trivial, 11 hour days routinely, often more, feel drained...some features of burn-out. No time for meetings/management stuff, quality beginning to slip as a result. Getting busier, lot of inefficiencies in how we work, on call surgeries 'abused' A lot of the time is spent on "paperwork" type issues...arising from telephone and face to face consultations...overflows into my days off... at least 2hrs remote working...every day off and Saturday and Sunday. Long surgeries...Non-stop stress Overwhelmed..12.5/day hours here...and at least 4-5 hours...from home on days off. Current system fragile...no space for unexpected... burnout a real possibility.... On some days I hardly speak to anyone else in the team...pinned to the computer/ phone or seeing patients.

Outside a traditional surgery Many practices pride themselves on good access, and they are working hard. But with scenes like this, I began to see how good intentions are not enough. They need a method. People waiting on the phone, the same, unseen

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

Evidence of busy times at 8am, and not much later.

My ideal work Administrative staff views Clinical staff views Flexibility...upbeat...positive...friendly To be able to offer more appts as this is sometimes difficult. To always be polite and helpful to patients. Workload...more manageable. Clinical staff views Manageable lists.... Fewer inappropriate attendances. More efficiency and not feeling...risk of missing the really important ones Less of the "paperwork" element. Variety of clinical problems. Time to have regular clinical meetings so the standards at the practice are maintained, time to manage elderly frail people better. The partners need time to be ahead of changes in the NHS, to manage the practice in a planned way and have time to communicate changes properly with all of the team.

Fear losses if changes are made? Administrative staff views Patients will be wary...if can’t get what they need at the time they need. Need to be kept aware of the changes and know how to deal with them Alteration in working hours/days...reduction New service may generate more complaints and lower satisfaction scores Wary of breaching patient confidentiality Clinical staff views Worried that patients may not like new system, patient satisfaction may drop...clinical risk may increase. (Loss of) eye contact/body language etc. (Loss of) income...(less) efficient Patients may be at work or on there way when GP calls to triage them. That the process may disadvantage the less assertive and people with poor communication skills or who are depressed. (Will not be able to) notice the incidental (symptoms) over the phone. Older patients...have been used to a different system. Changes may limit continuity That it will be very intense...then won't have enough slots to see patients. (Clinical) risks; PSQ will suffer, more complaints.

Reception data capture: Monday the highest

It’s very busy at 8am. By afternoon, little to offer.

77% of patient requests agreed. 10% told to call back

Continuity: 40% of patients name a doctor

Vast majority of requests are for same day

About 16% of requests are walk in – is it hard to get through on the phone?

Reception dealing with wide variety, high repeat scripts

GP volume is highest on Friday

Acuity is typical of most practices, majority acute, and new to follow up is 58%

Urgency also typical: most demand is acute & routine

Today, only about 20% of GP consults are by phone

But 80% of them are resolved over the phone (small number of NP telephone consults, 33% resolved, not sure about nurse?)

Nevertheless, you consider only 20% were “face to face not needed”

Continuity: GPs view, 30% important, lower than average

Navigator: GP consultation rate up 24% over 2 years. Wow Navigator: GP consultation rate up 24% over 2 years. Wow. But current consults weekly rate 6.4% - moderate

Weekly pattern shows most on Fridays. Hmm.

We’ll be tracking phone response times, currently 2 hours

And days wait to see GP, currently 4 to 5 (though 40% are same day)

An interesting feature – your consults are much longer than most

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

A practice in the Patient Access community looks a little different Dr Chris Barlow of Quorn, one of the earliest pioneers in 2000 The evidence led me here. Simple. Patient calls in. Doctor calls them back. Deal with the problem today. Brilliant. The thinking is to understand patient demand, and respond simply and appropriately. Monday morning 8.30, Busy day, going full tilt. All carefully worked out.

The traditional view of general practice, every problem requires 10 minutes face to face with the GP Traditional thinking says one size fits all patients: whatever the problem, the answer is 10 minutes face to face with the GP. We all recognise that patients and problems are not like that. The new thinking is to accept the infinite variety coming in, and respond to each demand in the simplest, most effective way. The telephone response from a GP is the current most practical way we have found to do that. The effects are: professional service (the most qualified, best informed clinician is the GP with your notes), faster service (contact typically under an hour) and lower costs (evidence from many practices of time freed up, often over 3,000 patients per GP fte). Perfect service One tiny problem

A new principle is at work We help all our patients, all day, every day The Patient Access method makes this a reality. Well, after 6 we might suggest the patient will get a call back in the morning.

Magic 1: Over half need only the call Call fulfils demand See doctor See nurse How does the magic work? Common ratios seen among all Patient Access practices – only about a third need to see the doctor. Two practices, 8,000 patients, 9 months to May 2011

Magic 2: The call takes about 4 minutes Traditionally, all patients take ten minutes. Why? Patient demands are infinitely varied in shape. Patient Access allows the GP to fit the response just right around the patient. Calls are mostly short, but can vary, as can appointments. Four practices, 17,000 patients, 9 months to May 2011

Simple, but the whole system changes Reception takes call GP phones patient Problem solved Come and see GP Admin question Come and see nurse 20% 10% 30% 60% PA Navigator measures the flows, which vary by GP & practice.

Clarendon Practice, Salford, turns round Dr Jeremy Tankel, GP Principal Harry Longman, Patient Access harry.longman@patient-access.org.uk

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 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 After Rising demand – falling morale Waiting room stress Grumbling patients All pre-books gone Mad rush on phones at 8am 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 A training and teaching practice, with a new NP. Previously drowning in demand, now feeling on top of workload Before After Frustrated, stressed doctors Miserable reception staff Unhappy patients Reputational issues List size effect 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

You lead. We guide you through the change 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