1. Field House Surgery What is it like to be a patient? Meena Modi, Harry Longman Meena.modi@patient-access.org.uk Telephone

2. Pathfinder – for informed consensus What your staff survey showed The data capture from GPs and reception Navigator analysis from SystmOne Pulling it together – current system and how it could change Solving the problem – your decision

3. Staff survey – what patients think Receptionists: No real problems Building is always neat and tidy Only frustrating thing is lack of appts Having to wait for bookable appts Some patients don’t like phone calls – prefer appts Some patients complain that appts not available for 3 wks. Some praise too

4. Staff survey – what patients think Doctors: lack of appts, difficulty with phone and problems with repeat scripts not given enough info why difficulty with a certain GP ie patient not told that GP they requested is on holiday

5. Staff survey – what patients think Nurse: Main complaint – difficulty getting appts Appts with GP of choice Patients unhappy about recent changes in GPs Communications and reception staff better recently, but still problems with appts system

6. Staff survey – what patients think Admin: Patients generally happy with review appts Long waiting times for routine appointments means patients often unhappy to wait and use same day apt instead Not enough appts for Medicals and hard to give patients a convenient appt before their licence expires. Long waits for post-natal and HGV medicals

7. Staff survey – what patients think Admin – cont: The on-call GP usually has an overwhelming demand which causes both the GP and staff on the day added stresses. GPs are working flat out with no room for allowances for staff holidays and sickness which again adds pressure. The team we have in place now is the best for a long time. there just aren't enough GPs and appointments to go round

8. Staff survey – daily work Receptionists: Most days work is fine. Frustrating not to be able to offer appts Would be good to work as one big team rather than smaller teams Patients don’t like having to wait at desk Frustrating when patients ask for sick notes to be issued on the day, as urgent

9. Staff survey – daily work Doctors: On call days have been unsafe with the pressure of work (tel calls can exceed 60 plus tasks scripts etc) The reliance on locums and the expectation that salaried partners will work far in excess of the contract is non sustainable

10. Staff survey – daily work Doctors – cont: very intense and complex workload not enough hours in the day increasing complexity of managing conditions increasing elderly population(real or perceived) heavy visit load recruitment problems in Bridlington fear of litigation other pressures esp of admin and cpd/revalidation,cqc/new qof targets GPs constantly being attacked by media, politicians....however very supportive team appreciative of individuals strengths and weaknesses

11. Staff survey – daily work Nurse: Multiple appts for same pt seem unnecessary e.g BPwith one HCA, then bloods 30 mins later with another HCA. Generally good, problems occasionally with extra extras' being slotted in. Prefer to manage my own clinics and not have other people making changes to lists

12. Staff survey – daily work Nurse – cont: feel frustrated by urgent (embargoed) allocated appointments being used routinely weeks in advance or inadequate appointment times being allocated leading to time pressures & unsafe working. Telephone messages can cause problems- if no time is allocated to deal with telephone messages then these are squeezed in between the already booked appointments making it a rushed consultation & giving a disservice to the

13. Staff survey – daily work Admin: Large quantities of telephone calls, can be frustrating when trying to summarise or do template management etc. This is being addressed Extremely busy Practice and seems to be getting more so. Workload is heavy for all Departments and staff get tired, high levels of sickness. Never enough hours in a day but this is the NHS. No structure to CCG at the moment so never know who to turn to for answers to queries.

14. Staff survey – daily work Admin – cont: The only frustration at present is that some staff do not seem to have a lot of work to do whilst others, including myself, are always very busy. I do prefer to be busy. Enjoy my work, have good working relationship with medical secretaries at other organisations, have made role my own and feel appreciated by GPs/Manager and also patients.

15. Staff survey – daily work Admin – cont: the only frustrations I have are lack of appointments for medicals especially with GP holiday time. am overwhelmed and very stressed in my work. On a good day I enjoy my work and the people I work with. Staff sickness causes pressures across the board and makes a full day even more stressful.

16. Staff survey – my ideal work Receptionist: work is how I expect it to be, good strong team, sometimes a bit of a challenge. Generally a good place to work. My ideal picture of what my working day should be has more to do with hours then the environment were I work.

17. Staff survey – my ideal work Receptionist – cont: Love the job even with all the stress, would be nice to be fully staffed at all times, also to have two people on the front desk at busy times would like to be able to offer patients bookable appointments quicker than am able to

18. Staff survey – my ideal work Receptionist – cont: to have more appointments available to cut down the amount of prescription requests which is difficult because of the amount of patients and medication they are on. So some help would be nice.

19. Staff survey – my ideal work Receptionist – cont: Many more Urgent, Same Day & 24/48 hour appoitments with Doctors/Nurse Practioner. less stressful, politer patients, don't mind busy - would hate to be sat around do nothing, being able to offer patients appointments they want more often, less paperwork - seem to get more even though meant to be paperless surge

20. Staff survey – my ideal work Doctors: Is the contract I agreed to, I am not and do not want to work as a partner here. Regular surgeries availabilty of appts and a regular lunch break would be nice. I love medicine all I want is a manageable safe workload and to give a very good service to all patients rather than a satisfactory service

21. Staff surveys – my ideal work Nurse: Ideal work - supportive staff, non-judgmental listening environment - willing to learn from things not going to plan. Encourages learning. Helping patients - either to be able to give the care needed myself - or have easy access to the right person. To be able to give holistic care.

22. Staff survey – my ideal work Nurse – cont: Pretty much as it is now An ideal working day would be appropriately allocated appointments, with the appropriate clinician with adequate time.

23. Staff survey – my ideal work Admin: I would like to have a more manageable work load. I would like staff to be more self sufficient. I would like the GPs to be positive and work together to solve the issues we have around capacity and demand. I would like to see patients who are genuinely ill on the day be seen by a clinician. I would like to see a reduction in the time a patient has to wait for a routine appointment and reduction in the time taken to answer the telephone.

24. Staff survey – my ideal work Admin – cont: I would like to be able to give an appointment for a medical exactly when the patient needs on Ideally I would like every day to be busy, but not ridiculously so, with a mix of phone calls/queries from other secretaries and patients, and a variation of work from GPs/Practice Manager (and then able to get away on time at end of day)

25. Staff survey – my ideal work Admin – cont: Enough appointments/ no waiting lists for all types of clinics. GP's have enough time to complete paperwork and patients not having to keep chasing medical forms etc An appointment for everyone who NEEDS one (not wants one). More patient awareness of other services available eg pharmacist. All staff being competent in ALL areas of work. GP's working from the same Protocols.

26. Demand is about 400 f2f and 200 phone consults pw, suggesting an effective rate of 520 pw or about 5.7% of list, moderate level.

27. Appointment supply is high on Monday and Friday, low mid week.

28. While phone calls are almost all same day, the wait for a face to face has been lengthening to an average of over 7 days.

29. While many f2f are same day, many are booked 2 to 3 weeks ahead or more, which skews the mean.

30. The pattern of booking through the day starts high before 8am, but is then fairly well spread.

31. Your reception data: variation through week (Tues high after BH). 30% of requests unmet, eg phone call instead.

32. Drilling down to the average day on reception: very busy first thing, not much to offer later on. We always see this spread out.

33. Outcomes to patient requests on reception. 11% “call back another time” will be re-work next day.

34. Vast majority of patient demand is for the same day. A few are a week or two out – we find these soon disappear.

35. About 60% of f2f appts appear to be same day – how many are re-work?

36. Consultation data collection: 5 days, most f2f and some phone

37. For all types, a mix of acute and surprisingly high chronic

38. Your view is that almost all the appts are appropriate.

39. Another way to look at this: follow ups at 60% are surprisingly high. Usually see other way round, 55-60% new.

40. Interestingly, when GPs phone the patients, outcomes are 55% resolved over the phone for acute conditions, rising to 85% for chronic. This is normal.

41. Continuity: you estimate it matters in just 45% of consults. (range 40-60%)

42. For phone consults, where you achieve continuity 73% are resolved over the phone – good reason to take care to match patient and GP

43. Continuity within the month is around 65-70%. This could be much higher, and at this level is a source of frustration for patients and doctors.

44. Duration of appointments, mean f2f 7 mins and phone 2 mins, low end.

45. Distribution of recorded consultation times is fairly narrow. Is there any sense that sometimes more complex problems are rushed?

46. Response times to most telephone calls is reasonably quick.

47. Average response time improved recently. Tracking this week by week will be important feedback.

48. Summary: it is fixable Surveys and data reveal a tricky situation, supply not meeting demand, unhappy staff and patients not able to see the doctor they want to, when they want to. Stress and pressure all round, significant amounts due to rework, patients having to call back and “duty doctor” overloaded. Unusually high follow-up ratio, probably making it difficult for new, acute patients to see the GP, even though the vast majority of patients want to see the doctor today. From phone consults, a good rate of resolution especially when continuity is achieved. Capacity will be generated from this, again allowing GPs to cover chronics by phone. Continuity measured statistically shows moderate level – this can rise over 80%, we have seen over 90%, with careful design. The problems are fixable, demand overall is moderate and you can turn this all around within a month.

49. How? A new system. Simple, but different 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 10% 20% 10% 30% 60% 70%

50. “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 How did they change? The launch programme…