1. Dr John Oldham OBE

2. The Cycle of Fear Increase Fear Micromanage Kill the Messenger Filter the Information ©John Oldham 2002

3. Every system delivers exactly the results it is designed to give Every system delivers exactly the results it is designed to give ©John Oldham 2002

4. Diffusion of Innovation 35% Late Majority 35% Early Majority 15% Laggards 13% Early Adopter 2% Innovators ©John Oldham 2002

5. An improvement method that relies on spread and adaptation of existing knowledge to multiple settings to accomplish a common aim. It is not: A research project for new knowledge A set of conferences A passive exercise Collaborative Process ©John Oldham 2002

6. Collaborative Process Select TopicParticipants Planning Group Identify Change Concepts LW0LW1LW2LW3 Support Project Managers E-mailPhone Discussion GroupAssessments Access to expertisePeers Pre work ©John Oldham 2002

7. Collaborative Culture Respect Group learning and rapid doing No blame Flexibility - ideas - methods Firm on results ©John Oldham 2002

8. Fundamental questions for improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement? ©John Oldham 2002

9. Model for improvement Act Plan Study Do the test execute it rationally on results for next cycle on results ©John Oldham 2002

10. Example of a PDSA Cycle Plan 2 doctors on Tues and Thurs evening after surgery to call list of identified patients with advance booked routine appointments to determine if the routine appointment is still necessary. Start 13th June.Do Carried out 13/15/20/22 June ©John Oldham 2002

11. Study 15% appointments could be cancelled. Some telephone numbers not updated, some patients no telephone, language problems. Required 2 - 7 minutes consultation time. High patient satisfaction.Act Timetable the telephone consultation in on Tues/Thurs evenings Extend to 3 doctors Assess non-contact rate ©John Oldham 2002

12. Repeated Use of the Cycle Theories Testing changes Changes resulting in improvement A P S D A P S D D S P A A P S D ©John Oldham 2002

13. Advanced Access in Primary Care

15. “Every system delivers exactly the results it is designed to give”

16. 30 30 30 30 30 120 110110 100 115 0 10 10 20 5 Day Mon Tues Wed Thurs Fri Max no of avail 150 150 150 150 150 appointments Daily Demand 175 150 125150 150 Blocked urgent for the day Filled routine Free routine © John Oldham 2001 ©John Oldham 2002

17. 30 30 30 30 30 120 110110 100 115 0 10 10 20 5 Day Mon Tues Wed Thurs Fri Max no of avail 150 150 150 150 150 appointments Daily Demand 175 150 125150 150 Blocked urgent for the day Filled routine Free routine © John Oldham 2001 ©John Oldham 2002

18. Demand DNAs Efficiency Rework Wait Times 10days Supply Reservoir Mark Murray ©John Oldham 2002

19. Paradigm Shift Old In order to protect today, we push work to tomorrow.New In order to protect tomorrow, we pull work into today.

20. The Fears Schedule Saturated Demand is Insatiable

21. Components of Advanced Access Understanding profile of demand Adjusting the handling of demand Matching capacity to demand Contingency plans Communicate,communicate ©John Oldham 2000

22. Understanding the Profile of Demand

23. What is current daily demand? Any request for any type of appointment on a single day i.e. includes appointments for doctors and nurses for investigations and consultations. It includes all requests made on that day WHETHER FOR THE SAME DAY OR A FUTURE DAY.

24. How do we measure current daily demand? Count by tick box (e.g. as per demonstration sheet) each day for 5 days.

25. Demonstration tick sheet Appt Mon Tues WedThurs Fri Total with/for (wk) Doctor //// //// F-ups /// Nurse /// Practitioner F-ups Practice //// Nurses F-ups

26. Changing Demand

27. Responding to demand ©John Oldham 2002

28. Some Examples of Changing Demand Telephone follow-up reduces face-to-face consultation by 15-20% Telephone management of same day requests reduces consultation by 30-50% Advanced access reduces non-attenders by 50% E-mail consultation/queries Reduce follow-ups on Mondays ©John Oldham 2000

29. Chronic Disease Management Self-help Number% List % Variation against HA average Total number with asthma 689 7.7 + 0.9 Those with Asthma receiving:- Prophylactic Medication457 83.0 + 30 Self Management Plans525 80.0 n/a Admitted to hospital 1 0.8 -91.6 ©John Oldham 2000

30. Matching Capacity to Demand Work down backlog Anticipate associated needs Match team to work –who does it now –who could do it –what is the next step

31. Contingency Plans Holidays Training Sickness Epidemics

32. Day Mon Tues Wed Thurs Fri Max no of avail 150 150 150 150 150 appointments Daily Demand 130 115 80115 130 With adjusted Handling of demand Free appointments Pre-bookable follow ups ©John Oldham 2002

35. STEP 1 Dissatisfaction with life as you know it STEP 2 Understand the demand each day of a typical week STEP 3 Shape the handling of demand STEP 4 Match capacity to demand Work down the backlog STEP 5 Put contingency plans in place