The Greenwich Good Access Guide...Page 7 Greenwich Good Access Guide Measure demand Patient demand is largely predictable. Data from over 7 million records shows the demand for GP

Page 1 Greenwich Good Access Guide

The Greenwich Good Access Guide: Opportunities for Improvement


CONTENTS PAGE Improving Access Check List 4 Measuring Demand 7 Step 1: Understanding Total Demand 7 Step 2: Understanding the Demand for same-day 7 and pre-booked appointments Shaping Demand 9 Telephone triage and telephone consultations 9 On-line booking of appointments 10 Smartphone Apps 10 On-line self-help and e-consultations 11 Home visits 11 Wider use of local pharmacies 12 Proactive care 13 Care Planning 13 Nursing Home Visits 13

Matching Capacity to Demand 14 Telephones 14

Number of people answering calls 14 Customer Care 14 Volume of incoming calls 15 Number of lines 15

Consultations and Appointments 15

Balance between same day and book ahead appointments 16 Too few appointments 16 Book ahead time 17 Length of Appointments 17 Reviews 17 The popular doctor 17 Managing people who do not attend (DNAs) 18

Staffing skill mix and workload 18 Pharmacists as part of the practice team 19

Identifying opportunities for improvement through understanding 20 demand and capacity Summary 23 Templates for Measuring Capacity 25


Every practice should have a vision of what good access is. This should be formed through engagement with staff and patients and should be something that practices are constantly working towards. For practices facing increasing demand and expectations from their patients it is more important than ever that practices are in control of their access, not only offering patients what they require but providing a manageable and sustainable work load for their staff.

Acknowledgements We have put this Guide together drawing on a number of sources of expertise and knowledge, including the Primary Care Foundation www.primarycarefoundation.co.uk

Good access is about:

• Patients being able to book an appointment quickly, within a reasonable timeframe, and pre-book one if they wish;

• Patients being able to see a preferred clinician if they wish to wait longer for an appointment;

• Patient access to reliable information about the practice, so that they can make their own decisions about the access they require;

• Patients not only being able to book an appointment on the telephone but by other means, such as through the internet, email, text, Skype and apps.

• Patients contributing to good access through Patient Participation Groups and other forums; and

• Patients being able to telephone the practice throughout the day

http://www.primarycarefoundation.co.uk/


Improving Access Check List

What we have learnt from piloting new ways to improve access in Greenwich

Consult Before implementing any new system or service:

CHECK:

With patients to see what they think.

With the CCG to see if they are considering supporting any such systems or have some helpful information.

With staff to see whether they see a need.

With nearby practices to see if they have done something similar

Plan the changes GP practices may be relatively small organisations - but their operational processes and the way that patients interact with the operational process is complex. Making a number of big changes all at once is likely to lead to extraordinary and potentially unmanageable distortions to the workload and to inevitable disappointment.

CHECK:

Any changes that the practice agrees to make are planned as modest steps

Pick the Right Time Many practices make a change and, because there is pent up demand from patients who have been waiting to be seen, the immediate effect is an increase that can be difficult to manage. You should anticipate this and may well want to choose to avoid making change whilst some staff are away and even to work hard to catch up as part of the preparation.

CHECK:

You choose a time to make a change when there is sufficient resource available to manage any unexpected bulges in demand

Adapt and re-invent It is much easier to improve by adapting the systems and processes we already have in place than to completely replace them.

CHECK:

You consider others‟ ideas that are already working first and adapt them to work even better in your own situation.

A round man cannot be expected to fit into a square hole right away. He must have time to modify his shape. Mark Twain


Unlearn old ways This is the flip side of re-invention. Running different systems in parallel and partial implementation can detract from the benefits the good practice should be delivering. One aspect that can hinder „unlearning‟ is the lack of belief that the new way will work.

CHECK:

The old ways of working are making way for the new

Communicate and engage with staff Changes need practice staff to be motivated advocates to communicate the changes in a positive way by explaining the opportunities and benefits they will provide patients. The challenge for the pilots, especially in the case of the telephone triage and consultations was that staff were initially skeptical of its positive impact and concerned about the pressures on the workload.

CHECK:

You have communicated well with your staff about the planned changes

Communicate and engage with patients It is crucial that patients know about the change or new system and that you incorporate their ideas and concerns.. They should be kept involved and informed throughout the process. Otherwise, they may never find out about your efforts. The patients most likely to be anxious about change and uncomfortable with new systems need bespoke communications to explain how the changes will not threaten their ability to get access to GP‟s. Also, if patients don‟t know about the changes they will still behave as if the old system is operating.

CHECK:

You have communicated well with your patients about the planned changes

Communicate your successes It is very important to share improvements with patients and staff even if they are small changes. A number of small changes can build into a big change.

CHECK:

You are sharing your successes

Identify any support you need We learnt from our access pilots that new schemes cannot be implemented just as an off the shelf approach. Support is needed at the start to build on previous knowledge and help staff and patients to adapt to the new system and make modifications to fit the practice. Key elements of this include: technological requirements, staffing at key times of the day, and allowing sufficient time for calls to prevent regular overrunning.


CHECK:

You have considered what support you might need and have talked to others in your syndicate

Consider what you can gain from peer support and sharing

knowledge and ideas Many of the challenges faced by the pilot practices were not unique to their practice. There is benefit in improving the channels of knowledge-share between practices. The workshops we ran for the pilot practices so they could compare progress were very helpful in identifying some of the barriers.

CHECK:

You have considered learning from other practices in your syndicate and even twinning with another practice facing similar challenges

Train your staff To get the most out of any new system or service, staff will need to be fully trained on its potential. Training of receptionists‟ and GPs, if they are doing new tasks such as phone consultations or triaging, is likely to improve performance. In particular, training of triage staff to better be able to choose for example whether a telephone consultation or face to face appointment is required, may have a positive impact on capacity.

CHECK:

You have identified what training may be needed

Evaluate The three key questions for improvement are:

What is it we want to achieve?

What steps do we need to take to get there? and

How will we know when we have got there? If you don‟t measure the impact of a change you won‟t know whether you have been successful or not.

CHECK:

You have a plan to monitor and evaluate any new changes you implement


Measure demand

Patient demand is largely predictable. Data from over 7 million records shows the demand for GP consultations is an average of 6-7% of the practice list per week. The variation is predictably driven by deprivation and age profile, the highest seen being 10%, with few family practices below 5%.

Within the week there's a daily pattern, for example Mondays are likely to be nearly a third of the total weekly demand, and this varies little between practices.

This means we can estimate how many patient calls to expect per day. Even through the day, we can estimate how many will call each hour.

The key is to understand not just the demand for urgent or same day care but the totality of the demand.

Understanding demand means the practice can schedule the necessary capacity. This means that the practice can meet the requests of patients regardless of these being for a same day appointment or addressing a problem in the future.

Step 1: Understanding Total Demand In order to make changes to improve access you need to understand your practice‟s demand. You could base your estimate on the predicted percentages above, or you can gather information for yourself that will help develop a fuller understanding of your practice‟s capacity. The best way to measure demand is by counting the number of requests for appointments on each day of the week.

TIP: Remember that daily activity is not the same as daily demand

The easiest way to collect this information is to use a tick-sheet and keep the task as simple as possible:

Equip a receptionist with a tick sheet template and record when a patient requests an appointment, even if one isn‟t available. A template is attached at the end of this guide (Form A).

Collect on a weekly basis.

Measuring demand on a regular basis (e.g. weekly to begin with then monthly or quarterly) is invaluable in helping to build a comprehensive understanding of what to expect and to identify fluctuations and their causes, such as seasonal variations.

Understanding how much demand arises each day and in total across the week is important in helping to ensure that there is enough total capacity each day. The information you gather may not be perfect but it will be good enough to get you started.

Step 2: Understanding the Demand for same-day and pre-booked appointments Understanding the different demands for same day access and book in advance appointments will help you gather information on the proportion of people that would normally expect to book in advance each day. Understanding what proportion of appointments are likely to be pre-booked each day is important in helping to ensure that there is enough total capacity each day. Many practices

MEASURING DEMAND Before you can start to make improvements, you must understand demand and how your appointment system works. For example, do you know how many patients come through the door each week and when?


are surprised to find that despite the constant feeling of pressure within the surgery, their demand and capacity are usually matched. Sometimes practices find that the totality of demand is similar to capacity but there are problems on certain days of the week that they need to address.

Form B at the end of the Guide is designed to help collect information about the total number of appointments needed each day and the proportion that will normally be pre-booked.

You can now compare the demands on your practice for each day of the week against the capacity to cope with the demand.

Capacity is the actual number of appointments available. This helps you to make a quick comparison between your levels of demand vs your current appointment supply.

The data collected by the above process can be entered into an Excel spreadsheet, and converted into a bar chart, example below:

TOTAL GP DEMAND OVER MAY 2010

99

84

9789 87

74 74 7772

66

0

20

40

60

80

100

120

Mon Tue Wed Thu Fri

Ap

po

intm

en

t re

qu

ests

Demand

Capacity

In the example above, the reception team populated tick sheets to capture every patient request for an appointment (GP and nurses). These requests were then profiled against the actual capacity offered during the same period. These results allowed the average weekly profile to be calculated. In this case, the average daily demand was 91 appointments while the average capacity was only 73 leaving a shortfall of 18 appointments each day.

TIP: Is there a day where the demand exceeds capacity? Is there a day where capacity exceeds demand?

TIPS: appointments What to say Although there needs to be flexibility in the structure of telephone consultations, several key stages can be identified:

• Identify yourself and the caller/person being called – the patient whenever possible. • Gather information, including social context and clinical history. • Address the biomedical aspects of the problem and the patient‟s perspective. • Give a diagnosis or interpretation of the patient‟s problem, with an explanation. • Signpost the point at which a triage or management decision must be made. • Negotiate the outcome according to agreed guidelines. • Make follow-up arrangements sharing thoughts on possible developments. • Prepare for the next call and be professionally safe, keeping good records.


1. Telephone triage and telephone consultations

Telephone consultations can be cheaper and quicker than seeing patients face to face, but they carry risks. Not all conditions are suitable for phone management, some will need and patients will need a face to face appointment and a personal examination. In the right circumstances however they can increase efficiency, improve access and boost patient satisfaction.

Greenwich Pilot Scheme to utilise GP telephone triage and consultations to improve access In Greenwich 5 practices piloted the systematic telephone triage by GPs of all requests for appointments, telephone consultations or visits in 5 practices. This was one of three different pilot schemes we have piloted in the last year in Greenwich. This work was supported by an outside organisation, GP Access, who undertook an initial detailed analysis of the current practice supply and demand, and then trained GP's and practice staff in the new system. The patient phones the surgery for an appointment and is told by the receptionist that a GP will phone them back. The GP then calls the patient back as soon as possible and decides whether to undertake a telephone consultation with the patient or that the patient needs to be seen face to face and books them an appointment for that day. Average waiting time for appointments reduced from 4 days to less then a day as telephone consultations replaced face to face consultations.

Phone consultations are popular with patients. Three quarters of patients were satisfied with the phone consultations although some patients, particularly older patients, were less likely to be happy with the change. Patients enjoyed being able to talk to a GP quickly without them having to visit a surgery.

TIPS: Tut how many appointments If you are considering introducing a combined GP triage and consultation appointment system these are some issues to be aware of:

• Consult well with your patients in advance of introducing any new changes • Be prepared for the increase in phone calls at key points in the day,

potentially producing long waits for patients and capacity pressures for staff operating the phones if your capacity is not in balance with demand.

• In compensation for this you will be able to spread the calls throughout the day and no longer have a high peak of calls at 8 am.

• Ensure you have adequate telephone technology with the capacity for the increase in demand.

• You need sufficient phone lines to allow for incoming and outgoing calls with a visible queuing system and good quality headsets for the GPs

• Try to ensure that the triage/consultation calls remain close to 5 minutes. • Provide training for staff including locum staff

Benefits • There is increased efficiency. By talking to patients before they make an appointment,

doctors can ensure they only see people who would benefit from a face-to-face consultation.

• Waiting times and appointment systems can be better managed, leading to greater patient satisfaction and lower staff stress levels.

• Patients have another channel through which to access primary care. This is particularly useful for people with reduced mobility or very little spare time.

• Telephone consultations can increase the opportunity for a patient to consult their preferred doctor, reinforcing the relationship, to the benefit of both parties.


Some of the practices, with some adaptation of the model, intend to keep on using this new approach as they found they had created additional capacity within the practice.

Other practices won‟t be continuing with this approach as they found they had issues with increased overall GP workload as well as with technology and phone systems. The workload increase was most marked when the telephone consultations expanded beyond the recommended 5 minutes - which they found difficult to keep to.

2. On line booking of appointments The new GP contract contains a commitment to expand and improve the provision of online services for patients, including extending online access to medical records and the availability of online appointments. Allowing patients to create, amend and cancel their appointments online is becoming a popular alternative. It can be particularly convenient for patients when the practice is closed or telephone lines are busy.

3. Smartphone apps

A small number of practices have gone further than simply offering online booking and have funded and developed their own smartphone app. Whilst an obvious limitation is that patients who do not use smartphones are excluded – it is currently estimated that at least 54% of the UK population use such devices. Although there is very little evidence in this area at present, existing cases in which apps have been used suggest that they can help improve access in combination with other measures. This approach builds on the already widespread

TIPS: Tut how many appointments • Put a marketing strategy in place involving reception staff, leaflets, letters to patients and

newsletters to raise patients‟ awareness. • The Royal College of General Practitioners and NHS England have produced a whole

array of patient information for download – posters, leaflets, appointment cards, practice signage, contents for digital signage boards and check in screens, patient FAQs, an example of a form that practices could use to request access to on-line services, etc.

• Plus there is useful information for practices on getting started • This is the resource pack link: http://www.england.nhs.uk/wp-content/uploads/2014/10/npo-

guidance-291014.pdf • Online booking is not for everyone. Reassure those who don‟t want to use the new

system that the old one continues.

Benefits of on-line booking • Gives patients 24/7 access and reduces pressure on practice phone system • Quick and easy to use, popular with patients who have busy lives (GP Patient

Survey found a third of patients say they would prefer to book appointments on line) • Can be popular with older people and those with hearing loss or a learning disability • Patients receive automated booking confirmations – no need to reconfirm by

telephone • Reduces incoming calls and so relieves workload for reception staff (although staff

still needed to run online system) • Appointments can be cancelled easily, reducing „did not attends‟ • Some suppliers estimate there is a 67p saving from each appointment booked online • Practices can choose how many appointments they want displayed, and are

therefore able to be booked online • Some systems allow patients to send a message with their booking to tell the

clinician what their consultation is about • Log-in details can be revoked if a patient misuses the service

http://www.england.nhs.uk/wp-content/uploads/2014/10/npo-guidance-291014.pdf

http://www.england.nhs.uk/wp-content/uploads/2014/10/npo-guidance-291014.pdf


use of automated appointment reminders that are sent via text message to patients‟ mobile phones.

Whilst current examples of apps being developed appear to be on an individual practice level, limits on practice resources and time means that this could be a development best pursued by practices pooling resources and working together - such as across a syndicate.

4. On line self-help and e-consultations

Greenwich Pilot Scheme to improve access for patients through on-line consultations.

We piloted an on-line self-help advice and GP consultation facility (WebGP) in 3 practices in Greenwich. The model encourages patients to consider self-help and other services first, moving on to a consultation with a GP in their practice after other avenues had been explored (including pharmacist and NHS 111 advice). The aim is to release productivity within the practice as well as improve access.

The Hurley Group supported this pilot and worked with each pilot practice to set up „WebGP‟ on the practice web site. This enabled patients to go online for conditions or concerns that were not urgent, including access to a self diagnosis algorithm, and could engage in an on-line consultation with the GP.

The requirements for each practice participating in this project were low as most of the work required was done by Hurley so there was not much work required from the practice. However it was fundamentally important that each practice should develop and deliver a marketing plan to ensure that their patients were aware that this facility was available.

When we evaluated the pilot we found that overall patient awareness and uptake of the facility for on-line advice and consultations was low across participating practices. This made it hard to assess its impact. There was also a steady drop off in usage likely to be due to lack of publicity after the initial launch where in some cases text messages were sent out. For those patients who had used online symptom checkers and consultation the majority of patients were positive about the experience.

TIP: If you are considering putting in place the option for patients to consult on-line undertake a major marketing and promotion exercise. However helpful it won‟t get used if patients don‟t know about it.

5. Home visits

Those who request home visits are often those with complex multiple pathologies where the continuity of care is important - but they are also the group of patients that is most likely to be admitted. It is important to assess and sometimes to see such patients early to avoid the risk of deterioration to such an extent that they become more likely to need admission.

Case Study The Robin Lane Medical Centre in Leeds developed a smartphone app through which patients can request appointments, send secure messages to clinicians and set appointment reminders. The £5000 cost for developing the app was funded by the practice itself.

In addition to the convenience the app offers to some patients, the practice has found that it has helped to reach patient groups who may not ordinarily interact with their GP – for example young people seeking confidential advice about sexual health.


Practices should assess home visit requests for new, or exacerbation of existing problems, as soon as possible (idealy within 20 minutes). There are two advantages to this process. The first is that some visits may not be necessary and another, less time intensive intervention may be appropriate. The second is patients who will benefit from early intervention will be identified and responded to rapidly and not admitted to hospital in the evening when diagnostics and senior clinical opinion are unavailable.

TIP: Community staff can also be used effectively in this role

6. Wider use of local pharmacies

Community pharmacy is the gateway to health for 1.6 million patients each day. Patients greatly value the fact that they don‟t need an appointment to see a pharmacist. Pharmacy‟s accessibility in terms of location and long opening hours is seen as a significant benefit to the public.

Triage and signposting to health and social care services is a core component of the work in community pharmacy.

Your local pharmacies can provide the practice patients with easy access, online or in person, to information on self-care and appropriate advice and support your patients in the management of medicines and long-term conditions.

You may want to consider developing your relationship further with your local pharmacies to identify ways of working that will be of mutual benefit.

You could consider doing more to promote the pharmacy as the first point of contact for patients, advertising the wide range of services accessible through the local community pharmacies both to help keep patients healthy and to provide personalised care and support when unwell.

TIP: Work with your Patient Participation Group to identify ways of promoting the use of

Home visits and collaborating with other practices – Halton and St Helens case study St Helens borough in Merseyside had one of the highest emergency admission rates in the area. There were 150 admissions per 1,000 population. This compared to the target of 120 or fewer. Patients would call their practice in the morning, hoping for a home visit, but find out that their doctor was fully booked for the entire surgery. In some cases, this resulted in a delay of over three hours from time of the request to the visit being made. If the condition deteriorated, or they thought it did, patients or their carers frequently called an ambulance or went to A&E. There was therefore a need to reduce emergency admission rates. So, twelve practices in a St Helens consortium devised a shared acute visiting service. They employed a GP dedicated to home visits. Now, patients who request an urgent home visit call their practice and speak to their own GP or a practice nurse. The medical professional assesses whether or not the patient needs to be seen. If so, the doctor from the acute visiting service is sent. Three quarters of patients are seen within an hour, with appointments lasting up to 20 minutes.

„The results have been „phenomenal‟, says lead GP Dr Shikha Pitalia. „Since we launched the scheme we‟ve reduced emergency admissions by 30%‟. The benefits are significant, for the practice as well as the patient. „Just one or two urgent requests for home visits can significantly reduce the availability of GP appointments. Sharing a home visit doctor gives us back three appointments a day on average,‟ says Dr Pitalia. The system borrows the infrastructure of the local out-of-hours provider, who recruited a doctor with knowledge of the local referral care pathways to provide an acute visiting service. Regular monitoring of the service ensures that clinical standards are maintained.


pharmacies more and providing good information about the services, in addition to dispensing, that all of your local community pharmacies provide

7. Proactive Care

Care Planning

Proactive care planning for patients with long term conditions and complex needs not only contributes to continuity of care but has a positive effect on access.

Embedding a care planning approach into primary care stands out as a solution that has the potential to both improve quality of access for patients and help manage demand in general practice by empowering patients to become experts in their own care.

TIP: From April 2015 Greenwich practices will be receiving „Year of Care‟ training in

preparation for implementation of a care planning approach - as part of the new contract in place to deliver extended long term conditions services in primary care.

This care planning approach in Greenwich will offer patients with long term conditions support for self management and help them to engage in decisions about their care.

It will also help to put access to general practice on a more proactive footing for these patients.

Rather than the onus being on the patient to approach their GP, the practice identifies patients in need of long term support and works with them to design their care according to their needs and goals. There is strong evidence that care planning leads to improved self management by patients themselves, enabling that person to make more informed and personally relevant decisions about accessing health or social care.

As the number of consultations required by the patient in an ad hoc way decreases, this frees up practice resources that can be used to improve access for other patients.

Nursing Home Visits

Case study: Pooling practice resources to deliver planned care for care home residents in Cumbria

An initiative called „Better Together‟ has been launched in Wokington, Cumbria, combining five practices covering 33,900 patients. As a means of increasing access, these practices have banded together to establish a new team providing dedicated services for residents in local care homes, focusing on proactive (rather than reactive) care.

This team will undertake scheduled visits in order to create proactive care plans for patients, as well as undertake end of life care and medication reviews. This project has been undertaken in response to local concerns around the level of access to GP services and historically poor health outcomes linked to levels of deprivation in the local area, and it is hoped that it will help mange demand for GP services in a proactive fashion alongside improving the overall health of their population.


1. Telephones There are four aspects which will impact on the ability of patients to get through on the phone:

• Number of people answering calls • Customer care • Volume of incoming calls • Number of lines

Number of people answering calls The „look-up‟ table below uses the Erlang formula to calculate the number of staff required to answer the phone in each hour to ensure that 90% of calls are answered promptly, based on your reported call volumes and length of the average call.

Calls per hour/average call length 40 60 80 100 120 150 180 210 240

2 1 1 1 1 1 1 1 2 2

4 1 1 1 1 2 2 2 2 2

10 1 2 2 2 2 2 2 3 3

15 1 2 2 2 2 3 3 3 3

20 2 2 2 2 3 3 3 4 4

25 2 2 2 3 3 3 4 4 4

30 2 2 3 3 3 4 4 4 5

40 2 2 3 3 4 4 5 5 6

50 2 3 3 4 4 5 5 6 7

60 2 3 3 4 5 5 6 7 7

75 3 3 4 5 5 6 7 8 9

100 3 4 5 5 6 7 9 10 11

125 3 4 5 6 7 9 10 11 13

150 4 5 6 7 8 10 11 13 15

180 4 5 7 8 9 11 13 15 17

200 4 6 7 9 10 12 14 16 18

This table identifies the number of dedicated staff that are needed to answer the telephone and achieve a service

level of 90% of calls being answered in 30 seconds for a given number of calls per hour (vertical axis) and a given

average call length in seconds (horizontal axis) You may want to ensure that during the 'peak period' for incoming calls the duty reception staff dedicate their time to ensuring that the phone is answered promptly. During the less busy periods, when it is possible for some of them to undertake other tasks, you will also want to ensure that at least some are in a position to answer calls promptly when they do come in.

Customer Care You may also find it helpful to look at the differences between individual receptionists to identify those that have developed an effective approach that succeeds in both sounding

MATCHING CAPACITY TO DEMAND

The following sections in this Guide offer practical advice and tips about how you can help to match your capacity to the demand you face


welcoming, helpful and supportive while steering the conversation to handle different call-types in a time-efficient way.

TIP: Reviewing how your team manage calls can encourage reception staff to identify a model 'script' that others can follow so bringing down the average length of incoming calls

Whilst such a script can never be followed slavishly, users typically find that it helps them to structure the conversation and to bring down the average length of calls. Staff should offer book ahead slots first followed by same day if required. Starting a conversation with “I don't have anything left for today” is not the most positive start to any engagement.

Volume of incoming calls If there are issues in the practice of getting an appointment with the doctor of choice, lack of overall capacity, too heavy a focus on emergency or same day appointments or other issues that lead to patients ringing again then the call volume will be higher than a similar practice which does not have these issues.

Number of lines Check the number of incoming phone lines.

TIP: A good rule of thumb is that you should have at least 2 more lines than the largest number of dedicated staff required in any hour during the week

This sometimes allow patients calling to queue yet still be answered promptly as soon as a receptionist becomes free rather than receiving an engaged tone. The bigger advantage is, however, that in most systems it will allow the practice visibility of the number of incoming calls that are waiting (the queue). This visibility makes it easier to recognise when to allocate additional staff to answering the phone allowing the manager to respond to periods of particular demand. A practice that has too few people answering calls promptly will find that it needs more lines if patients are to avoid getting an engaged tone - the actual number required will be limited by how long callers are prepared to hang on before ringing off (or how many times they are prepared to keep trying before giving up).

TIP: Queue systems can smooth out very short term peaks

2. Consultations and Appointments Do you understand your practice capacity? Do you offer the right number of appointments, the right mix between same-day and pre-bookable, how they are spread across the week and how you might compare against some national averages as a rough guide?


TIP: appointments To work out how many appointments you offer per 1000 patients, simply total all of your routine (same-day and pre-bookable) appointments in a given week (for example, for doctors and the practice nurse), divide the figure by your total list size and multiply it by a 1,000.

Balance between same day and book ahead appointments General Practice workload splits, on average, into 1/3 same day presentations and 2/3 book ahead. This varies by individual practice depending on a number of factors including the consultation style of the staff and the nature of the practice population - with younger lists generating more same day appointments and older lists tending to require more book ahead appointments. The ratio includes all activity and not just GP appointments.

TIP: Having too high a proportion of same day appointments can drive patients who would book ahead to seek a same day appointment as this is often the only option left when they call

It also makes it harder to get the doctor of choice and can drive a higher level of activity as patients return to see the doctor they really wanted to see the first time round.

Too few appointments Many practices are very busy and staff feel as though they can never keep up. Two signs that indicate that the practice is not offering enough appointments can be:

• a consultation rate which is below that of similar, local practices • patients who are unable to get an appointment

TIP: The question that you need to answer is “Are we offering too few appointments or are we using those we do offer in a less than effective way”?

TIP:In the majority of cases practices are offering enough appointments but not using them effectively

Consultation Rates: Crude comparisons with national averages • The average patient has 5.5 consultations a year (compared to only 3.9 consultations a

year in 1995). This is not just for GPs but for nurses and other professionals as well. • This is approximately equivalent to 100 appointments per week (for both GPs and nurses)

for every 1,000 patients (note: the Greenwich PMS contractual obligation is for 66 face to face appointments/11 hours per 1000 registered patients per week).

• This crude average varies significantly with characteristics such as age, sex and deprivation. For people aged over 85 the rate rises to over 13 consultations per year.

• There is evidence that people aged 50 in the most deprived areas consult as often as someone aged 70 in less deprived areas.

• This means that the average for some practices is less than 4 or higher than 8 consultations per year – you may want to consider your consultation rates and the number of appointments you offer, and how that reflects the demands of your patients.


Book ahead time Short book ahead times, primarily designed to reduce DNA rates, tend to drive work back into the system as it is more difficult to get an appointment with the doctor of the patient‟s choice.

It is suggested that practices consider allowing patients to book further ahead as this prevents patients being forced into the same day system and overloading it.

TIPS: Evidence shows that it is helpful to allow patients to book ahead for a

minimum of 6 weeks If Mondays are your busiest day, avoid booking on Mondays

This will also allows patients a greater chance of seeing the doctor of their choice. To enable patients to book ahead, receptionists should use a fairly standard script which starts by offering a book ahead appointment for as far ahead as they are available

TIP: Reception staff should also be encouraged to offer book ahead appointments when they first talk to patients and use a structured script rather than starting by trying to fit in the patient in as soon as possible.

Length of appointments Some consultations may be too short and patients may come back within a short space of time if their concerns were not fully addressed. Practices should normally be very cautious about reducing the length of their planned consultations.

Reviews Are some clinicians calling people back more frequently than might be expected (bearing in mind that they may have different case mix)? All clinicians generate a large amount of their future work by suggesting when a review is needed.

TIPS: Consider the 'new to review' ratio If Mondays are your busiest days don‟t bring people back on a Monday

The national NICE guidelines suggest clinical assessment is 'at least annual' for those suffering mild, moderate and severe (stages 1 to 3) COPD yet some practices and individual clinicians review all such patients much more often than this.

The popular doctor Having a doctor or doctors who have high review rates or are very popular with patients can increase overall demand to a level which makes it difficult for the practice to cope and it can result in considerable tension within the practice.

Sometimes there are very different views about whether the popular doctor is providing excellent care by really getting to the bottom of the patient's problem or whether they are choosing to see the easy patients.

TIP: The practice should look at new to review rates by individual doctors and nurses and also looks at the number of consultations undertaken by the different people within the practice


Managing people who do not attend (DNAs) While there is a clear benefit in reducing DNAs in hospital, particularly for capital or resource intensive procedures, there is a view that practices can generally be relaxed about a modest level of DNA patients in general practice. Appointment times are relatively short and the loss of either capacity or time is generally minimal – in fact, most clinicians welcome the chance to catch up, catch their breath or complete that difficult referral letter from earlier in the day. Practices may consider not spending a disproportionate amount of time and energy trying to reduce them (which is not to say that approaches such as text reminders may not be helpful and are likely to lead to better care for the less well-organised patient). It is possible that high DNA rates may be a symptom of a system that is not running as smoothly as it might and that some patients may be trying to „game‟ the system, booking an appointment in case they need it.

TIP: As access improves practices often find that DNA rates tend to drop as patient confidence in getting an appointment grows

3. Staffing skill mix and workload General practices vary considerably in their staffing and the way that different skill groups are deployed. In general, nursing staff will tend to see more patients with planned appointments and will often have longer consultation lengths, and GPs will tend to deal with those with multiple pathologies or that are particularly complex.

There is, however, enormous variation both across and within different professional groups. In addition, new roles are becoming more common, while there are further complexities in the different roles within a training practice.

There has been a change in the proportion of patients seen by nurses in primary care. In 1995, 76% of consultations were undertaken by GPs, 21% by nurses and 3% by other clinicians. In 2008, approximately 62% of consultations were undertaken by GPs, 34% were undertaken by nurses and 4% by other clinicians.

Some key findings from the last workload survey 2006/7 are provided below for comparison.

GP Partners 36.6 22.7 62% 86.9 17.3 8.3 112.5 114

Salaried GP 23.6 16.6 70% 66.1 7.9 4.1 78.1 122

Nurse Practitioners 28.4 20.2 71% 56.1 17.7 5.4 79.2 103

Nurses 22.5 17.5 78% 59.8 7.6 2.1 69.5 114

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Comparison of the norms above with those in your own practice and careful consideration of who does what within each skill group may highlight individuals or groups where productivity is an issue that needs to be addressed.

TIP: Practices often find that they need to remove obstacles that hinder some individuals or groups from working as productively as they would like.

4. Pharmacists as part of the practice team

Whilst primary care is facing an immediate crisis of falling workforce and rising demand:

• A significant number of suitably qualified pharmacists are available

• Pharmacists‟ under-used skills could play an important role in helping GP practices and primary care providers fill their gaps quickly, practically and cost-effectively

• Pharmacists working in GP practices have helped drive significant improvements in care provision and working patterns

• Patients report feeling satisfied and safe with pharmacists in GP practices

There is a sustainable business model for GP practices to employ a pharmacist as part of a review of skill-mix and staffing. GPs spend significant time managing prescribing, reviewing medicines, reconciliation of letters and discharge forms, addressing patient compliance and managing long-term conditions. These are common roles for pharmacists.

The economies of scale of employing pharmacists who can work across multiple practices were an initial attractor to providers with chains or groups of practices. Yet the model has delivered so well that GPs are now seeking a pharmacist for each practice.

The pharmacist helps practices in many financial areas, for example delivering on QOF, local and directed enhanced services and immunisations and vaccinations.

Practical example

The challenge To increase capacity within the practice nursing team.

The role of workload analysis Identified workload activity for the nursing team.

The solution Two tasks currently carried out by the practice nurses could, with training, be done by healthcare assistants: • assessment of foot pulses in diabetic patients; and • first-line intervention in smoking cessation.

Result • Two healthcare assistants trained in foot pulse assessment. • Freed up 23 hours of practice nurse time per month.

• Plus new pathway implemented – healthcare assistant first-line intervention for smoking cessation.


TIP: AVAILABILITY: There are an increasing number of highly trained and skilled pharmacists emerging from

university, yet not doing the jobs to match their skill levels Many independent prescribing pharmacists do not have work fully using their qualifications. One practice, unable to recruit a GP, recently advertised for a pharmacist in a trade

magazine and received 150 applications

The variety of services pharmacists deliver in general practice is considerable and includes chronic disease management, diabetes, asthma, COPD, hypertension, depression and arthritis. Pharmacists have staffed walk-in centres, and can be used to good effect in triage for common ailments (pharmacists can do chest assessments, for example).

Pharmacists have a broad skill-set in analytics as well as prescribing knowledge to develop a new care model with a pharmacist as part of the practice team.

5. Identifying opportunities for improvement through understanding demand and capacity

A Greenwich Access Pilot In another of the Greenwich Pilot Schemes to improve access, practices were helped to look at their own data to see if they could identify any of the opportunities for improvement highlighted above through a better understanding of their demand and capacity.

Five practices undertook this work supported by an outside organisation, the Primary Care Foundation, who used a web based tool to produce a semi-automated report based on a sample week for individual practices based on their own data that offered a clear analysis of the practice, compared them with the other pilot practices and offered suggestions for improvement. Practices had the opportunity to benchmark their systems with other practices. A meeting was held with each practice, and a workshop was held bringing together all the scheme 2 pilot practices. It was then up to each practice how they responded.

The benchmarking/comparison exercise between the practices revealed a lot of variation between in the way in the systems employed and the way practices operated. For example there was variation in how skill mix was deployed by the practices to meet patient demand as illustrated below:


9

Scheme 2 Practices deploy a range of skills in delivering care to their patients

3 4 521Practices

NHS Greenwich CCG October 14

The pilot had varied impact on the different practices involved. In some practices the process was significant, allowing them to pursue methods such as offering telephone consultations and better receptionist screening in ways that had an impact on patient outcomes. For other practices, the recommendations were thought by the practices either not to have added any new thinking or were only implemented to a limited extent.

Once the recommendations had been presented, it was up to the individual practices to implement the recommended changes. Some practices felt that they were under a lot of pressure, and in order to make improvements they needed additional support.

Improvements included:

• One practice said that they had made some changes in response to the

evidence that they were offering fewer appointments according to their size and demographic mix when compared to similar practices across the country and as a result put on an additional GP session and increased the role of the nurse practitioner.

• Another practice said it made them take time to study and reflect exactly what is going on with the appointment system they were operating.


Summary Step-by-Step guide

Five key principles of moving from restricted access to responsive access

1. Measure demand Before you can start, you must understand demand and how your appointment system works. For example, do you know how many patients come through the door each week and when? • Equip a receptionist with a tick sheet template and record when a patient requests an appointment, even if one isn‟t available. A template is enclosed at the end of this guide. • Separate „book on the day‟ and pre-bookable requests. • Collect on a weekly basis. This will enable you to identify variations in demand for same-day and pre-bookable appointments, roughly how many appointments you might need each day and the general split, that is, how many appointments might need to be left for same-day and how many are for pre-bookable. This information will be important when comparing against your current capacity. A total tally sheet is also provided for you to compare demand to appointment supply.

2. Shape demand Start looking at ways you can shape demand. Not everyone needs to be seen by a GP in a consulting room. Consider opportunities for:

• GP triage • telephone consultations • skill mix • internet booking • on line consultation • patient education • group sessions (for example, smoking cessation) • wider use of local pharmacies.


Summary Step-by-Step guide continued

3. Match capacity to demand Consider the following:

• Mondays are the busiest day, followed usually by Tuesdays, Fridays, Wednesdays, Thursdays. • Two thirds of your day‟s workload will come in before midday. • Generally, most of the unwell people will call before 10.30am. • Are you offering enough appointments?

4. Contingency planning Always plan ahead for holidays and try to account for sickness, and the flu season. • Try and calculate demand and capacity weekly to identify when and how many extra appointments are necessary when there are GP shortages. • Pre-booked appointments could be suspended on Mondays and reintroduced when the pressure is reduced. • Try increasing the number of telephone consultations.

5. Communicate It is crucial that you always communicate change to staff and patients. Their feedback is crucial. • Discuss at weekly team meetings. • Use simple patient questionnaires or other methods to gain feedback. • Test out small changes before implementing on large scale. • Set up patient groups to help resolve access issues.

Tip Change can be scary, so ask yourself:

Is everyone in the practice on board?

Do they recognise a need for change?

Do the changes that you have made feel as though they are not working - even when they are?


SPACE BLANK FOR YOUR NOTES


FORM A Total Weekly Demand Data collection form Instructions Please tally all appointment requests during the course of this week. This should include appointment requests made by telephone; those made in person.

Include follow-up appointments. Requests for appointments should be recorded against the day that the

appointment was requested regardless of whether it was required for that day. (Do not record when the appointment was actually made)

You may need to have several of these forms at each point where appointments are

being requested to capture all appointments requests.

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

TOTAL

TOTAL

TOTAL

TOTAL

TOTAL

Grand Total________


FORM B Total number of appointments needed each day and the proportion that will normally be pre-booked.

Instructions Please tally all appointment requests during the course of the week: This should include requests made by telephone; those made in person and follow

ups. Requests for appointments on-the-day should be recorded in the left column

regardless of whether an appointment could be made or not. Use the right column to tally requests for pre-booked appointments. It does not

matter how many weeks in advance the appointment is requested for but just mark the day for which the request was made.

You want to find out the variation in demand for the same day appointments and how

many appointments are needed each day.

Appt

requested for today

Book in advance Appointment request for:

Any day

Mon Tues Wed Thurs Fri

Monday

Tuesday

Wed

Thursday

Friday

TOTAL

Documents

The Greenwich Good Access Guide...Page 7 Greenwich Good Access Guide Measure demand Patient demand is largely predictable. Data from over 7 million records shows the demand for GP