1. South Axholme Practice Pathfinder What is it like to be a patient? Harry Longman harry.longman@patient-access.org.uk harry.longman@patient-access.org.uk

2. Pathfinder – for informed consensus on change Analysis You know you have a problem and something must change You’ve seen the evidence that this works elsewhere But you want to see the picture with your own data Within two weeks, and without any paperwork, you find out. Now you have the basis for consensus on change. Meeting with partners Decision Leadership questionnaire Navigator 6 m history Navigator 6 m history Datalog Reception, GP Datalog Reception, GP Staff survey

3. Over two years there has been a slight fall in face to face consults and rise in telephone consults. Patient contacts are about 5% of list pw.

4. Looked at by time of day, opening at 8.30 is a bit busy.

5. Monday has about 50% more demand than other days

6. About 68% of appointments are booked same day

7. But the average wait to see a GP is about 3 days.

8. Phone consults are responded to, over a variable time up to 4 hours

9. Continuity is flat around 65%. Reflects frustrations.

10. What do patients think of our service? Administrative staff views – (Patients) become frustrated when they cannot get appointments straight away. – Seem to get more demanding about who they will and won’t see. – Often want to see one GP on the day and will not accept that this is not possible – Some have unrealistic expectations...and...this seems to be on the increase Clinical staff views – Hard to get appointment with specific doctor when they want one. – Some (perceive) rudeness from practice...also feel some of us don't listen. – Frequently complain that they cannot see the same doctors which in some situations is important. Makes it difficult for follow up and continuity of care. – Complain about having to disclose information to reception staff when trying to book appointments. – Patients (want) a time that suits them.

11. My daily work at present Administrative staff views – More and more stressful with everchanging goal posts – Patients unable to have appointments with their GP of choice. Clinical staff views – Often very busy, non-stop, frustrated by rude patients. – Patients come in and demand their prescriptions on the spot (ie they have run out completely). It puts us under pressure to work faster which can lead to errors. – Workload heading out of control. – Patients (regularly) booked inappropriately. Could have been dealt with over the phone...or by the nursing team. – Some of our patients openly admit that they lie to the reception team in order to get the appt...the time...the clinician they want. – I find it frustrating that we remain too doctor centered!

12. My ideal work Administrative staff views – Peaceful – For the GPs to be happy with service the receptionists are providing – For receptionists to be happy with what they can offer – For patients to be happy with the service they are given Clinical staff views – Where the system works without having to interrupt the doctor too often – To use the phone and email more...a reduction in consultation numbers – Patients would benefit from using more telephone consultations – Would prefer to use my time more effectively with the patients who really need to see a doctor rather than wasting time dealing with prescription requests, patients who come in just to complain...and patients who have refused to see our nurse practitioners when it would have been appropriate for them to do so. – I would like to focus my time on complex patients and our older patients.

13. Any fears in the face of change? Fear not working in a safe and efficient environment Loss of my job, loss of wages Patient welfare if appointments/hours are reduced Open to change if there is a benefit i.e. time saving, more economical etc. As long as I can see a point to the change I’m all for it! I don’t like change for change sake. No. The situation is so busy that I have nothing to lose. I feel care is less thorough caused by the ongoing increasing pressure on the service.

14. Reception data capture – 47% of requests are for GP, of which 1/3 are for named GP. Others mostly nurse or admin.

15. Monday is the busiest by a long way. 83% of bookings are by phone, 17% walk-ins quite high.

16. And everything seems to happen at 8am.

17. But although 79% are given agreed clinician and date, others are not and 10% have to call again – rework.

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

19. 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

20. Vast majority of patients want an appointment today, with a few others booking one or two weeks ahead.

21. 56% of GP patients are acute, a further 9% exacerbations. People need help on the day.

22. Over 87% of GP consults are face to face, only 12% by phone

23. But of these, 73% are solved over the phone

24. While your view is that currently under 10% did not need a face to face

25. Clue to a practical solution… “How can we help all our patients, all day, every day?”

26. 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

27. 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

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

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

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

31. 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?

32. Simple, but the whole system changes 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%

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

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

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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. “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

43. 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