Bosworth Medical Centre Pathfinder What is it like to be a patient? Harry Longman

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

What do patients think of our service? Administrative staff views – (Patients) find it difficult to get an appointment – Hard to book with the GP that they want to see Clinical staff views – Patients use emergency appointments as no other way to get seen – Complain about arguing with reception...can’t book ahead – R eception staff can be rude – Takes too long to get appointment – Have to queue up on Monday mornings for appointments – Can't get through on phone – Get annoyed at waiting when in the surgery – Difficult to get appointments to see doctor of choice – Challenging to get appointment at (the patient’s convenience), many wish to book ahead but (are) unable – Frustrated by barriers...gatekeeping.

My daily work at present Administrative staff views – Patients hate the fact that they have to ring every day for appointments. – Expect to get what they want straight away as soon as they phone or (show up at the surgery) Clinical staff views – Demoralising...dread seeing long queues at reception when arrive at work – Generally run 20 (to)40 minutes late...long working hours with no break – Intense work and can cause 'brain-ache!‘. – Hate being duty doctor – Increasing demands. Doctor dependence. Chances of burnout high – Increasing workloads and admin work. Difficult to maintain the standard (we) would like – Feels like fire-fighting all the time....signs of stress and dis-satisfaction. – Little time to meet and speak with colleagues – Often patients could have been dealt with on the telephone with simple advice – Lots of patients complaining about access - this often takes up time during the consultation!

My ideal work Administrative staff views – To (be able to) cope with the demand of calls that we get every day – To be able to deal with patients’ enquiries without the stress...and help more urgent patients – Ability to meet patient demand and have patient satisfaction with service Clinical staff views – Running to time – Following up my own patients i.e. better continuity; less stress – See (patients) that definitely need seeing...cutting down surgery times. Have time to do admin work and audits and quality improvement services. – Minimise risks...devote more time to deal with complexities...better personalised care. – Time for patient education – Have a "GP surgery" and not a "walk-in centre"! – Less stress; fewer patients complaining – Reducing face-to-face consultations...to (only) those genuinely needed – Workload consistent and manageable

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

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

Reception data capture: 68% of calls are for a GP, others for nurse, admin.

Vast majority of GP demand comes in first thing – a few more after 2pm. Most are telephone but significant 14% are walk ins.

Data shows 81% of requests are agreed. 10% told to call back – this is a big feature of staff survey feedback, rework from patients told to call back.

Almost all requests for GP are for the same day.

Only 20% of requests for named doctor, but still an issue at times: “wanted Dr C not in so settled for Dr S”

GP consults 94% face to face, 6% telephone and a few visits reported

Of small proportion of telephone consults, nearly 80% resolved over phone

Acuity: unusually high proportion of chronic routine. Don’t know why. Reflected in New/FU ratio of 50%

GPs view: already, you say a significant proportion of consults did not need to be face to face, 1/4 for chronic routine. This always rises!

Continuity, the GPs view: important in 43% of consults, but missed in 12%.

Current supply of consults is over 90% face to face, with around 550 or 6% of list in a full week.

The average wait to see a GP is around 4 days, but this is not the full picture…

The majority of patients appear to be seen same day, but some are booked 1,2,3 or 4 weeks ahead.

It appears that a stable 70% are seen the same day they book. So where is the problem?

There’s a mad rush to get the appointments at 8.15, and almost nothing available after 9. A few telephone slots are given out later.

Telephone requests are responded to some time same day, in avg 70 mins

Continuity of 65-70% within month is average for the practice size – but it could be much higher

Consultations f2f have become a little shorter, near 8 mins, but the small number of telephone consults are longer than average.

Current Bosworth model Reception takes call GP sees patient 10 min slot GP sees patient 10 min slot Problem solved 50% “routine” 50% “urgent” “All gone. Call back tomorrow” See any GP/locum Poor continuity, repeat booking Patient pressure – call early Hang on in hope

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

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

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

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

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?

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%

Clarendon Practice, Salford, turns round Dr Jeremy Tankel, GP Principal Harry Longman, Patient Access

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. 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 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

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

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

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

“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