1. Little London Surgery What is it like to be a patient? Harry Longman harry.longman@patient-access.org.uk harry.longman@patient-access.org.uk

2. Deciding Preparing Detailed planning Staff survey Patient comms Whole team meeting New deal for patients Predicting demand & matching capacity. Patient & staff feedback Launch day Adapting Affirming “Bringing the baby home” New measures help tuning. Adapt to local needs Continuous improvement Yes. Pledge to each other and to patients Launch programme - just 12 weeks to a happier, less stressful practice

3. What do patients think of our service? Administrative staff views – Frustrated at the lack of available appts and the difficulty getting through on the phones. – Not happy about only being able to book on the day...appts go so quickly. – Not happy that they cannot see the doctor they want. – Not happy, having to wait too long for everything! Clinical staff views – I would have always said patients were quite positive about our service but of late...it has changed greatly...from my own perspective...speaking to patients in my own clinic. – Some do understand and use appropriately...but most of the time is inappropriate use of service....

4. My daily work at present – admin views We are at rock bottom. Fed up of being shouted at by patients. Very difficult patients want everything now.... I seem to be fire fighting everyday with constant grumbles from both staff and patients about the appointment system and availability of Drs

5. My daily work at present – clinician views Always busy, never having a full, if any, lunch break. Extra patients squeezed in, never time for admin. Very long days averaging 14 hours most weekdays. Frustrated..... Stress...not enough time in the day...pressure...demand. Too busy to spend full time with patients when required. Everyone is so consumed with their own workloads...difficult to run an effective service. Although enjoy seeing patients...work has become (a) burden. Reduced job satisfaction...not enough time to...manage patients well.

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

7. 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

8. My ideal work Administrative staff views – To be able to help all patients. – To be busy but be able to cope, not stressed out. – To help the surgery run more smoothly and efficiently. – Patients can access the services more appropriately. – A reduction in DNA's. – A happy environment. Clinical staff views – Time to deal with patients properly...remember why we became clinicians. – More team cohesion where everyone feels valued and values everyone else... – Atmosphere happy, less stressful...proud of what our practice is achieving. – Continuity...work for the good of the patient...achieve best outcomes. – Manageable. – More personal development professionally and work life balance. – Start 8.20, finish 6.30...and finish the paperwork.

9. Fear losses if changes are made? Administrative staff views – (Loss of) patient contact...missed diagnosis. – Nothing more to lose! – Access to doctors – Moving away from (being a) friendly GP Practice Clinical staff views – Changes being made far too quickly without adequate time and resources being put in place. – Loss of our reputation for compassionate care amongst our patients. – Spending too much time on phone. – Not opportunistically dealing with...face-to-face advice/continuity. – (Loss of) patient contact. – Service descending into even more chaos. – Worried about the patients who cannot speak English and the patients we want to follow up, how will they fit in the system.

10. A new simpler system Reception takes call GP phones patient Problem solved Come and see GP Admin question Come and see nurse 20% 10% 30% 60%

11. Receptionists’ day Reception takes call Admin question 20% solve 20% book to see nurse 60% list for GP For a patient list of 8,000: 10-12% call per week Monday is 28% of the week 220 – 270 calls, at 2 mins each 7 – 9 hours of calls. Other days 4.5 – 6 hours. NB many more calls will come in the morning, but will spread as a result of good service.

12. GPs’ day GP phones patient Problem solved Come and see GP Come and see nurse 10% 30% 60% For a patient list of 8,000: 6-8% call for GP per week Monday is 28% of the week 130 – 180 calls, other days 80-120 Plan for 40 each per GP per day. 40 x 5 mins, plus 16 x 10 mins Total consulting time 6 hours/day Availability of nurse consultations will reduce this by ≈ 40 mins/day Mornings more phone calls, becoming more face to face late morning and into afternoon.

13. Half the patients calling want a doctor

14. Monday is MUCH busier than other days

15. A spike of demand at 8am, a small one at 4pm? Suggests people are struggling to get in.

16. Most patients do get an appt, but 9% told to call another time – rework means taking the call again

17. One third of patients are walk-ins. This is high, again suggests it’s hard to get through.

18. 79% of patients request a named doctor – very high, and shows how much this matters.

19. Vast majority of patients want to see the doctor today- that’s why they called today.

20. Consultations – more on Mondays, good, but not so many more.

21. 63% of consults are acute or exacerbations, ie best dealt with today.

22. And new/follow up ratio is 63%

23. Very few phone consults at present, 94% f2f, but of the 7 phone consults, 6 resolved.

24. In your view, 24% did not need a face to face - this always changes!

25. Continuity: despite patient views, yours is that it matters only 30% of consultations

26. Language in consultations: although some have difficulties, 88% are native or adequate English

27. Demographics: more children and young parents than average. Rapid response very important to these groups.

28. A practice in the Patient Access community… 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

29. The traditional view of general practice One tiny problem Perfect service

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

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

32. 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?

33. A new simpler system Reception takes call GP phones patient Problem solved Come and see GP Admin question Come and see nurse 20% 10% 30% 60%

34. Consensus Preparation Detailed planning Staff survey Patient comms Whole team meeting New deal for patients Predicting demand & matching capacity. Patient & staff feedback Launch day Routine Review “Bringing the baby home” New measures help tuning. Build confidence Affirmation Yes. Pledge to each other and to patients Launch programme - just 12 weeks to a happier, less stressful practice

35. We are with you every step of the way Dr Kam Singh, “It’s given me a new lease of life”

36. 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

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

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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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