One Practice Journey – The view is getting brighter

It’s been too long since I updated on our off-road journey across unknown territories.

To briefly recap, in early 2013 we jumped off a cliff and hoped for a soft landing.
We removed all barriers obstructing instant access to a GP, and removed the dam which was holding back the floodwaters.  What happened next (over 2013 and 2014)  is well documented in previous blogs, and it hasn’t always been an easy cruise.

But we’ve changed.
We’ve learnt. We’ve moulded. We’ve morphed.
And I think we’re all the better for it.

To get us started and for the first year, we closely followed a strategy developed by a company called Doctor-First (meaning the patient gets to speak to the doctor first, not that the doctors are put first as many like to suggest!). The ethos is simple:  the most senior person (namely the GP) speaks to the patient first, identifies their needs, and directs them in the most appropriate way in order to minimise delays in their care and maximise efficiency. This avoids wasting patients’ and NHS time by giving them inappropriate appointments with the wrong person.

In an ideal scenario, the receptionist would be bypassed altogether and the incoming phones lines would all be directed straight to the desk tops of an army of GPs who would be waiting to deal with them. We didn’t get away with this. Data over the years has shown the patient demand in our Practice to be higher than the local (and National) average and despite 5 incoming phone lines and 5 GPs at the ready, there was no way we could keep up and stem the flow of calls between 8 and 9am. So from early on, we found need to adapt from the purist form of this model. The receptionists took the calls as usual and added them to the GP callback list of the patient’s choice.

For the first 6-12 months the improved satisfaction from  patients (who were all too familiar will being ‘turned away’ through lack of appointments in the previous system) was palpable. Complaints hit an all time low. Everyone was happy.

Before long though, the frustrations started to creep in. There is no doubt that to some extent this was due to a raising of the bar in terms of expectations. Patients could now be guaranteed to see a GP  on the same they rang – regardless of urgency – but they did have to wait anywhere between 5 minutes and 4 hrs for a callback to agree an appointment time, or to get advice. (The wait time was determined by the GP who prioritised the perceived urgency of the callback based on the information provided by the patient to the receptionist).

By the start of the second year, problems started to arise.

We remained a whole-time equivalent GP down and had a few comings and goings within the team (GPs, receptionist and nurse practitioners) making it difficult to keep up with the training required to make the system work.  Being reduced in GP numbers, the volume of call-backs per GP was higher than safe – and totally unmanageable at times of further workforce reduction such as during GP annual leave. On occasions, the daily callback list for an individual GP would reach over 120 patients. At the same time we all recognised our personal fatigue, which kicked in at around 45 patients. Cutting corners, the inability to listen, and risk of burnout became real fears.

GPs were becoming exhausted and the complaints started trickling in again.

The main issues were two-fold – ‘Why can’t I just book an appointment?’  ‘Why do I need to speak to a GP first’ ‘Why do  I have to wait 4 hrs for a callback?’

So we listened. And we adapted.

By now, patients were well aware that ‘telephone advice’ was very much an option for their convenience should they prefer it. It was also clear that they were becoming quite good at knowing when they needed advice, and when they needed an examination.
They were acquiring skills that the previous traditional appointment system had not allowed or required them to develop.

2015 was a good year for us.
In August, we were fortunate to recruit a fantastic, newly trained, full-time GP. She’s a rock. Not only does she buy-in to the whole partnership/collegiality/ vocational career kind of stuff, but she’s an excellent clinician with a head on her mature beyond her years. Such recruits are hard to come by in General Practice.  A few months later, our lucky streak continued when we successfully recruited and appointed not one, not two but THREE amazing Nurse Practitioners. All highly skilled with many years of experience in a variety of fields (including ITU, community matron experience and orthopaedics/MSK to name a few), this tremendous trio seem to have no end to their enthusiasm and dedication, wanting to develop specialist skills and partake in home visits.

Combined with listening to the changing needs of our patients, this new workforce gave us opportunity to make a couple of simultaneous changes.

Firstly, recognising that a new GP needs support and time to get to know their patients (and vice versa) we agreed to establish a two-tier choice system for our patients. This GP, and one other (by choice) would operate a traditional (10 minute) appointment system, as would the Nurse Practitioners (15 minutes). The remaining 3 GPs would continue to offer a telephone advice service – booking patients in for a face-to-face when appropriate, or directing them on to alternative or self-care pathways. Now, on phoning in, the patients would have the choice of booking directly into a traditional (10 minute) appointment slot with one of two GPs  or a (15 minute) Nurse Practitioner slot. Or…they could choose to go on a callback list of one of 3 other GPs. This system allows patients to choose a style and/or clinician who suits their personal preference and still allows for continuity.

Secondly, the workload and GP fatigue needed addressing. The data we had collated over the previous years gave us accurate figures for our daily/weekly demand for appointments. It was clear, than when all GPs were in, 36 callback appointments for each of the triage GPs (plus the traditional appointments of the others)  was more than enough to satisfy our demand and leave some spare capacity in the system. The only time demand rose above this was during periods of annual leave – and became unsafe. We calculated an ‘average’ daily figure per GP based on the information we had, added a little for extra capacity and a bit more (3% ) for year on year increase, and came up with  a magic figure of ’44’.

With this hybrid system in place, the callback list for each GP rarely reaches 44 – we usually have appointments to spare – but early in the day we have the comfort of knowing that we’re protected from going beyond our safety margins. The day ahead doesn’t appear so daunting anymore. Patients are dealt with more swiftly and efficiently by a GP who is still fresh and capable.  It’s not perfect – will it ever be in the current climate of underfunding? – but it’s certainly the best we’ve ever been able to offer. Yes, at times of reduced manpower, a small handful of patients are still asked to call back another day if the problem isn’t urgent, but urgent problems are aways squeezed in with little detriment to the GP. We are also fortunate locally, to be supported by an out-of-hours GP pilot which fires up after 6.30pm (see NHS Star). This is a system of local GPs working together to improve access outside core hours. However, despite governments protestations that the public want this kind of routine access, it has found itself under-utilised and is therefore allowing the appointments to be used as a kind of ‘over-flow’ service, for  GPs to book into during the course of the afternoon if they are experiencing above normal demand levels.
I can count of on one hand the times we have used this a an over-flow facility over the last 6 months, but it’s nice to know it’s there. The deadline stress has been removed.

The GPs doing the ‘callback’ system feel rejuvenated and are enjoying work once more.  We are acting in a true ‘GP Consultant’ role – or in other words, ‘Consultants in General Medical Care’. We advise, direct and educate 60-70% of our patients. Self-limiting conditions are managed by advice. Acute simple problems are seen by the Nurse Practitioners. This leaves longer appointment times for the GPs to see the more needy 30-40% of patients with complex conditions, mental health issues, or red flags. It’s not unusual for most of the patients I see face-to-face to have between 30 and 45mins with me. During which time they may pop in to see the nurse for essential tests and come back to me to discuss the results, or sit next to me while I speak to a local specialist for advice, or to arrange an urgent assessment.
They leave happy having had a complete one-stop service.
I go to bed knowing I haven’t cut corners.

Sad as I am to admit it, this is in stark contrast to much wasted time we have in the NHS.

A few weeks ago I spoke to an elderly patient who proudly advised me that she’d called the paramedics out at 2am that morning for a ‘sweat rash’ on her chest which was interfering with her sleep. The paramedics referred her on to NHS111, who, after a lengthy phone assessment, sent out a visiting nurse to check her. The nurse attended at 5am, confirmed the diagnosis, and advised her to call her GP in the morning to request an appointment to get some cream.  Between 2am and 8am, this patient had had 4 contacts with the NHS, and 5hrs of NHS time. This, for a condition which would have been sorted in a two minute GP consultation.
How have we ever allowed this to happen?

That same day, another lady had suffered with foot pain all day, and decided at 8pm she’d really like to see a GP. She followed the practice procedure for an out-of-hours appointment and called NHS111 in the hope of accessing an evening GP appointment, to which her daughter would gladly transport her.  Again, after a lengthy NHS111 phone assessment, the advisor on the phone determined that it was ‘not safe’ for her to travel to an appointment, but required a blue-light, 999, ambulance. The lady – who felt otherwise well- and her daughter,  protested vehemently to this suggestion, but to no avail. By now it was almost 9.30pm. The paramedics arrived promptly and were ‘delightful and thorough’ and sensibly realised very quickly that this was not a blue-light situation. By 11pm the paramedic assessment, together with paperwork, was complete. The lady was reassured, and advised to see her own GP in the morning for a reassessment.
By next morning, her pain had gone.

This kind of onerous, labour intensive practice is commonplace in the NHS. At the same, all over the UK, GP practices are closing because the funding doesn’t match the demands.  Local doctors have no spare capacity to take on their patients.  As demands and expectations continue to rise, so does stress and burnout amongst clinicians, with no new doctors coming along to replace them.

As patient numbers are rising, so are GP vacancies.

Any individual GP practice can’t supply a system that suits ALL patients. In order to maintain our sanity, we first need to accept this. Doctors tend to be individuals who have spent their life trying to please everyone – their parents, their teachers, and now their patients. They don’t like to provide a less than perfect answer.

Patients and GPs need to make a choice. Just as they might choose which GP to see within a practice for differing skill sets and personalities – they should also be able to choose (or leave!) a practice with an extensive telephone appointment system.
Not all our patients are happy. They never will.  But this is by far the most popular and least complained about system we’ve ever operated. And importantly, the GPs feel it’s sustainable.
Work has never felt happier.
Who knows, we may even make it to retirement.

The system which Doctor-First preaches, is  not rocket science. Anyone can have a go, but we have them to thank for giving us the support and confidence to embark on this journey. We’ve been very fortunate with our superb clinical team and very patient patients (!) but the real heroes here are the reception staff.  They have really turned things around. Discreetly and tactfully, they seek just the right amount of information from each patient, to enable the GP to priorities the call in terms of urgency, but also to help guide and advise the patient who might be the most appropriate clinician for the their needs.  Our skilled reception staff also have a good idea who and what might need a ‘hands-on’ face to face appointment, and which potentially self-limiting problems might be better encouraged to have an advice appointment first. Without them on-board, this system would be a certain failure. Good reception training and support is essential to this system.

It’s been a challenging journey with ever changing topography.  The initial path was cobbled and previously unchartered. Next we stumbled through mountainous landscape with steep inclines and rapid descents. The terrain will continue to change  depending on what is thrown in our path in an attempt to block our progress – but one thing is for sure, we have no desire to retrace our steps and go back.

Who knows what the road ahead will look like, but at the moment we’re just pausing to enjoy the view – and the journey has been worth it. 🙂

 

meanerdingheatherpath.jpg-large

***

Images showing demand data (= patient contacts)
2012  (Pre-change). Traditional system – flat rate appts/month
2013  First year ‘Doctor First’ system
2014  Second year ‘Doctor first’ system
2015   August – development of hybrid two-tier system
2016   Ongoing

We had feared year on year increased demand, but this has not been noted. But we are now comfortably offering far more patient contacts than we did with the traditional linear system.

CMPdemandto2016

CMPdemand BARchart2016

 

 

 

 

 

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All that Glitters is not Gold…

In February 2013, under pressure to provide a more sustainable GP service for both our patients, our staff and our GPs, our Practice embarked on a telephone consulting system which put a senior clinician (GP) as the first point of contact for all patients. The patient together with the GP who knows them best, decide on the most appropriate course of action and the suitable timing of any appointment required. Over the last 2 years, there have been ups and downs, but mostly ups. My previous blogs highlight the journey, and attempt to dispel some of the commonly held myths about such a system.

In addition to my GP work, I work as a GPwSI (GP with Special interest) in Cardiology at the local Acute Trust Rapid Access Chest Pain Clinic (RACPC). This role gives me lots of insight into what is going on, both within the Trust, and across the local GP practices. It’s quite an eye-opener, and indeed a privilege, to see things from both sides of the fence.

I would like to share an all too frequently encountered case scenario with you.

See how many ‘sub-optimals’ you can spot.

Recently, in the RACPC, I saw a lady who had developed on/off niggling left-sided chest pains one afternoon a week earlier. Overnight they had become much more severe and persistent. She waited until 8am the next morning to phone her GP for an appointment.  She tried phoning constantly between 8am and 9.30am but the line was engaged.

By the time she got though, she was told all the appointments for the day had gone. She was advised that if she felt it was ‘an emergency’, she could be offered a call-back from the ‘duty’ GP who would discuss her problem, and agree to see her if necessary.

She waited until late afternoon but no call came. Her resting chest pains were constant and persisting, and her anxiety was increasing, so she took herself to A&E.

At A&E, her cardiovascular system was examined and had an ECG, CXR and blood tests (including Troponins) which were all normal. She was discharged after 12 hours assessment, with a label of ‘possible angina’, and an out-patient referral was made to the RACPC.

I saw her there the following week.

By the time she attended RACPC, her pains had eased considerably, and were barely present. It was noted she had no risk factors for ischaemic heart disease and no exertional symptoms. The pains were usually triggered in bed, or when sitting. They were however exactly mimicked, and reproduced with severity, by palpation of anterior and posterior the chest wall – over the costal margins. (A simple examination which had not been undertaken in A&E).

A diagnosis of chest wall pain was made and she was discharged without further investigation.

This lady went through a protracted process, at a cost to her and to the NHS, for a diagnosis that may well have been made swiftly and accurately by her GP with no need for further investigations, no anxiety-inducing labelling, and no onward referral. But the system was overload and there were no appointments left. She became one of an ‘unknown’ demand volume – those that want to see a GP, but can’t, and are never really logged as potential workload.  I’d also like to bet her GPs weren’t enjoying a relaxed, lazy day and slipping off home promptly at 6.30pm with smiles on their faces…

But, I couldn’t help but feel, that if this lady had been a patient at a GP telephone-consulting Practice (and assuming the ‘999 ambulance’ protocol had not been triggered) she would have been given a priority callback by her usual GP,  and would have had the benefit of immediate and appropriate advice, along with the reassurance of a confirmed appointment slot for later that day; at a time that suited her.

Now A&E are no less and no more stretched than Primary care, but they are naturally more risk averse. As such they are more likely to investigate, and more likely to refer on. This is understandable and probably entirely appropriate, because the statistical likelihood of ‘serious disease’ in any population is immediatley raised the moment they step inside a hospital door.

Some Background figures

Last year, the RCGP estimated, that around 34 million people would fail to get a GP appointment. Estimates suggest, that this year about 1 million more patients will attend A&E because they can’t get a GP appointment.  Over recent years, the historical attendance data at A&E has been mapped by the Kings Fund.

Nationally, there are around 300 million GP consultations a year, and around 20 million A&E consultations. 

So consider this…
1 million more patients attending A&E this year, only represents about 0.3% of our GP workload being unable to get to see us.  To us in GP land, this sounds a very small problem.

But looking at it another way, as GPs are seeing about 15 times more patients than A&E, if 0.3% of of those are unable to get an appointment, then this translates into a very large problem for A&E.

What’s more, GP consultation rates are also on the increase – GPs are undertaking 40 million consultations/year more now than they did in 2010.

In short, the argument stating all patients are going to A&E anyway, so let’s put all the GPs there clearly doesn’t follow.  Quite the contrary. Certainly in core hours (8am-6.30pm) this could have a disastrous outcome.  Co-location of some services (eg out of hours) on the other hand, may be beneficial.

For those interested, there’s more useful stats in these posts:

So – A telephone appointment system is the answer, Yes?
Then why the blog title? 

Well here’s the thing.

A telephone consultation/appointment system is not a cheap cop-out. It’s also not designed for dossers who want to see fewer patients, fob the rest off, and then go home early.  If done properly (and that’s key) it’s hard work and long hours, but delivers a high quality service to the patients, and comes from the one person who knows them best. It’s also a service placed geographically at their convenience, and offers flexible appointment times to suit their lifestyles.  And since cost comes into everything, this has to be more cost-effective than a Secondary care based service, as General Practice is well recognised to be a highly cost-efficient option to our NHS.

It also needs GPs. Which we just don’t have enough of at the moment to make this work. Recruitment and retention of GPs is at an all time low. It seems new doctors are not going into hospital careers either, but many are choosing to work outside the UK, or seeking alternative employment outside the NHS.

On a personal note, since we adopted this way of working just over 2 years ago, our continuity-of-care rates and patient satisfaction surveys have never been higher. Additionally, for those GPs who suit it (and it doesn’t suit every GP)  it provides high GP satisfaction too. BUT – it needs properly funding – or at very least remunerating – for the extra workload burden which is mopped up in Primary care.  The A&E and Walk-In-centre attendance rates in core hours (red line) for our Practice, dropped significantly when we introduced this service in Feb 2013:

WIC attendances - early data         A&Eattendance afterintroDF

On a reassuring note, since we ‘opened the flood-gates’ and abolished the artificial barrier of a restricted number of appointments per week, our demand for GP/NP advice hasn’t risen at alarming rates. In fact – so far as we can see – the early data from early year 3 is looking encouraging.

The chart below maps the total number of our patients requests per week, for either GP or NP input. This is from our list size of 7,500 patients.

Annual demand 2012-2015

What’s more, a predictable pattern of demand seems to be evolving.
Predictability always makes any workload strategies easier manage.

So – All that glitters may not be gold.   But it might still be something precious.  

***

 

Special thanks to John Bye for his help sourcing data for this blog and (as usual) for allowing me to paraphrase him at times.. 😉

One Practice Journey – Light at the end of the Tunnel

Let’s hope it’s not a train…!

“Definition of insanity  – Doing the same thing over and over again and expecting different results”
                                                                                                                                                                   Albert Einstein.

It’s been a deliberately long time since my last update.   I wanted to report some news.

Things have been ticking along quite nicely. On some days, I’ve even thought …This is it…. we’ve cracked it

Not bad considering we’ve spent the last 12 months trying unsuccessfully to recruit another GP (along with the rest of the Nation) and are still working with far fewer GP sessions (and far greater patient list sizes) than we’d really like.

For those new to this blog at end of January 2014, we be celebrated the first anniversary of our new appointment system – where the most senior clinicians take all the calls, and together with the patient, determine the best course of action. GP appointments are no longer booked by the receptionist at the request of the patient, leaving ample appointment availability for those who need them most. (see earlier posts for the background and implementation of this system).

16 months on, and we’re surviving, but the past year has indeed seen some tough challenges.

We welcomed a new GP Partner in January 2013. She left 6 months later.
We welcomed a New Nurse Practitioner in August 2013.  She lasted 3 months.
Finally, a 7 session GP partner handed in his resignation in October 2013 and went on long-term sick leave a month later.  We ended 2013, 14 clinical sessions per week down.  😦

It would be unfair to say that this was any reflection on the new appointment system. The bitter truth is, we’d lost a similar number of key players over recent past years, even with our traditional appointment system. 21st Century NHS General Practice is tough. Expectations and demands on us are high, from all those who have a vested interest in our services – whether they be patients, politicians, secondary care services, solicitors, insurance companies, employers or the media. They each demand a ‘piece’ of our time and expertise, and all have their own agenda and needs.

Things picked up in February 2014 when we were lucky enough to recruit and welcome, a fantastic replacement for our first out-going GP partner of the previous year. We are currently (and at last!) in the interview stages of replacing our second outgoing Partner, and there is a BIG beam of light shining at the end of our tunnel…..(maybe even TWO BIG beams of light….)

So how about the telephone appointment system? Are we still surviving? And how about our patients?

Firstly, I’d like to dispel a few common myths and commonly expressed concerns.

1. The system discriminates against deaf patients or those who are unable to use the telephone.

We have a handful of deaf patients, some of whom rely on sign language or lip-reading, but we have many more who are simply elderly with impaired hearing and find the telephone difficult for any more than a brief conversation.

Our appointment system shouldn’t pose a problem to them at all.

What needs to be emphasised is that this system is a not a replacement for seeing the doctor in a traditional face-to-face appointment.  It’s simply an alternative option for those who want telephone advice for their own convenience.
We already know about many of our hard-of-hearing patients, and their notes are marked a such; others we asked to alert us to this problem.   These patients can just as easily book a face-to-face appointment with their chosen GP as they as they did in the old system – In fact more easily so, as we actually have free appointments available for them every day – all day – unlike the old system when all appointments were taken by 8.10am!

2. The ready availability of GP access over-nurtures our patients, raises their expectations and increases year-on-year demand

One thing that has really surprised me (and appealed) about this way of working, is how much easier it is to encourage self-care or appropriate watchful-waiting over the telephone than it is with the patient sitting next you already with the expectation of a prescription – or some other convenient form of management. Patient education is important and ongoing, with ‘information printouts’ being left to collect, or ‘web-links’ being shared, at least as frequently as prescriptions.  What is also refreshing to see, is just how welcoming patients are to this approach of healthcare.

After completion of our first 12 months, we have been able to start collecting accurate month-by-month comparison data on demand, and will continuing collecting such data year on year. Prior to February 2013 (like most traditional practices) we could only ‘estimate’ demand by how many patients actually managed to get the appointments which were on offer. We now know exactly what our daily demand is, to the dot.

Our “demand” is defined as anyone who needs a GP to make a clinical decision for them. This may be to see and examine them; to consider and advise on their symptoms;  to request for a medication which has not been authorised as a regular repeat for them; to request a sick note, or a letter; or sharing of a blood result or hospital communication. This is true demand of a GPs workload in today’s NHS.

We have only 4 comparison figures so far (Total patient-GP contacts for months of February, March, April and May) but the graph below shows our 2014 demand (red) compared to 2013 (blue).

Annual DF comparisons

 

The a slight fluctuations in April and May tallies with in which month the Easter and Spring bank holidays fell each year.  Apart from that, demand has been pretty static so far.  Given that most GPs would expect to see a slight year on year rise in demand Nationally, maybe this plateau is even more significant than it first appears?

Fingers crossed.  Only time will tell.

3. OK –  but telephone consulting is just ‘bad news’ this is not what ‘being a good GP’ is about….

It is true, we gain a lot of ‘soft knowledge’ from our patients and their families when seeing them face-to-face and one GP recently commented on Dr Jonathan Tomlinson’s “A Better NHS” blog, that a telephone based consultation risks missing those “critical door-handle moments”. The beauty of the system we use is that by allowing much greater use of, and access to, telephone consultations by those who actively ‘want’ them (in our experience around 60-70%) then we free up face-to-face consultations for the rest who really need a face-to-face appointment. Indeed, in our experience, it is this latter group (30-40%) who are more likely to be those ‘door-handle-moment’ patients.

In fact, all we have done is create a ‘distillate of need’ and freed-up more GP time for those that do really need it.

In summary, the job is immensely more satisfying.  Both doctors, staff and patients are happier and more relaxed.
The patients are well versed in self-care – yet know they can see the GP (of their choice) whenever they need.
And all this whilst working at 8 GP-partner sessions down on our of capacity of 1yr ago? Yes, there have been some hard days – but is that really so surprising?

Are we nurturing a rise in our patients’ expectations? Yes, I suspect we are. In any service, the more you exceed expectations, the higher you raise the bar.  Two years ago we had a steady stream of complaints from people complaining they had to wait 3 weeks to get an appointment with the doctor of their choice. Now we get complaints they have to wait up to 3hrs (on a busy day) for that same GP to phone them (to arrange a same-day appointment).  Heigh-ho…
This is something we just have to manage. Complaints, however, are notably fewer.

The other thing to manage is perception of need. There is a fear, in both patients and doctors, of ‘missing something’ if a patient is not seen. This is a complex one. What of the patient with a simple presentation, who went on to have an adverse  – but possibly unrelated – event 48hr later? How will we ever know if the outcome would have been any different if the GP had seen him/her? And would this situation have been easier, or harder, for the patient/family/GP to accept if a GP had seen him/her and potentially ‘missed’ something in a face-to-face consultation? There are so many ‘unknowns’ and emotive factors in this scenario. The default is always to see the patient who wants to be seen, but what if both patient and GP had willingly agreed on the management plan not to be seen?

***

Adopting this type of approach in Primary care is quite a radical change. We have done things the same old way for a long time now. But, as  Dan Rockwell recently wrote – we too often believe that repeating the past will produce more success…But in a changing world, repeating the past makes us irrelevant. The danger of success is repetition. But the opportunity of failure is transformation.

Times are tough out there. Newly trained doctors are not choosing General Practice as a career, experienced GPs are retiring young and yet the workload continues to escalate. Only this week we heard the news that up to 40% of GP training posts now remain unfilled in some areas.  At the same time, the Government – recognising the workforce crisis – are declaring to make General practice the ‘Career of choice’ for at least 50% of new doctors. I wonder how they are planning to achieve this?

The NHS is a cost efficient delivery means for health as demonstrated by this image shared recently through the Executive summary of the by the Commonwealth Fund which shows ranking of healthcare relative to National spend per capita:

 

Commonwealthfind healthcare spend comparisons

 

What’s more – UK General Practice delivers 90% of these NHS contacts, on just 8.4% of the total NHS budget.
The government knows just how efficient UK General Practice is at delivering healthcare.  Just imagine what we could do with even a small amount of additional funding?

Funding would help make the job more attractive, certainly – but let’s make one thing clear – when GPs ask for ‘more funding’ what they are asking for is funding to provide more doctors for their patients. That is, more GPs to allow for a better doctor-patient ratio,  in turn allowing for more time per patient and a better quality of care.   We’re not demanding better incomes  – just more manageable and (most importantly) safer workloads.

The Royal College of General Practitioners’ “Put Patients First campaign” is campaigning for an uplift in funding of just 2.6%, to direct 11% of the NHS budget to Primary care, by 2017. 

Meanwhile, the only thing we can do to make the job more attractive is take back some control. In these difficult circumstances, at least we’re trying to do our best.

What I can’t stress enough is that this system is no substitute for a strong workforce. As we have discovered, it is not a solution for an under- resourced practice who are struggling to recruit and are reluctantly working at well above the National average list size.  But, if you have a full complement of experienced GPs, who work well as a team, know their patients, and who are willing to try and make a better life for themselves and for their patients, then go on…..go for it….give it a go….

Don’t let what you can’t do, stop you from doing what you can.

You know you want to.  🙂

 

Conflict of Interest declaration:
Owing to the success of our Practice’s implementation of this appointment system over the past 12months (and as a result of this public blog) we were approached earlier this year by Productive Primary Care’s “Doctor First” team and ask if we would be happy to become a training/mentor Practice for other GP surgeries who were embarking on this journey. So far we have mentored one such Practice, and were paid to do so by Productive Primary Care.
( No interest in persuading you to take it up though, other than I just feel it works well for us!! :))

 

One Practice Journey – The Winter Months.

“You can never cross the Ocean, unless you have the courage to lose sight of the shore”                                                                                                                                                                                                

                                                                                             Christopher Columbus

Happy New Year Everyone!

Well here we are. The last quarter. The winter months.

Time to reflect on the past year?

We are a very busy, high workload, General Practice, in Middlesbrough. When in full force, we have 4.25 whole-time-equivalent GP Partners serving 7,500 patients.  By the end of 2012, life was becoming too tough for both us, and our patients, and we felt we couldn’t go on.  So we changed.

At end of January 2014, we’ll be celebrating the first anniversary of our new appointment system – where the most senior clinician takes all the calls, and together with the patient, determines best course of action. GP appointments are no longer booked by the receptionist at the request of the patient, leaving ample appointment availability for those who need them most.  (see earlier posts for the background and implementation of this system).

The past year has indeed seen some tough challenges.

We welcomed a new GP Partner 12 months ago. She left in July.
We welcomed a New Nurse Practitioner in August. She lasted 3 months.
We saw our only other, wonderful, full-time Nurse Practitioner go on long-term bereavement leave.
We still have two key receptionists on long-term sick leave.
And finally, after one of our 7 session GPs handed in his resignation in October 2013, he went on long-term sick leave a month later.

We ended the year, once again, 14 clinical sessions per week down. 😦

This looks bad.  An immediate conclusion would be that this system is a disaster.

The truth is, that this turnover is a sad reflection of GP recruitment and retention Nationally, regardless of the systems in place. Looking back at our Practice over the last 10 years, this turnover and sickness record hasn’t changed significantly from previous years.  In fact, one deciding factor in the implementation of this change, was for this very reason, and to make the job more palatable.

Despite all of the challenges we faced this year, one thing came through over and over again….Not one person – be it GP, reception staff or management – at any stage, felt that reverting back to the old system was the answer.  All unanimously agree, that when under this much strain, the old system would not have served patients.  They would simply have been ‘blocked from access’ when appointments were restricted. This in turn would have led to increased complaints and aggression towards an already stressed team.

How have we coped? Have the patients suffered? Have we suffered?

Firstly, we are very grateful to an army of 3, excellent and committed, locums who have worked like Trojans doing regular sessions to help us out. They know who they are – but thank you so much to JB, TD and MP. They have gone over and above the call of duty and will be missed by patients… All except one that is, who we are delighted to welcome as our first replacement GP partner of 2014.  A new beginning. 🙂

Secondly, the reception team – several key players down – have worked their socks off to keep the ship afloat. They have excelled themselves. We take between 100 (Wednesday) and 220 (Monday) patient calls per day requesting clinical advice from either the GP or Nurse Practitioner. The same number of calls again, come in for nurse appointment requests, results, admin or prescription requests. This means between 200  and 500 calls every day, for our receptionists to field.

It goes without saying, that our wonderful Practice Managers, and the Reception Office manager, have had their work cut out too. All have risen, and shone.

It’s fair to say, at the start of the Autumn, morale was low. Workforce was down and we felt we’d been hit from every angle. We decided to chat to every member of the team on a one-to-one basis, simply to hear them out, and seek out their opinions. It was an invaluable exercise. We learnt so much and moved forward very fast.

By early December, spirits were higher than they’d ever been. We had the greatest turnout ever for the Practice Christmas Party – with 35 out of the 36 current working-well staff attending. This was a better turnout than we’ve ever had before, and bears testament to the wonderful solidarity we are currently enjoying. It was a great evening. (Photos on @thecoulbydoctor!)

The  newly set up Practice Twitter feed has also been a helpful resource. Still gaining followers slowly, but so far, nothing but positive. We’ve been able to spread news by word-of-mouth when the phone lines have ‘crashed’ and let us down (on more than one occasion!). We’ve been able to share news, promote self-help, and announce busy and quiet days, so patients can consider their own health consulting needs. We’ve enjoyed lost of positive feedback from patients through the Twitter feed and, so far…. nothing negative. We’ve also had some lovely feedback comments through the NHS choices site.

With such a reduced workforce – How come?

Despite the challenges, we know we have dealt with almost every patient who has needed our help in some way.  We know there are no ‘hidden masses’ who simply can’t get an appointment. The new appointment system makes it very easy to collect data on patient needs and workload demands. Despite considerable GP shortages, we have endeavoured to meet these demands, at the same time, educating and promoting self-help and self-care where appropriate.

On only three days in the last 12 months, when GP workforce was so reduced, and demand so high, did we have to make a professional duty-of-care judgement call, for patients safety. On these 3 days, our individual GP call-back lists we so high by late afternoon, we had to close the list, and with great reluctance, divert patients who called after 4pm, to walk-in-centres. We don’t take this decision lightly – it’s a rare occurrence, but on these days we were working until long past 8pm just trying to ‘mop-up’ the patients who had called throughout the day. GP fatigue and safe decision-making had to take precedence over access.

Early graphical data shows the change in pattern, in our patient ‘in-hours’ usage of Walk-In Centres and A&E soon after implementing our new system in February 2013 (our Practice denoted in red) :

A&Eattendance afterintroDF

WIC attendances - early data

The data is worked out in 6 month moving average – so basically the data is recorded as 100 in February, for the average previous 6 months data.  So, March, for example,  will be the last 6 months average data which will include 1 month working with Doctor First and 5 month of work on the previous system and so on for each following month.  This is so that we can see a trend from introducing Doctor First and after 6 months (Sept).

Walk-in Centre attendances have reduced both in hours, and OOHs.
A&E during surgery hours have also declined.

Our initial decline in share of walk-in/A&E is significant. We have about 4.7% of the Middlesbrough population and only have about 2.9% of the A&E/walk-ins during surgery hours.

These were “early day” graphs. A preliminary look at the more recent data, suggests this effect may have flattened out, but we need to graph it and take a closer look. I hope to have the complete 12 month data available to share within the next few weeks.  Regardless of outcome, this is certainly not our prime aim of the system. Our aim is to provide all our patients with appropriate and timely care, or advice, when they need it. Simultaneously, reducing GP stress, by becoming more in control of our own workload.

As intimated above, the phone system (provided free by the previous PCT) has let us down enormously on more than one occasion. When overloaded with incoming calls, it has simply crashed. This has been the biggest frustration for patients, and the only aspect which has given rise to a handful of complaints (interestingly, still nothing like the influx we were getting about the old traditional appointment system!). This the main aspect we need to address in 2014. Quotes for a new state-of-art phone system to manage the demand of incoming calls, are upwards of £10,000, and simply not a viable option in the current financial climate.
Moving to mobile networks seems to be a possible answer for reducing costs of outgoing calls.

Most patients get seen when they want, by whom they want. People should not – and are not – complaining that they want to be ‘seen’ rather than telephone advice, because they always get the choice. Those few that really need to pre-book, can.

We have another hard month ahead, then in February, we partially fill our workforce shortfall, when we welcome abroad a great new Partner who has already embraced the new system as a regular locum.  Processes are well underway to recruit another 6 session replacement partner early this year, and despite the current recruitment crisis in General Practice, we have a hopeful in the pipeline. (All fingers crossed).

Anecdotally, at least, I’m hopeful that demand is slowly falling.
If so, this will be a great achievement, and a welcome reward for the hard effort we have put in to patient education over the past year. Also, hopefully people are doing less “panic shopping” as they know they will have access whenever they need it. Certainly, this December didn’t seem as busy as last year, bearing in mind how many clinical sessions down we were. Come February, we will have month-by-month comparative demand data to compare with the same day of any given week in the previous year.
This, together with patient satisfaction, will be our ultimate measure of success.

The team is finally coming together and going from strength to strength.
Morale is at an all time high. The patients are happy. And despite what criticism The Government and media throw at us, the doctors once more, have time to talk – and laugh – together.

We’re glad we were brave enough to lose sight of the shore.     🙂

  IMG_20131213_2137392014 Here we come!

Dr Cathy Williamson, Dr David Bannar-Martin, Me, Dr John Bye and Dr Rachel McMahon

One Practice Journey – Autumn

“We’re all in the gutter, but some of us are looking at the stars”
                                                                                                Oscar Wilde.

We’re not there yet. But we’re getting closer.

The summer saw all the usual strains that accompany a reduced workforce. Thankfully, we also saw the usual summer decline in demand, of around 20%. After 6months of the new system, we see this as a small success. Many early reports, from other’s experiences, had warned us of an ever-increasing demand, even in these early months.

Patients are getting more GP continuity. In fact, if not spontaneously volunteered, patients are being actively encouraged by our receptionists, to request the same GP for ‘ongoing’ problems.  A specific request to change GP mid-treatment is also respected. Continuity like this, has to be better for individuals, and for immediate as well as long term outcomes.

‘Overspill’ outcome data is, so far, very encouraging.  In the early months of the pilot we were able to demonstrate a considerable fall in both walk-in-centre and A&E attendances during normal surgery hours. An ongoing project is in place, looking to see if this fall is being sustained, and also to compare it against local ‘control’ Practices over the same time frame.

But at what cost is all this achieved?

At present all the GPs have invested considerable time and money into this system. Increased phone costs are measurable, and as currently unfunded, will come from back pockets. Despite this, GP hours are as long as ever – even slightly longer as we still learn to tweak, and perfect, the system.

Time to call the patient back is still too long in our Practice. This needs to improve. We’d like to get this down to under an hour – let alone under 20mins which was quoted as the ‘average’ when the system was promoted to us! The earlier a patient calls in the day, the faster their callback time, but as the call-back list mounts, the delay increases. I’m ashamed to say that by midday, it’s not unusual for my own patients to be waiting several hours for a call-back.
But, they will get one.
And it will be me.
And they know I will be see them if necessary.

So why persevere?

I’m more convinced than ever this system is the way forward. I firmly believe it’s right for patients. The right patients are getting more of the doctors time. More thorough consultations for complex issues, mean less return visits and more holistic care.

Patients who prefer the convenience of a telephone appointment, generate more time for those who don’t. Complaints about the system are few. Compliments are frequent and flowing.

The GPs see around 40% of patients who telephone for advice or appointments. The Nurse Practitioners (by very nature of their patient populations, see around 75% of theirs).  Initially, patient perception can be of bad care if they are not seen face-to-face. This dwindles with time and patient experience.

Preliminary patient feedback survey can be viewed here: Dr First Coulby patient feedback.

12 Local Practices who are piloting this system recently met up, and all agreed the following list of advantages to GPs:

  • Much more flexibility in the day and find it easy to block time off later in the day if needed to respond to daily workload.
  • GP’s prefer knowing why patients are attending (ie having had a brief chat beforehand) for face-to-face and allows for future pacing and preparation of consultations.
  • It is now easier to coordinate care with nurses.
  • No more busy duty doctor days and a feeling of sharing the load equally amongst all staff.
  • Not running late anymore.
  • Flexibility to give later appointments in the day to meet patient choice. Less requirement for extended hours.
  • DNA rate fallen to almost zero.
  • Building much quieter especially in a morning.
  • Can deal with many conditions, and reviews, over the phone.

Data Crunching.

We have a list size of 7,300 patients.
Generally, a practice can expect 10% of their list size to call for advice/appointment in any one week.
So we should be prepared to provide/manage around 730 appointment requests each week. These will be divided fairly evenly across the week but slightly weighted on a Monday.

Over the past 6 months our data has been pretty consistent. With weekly contacts approaching 750 some weeks of February/March, but as low as 590 in peak summer.  This is expected summer decline.
September has seen an average of 650 contacts per week once again. Better than might be expected if the system was encouraging health dependent behaviour? But it’s early days.

Our Monday contacts, average around 170-220, with 100-130 each of the remaining 4 days.  All we need to do is distribute the doctors across the week accordingly. This makes rota planning, and annual leave cover, easy to predict and prepare for, where possible.

At the end of the day it all comes down to numbers. Like traditional systems, it works well when well staffed. Lose a key player, through sickness or annual leave, and the system breaks down. The number of patients needing to be seen each day reach levels where safety issues – for all parties – have to be considered.  I’m not yet convinced that this system is any better at such times. But I am convinced, that for some doctors at least, being more in control of your workload, and day planning, gives rise to reduced stress levels, even if the length of your working day is no shorter.

It’s not for everyone. We’ve had two GPs resign this year. Whilst it might be easy (and tempting) to blame the new system, we have to remember, we lost 3 good GPs in the previous 18 months, under the old system. It was their departures that drove us to reflect on our workload, our stress levels, and the needs of our patients.  Poorly met GP and patient needs, low staff morale, and patient dissatisfaction were the very catalysts that drove the change in the first place.

The driving forces behind retention of GP partners in the current NHS climate are complex issues.

The future?

As the winter demand starts to kick in, the truth behind the system will slowly unfold. If  our patient-education, self-help directives and reduced ‘return’ appointments over the last 6months have paid off, we should soon start to see more manageable list sizes.  This will be the real measure of the system. We remain hopeful.

The alternative?

Well, we can offer an 8-8 or 24hr supermarket-style ‘convenience’ service by working 12 hr shifts, spread the workforce we have, lose the GP-patient relationship, and forego all continuity of care…

I hope for everyone’s sake it never comes to that.

We can work until 8pm. We can work until 10pm. We can work for 24hrs. We can give more advice by telephone. But without any more doctors, we can’t safely deal with any more patients than we do now.

Working intelligently and efficiently is one thing, and we will continue to do so help our patients, and minimise our own stresses.  But we still need more resources, and proper funding, to do the job, and the patients, justice.

One Practice Journey – 6 months on and still standing…

“If you are going through Hell, keep going”        –      Winston Churchill.

Well here we are, 6months down, and still alive.

In  February 2013 we embarked on a new kind of appointment system. To find out more about this system and how we implemented it, please refer to my previous blogs, “One Practice’s Journey – Starting Out” and “Month 5 – June has been hard”.

In July, GP pre-booked annual leave began to kick in. On a backdrop of Nurse Practitioner sick leave, and whilst still awaiting the start date for our new Nurse Practitioner, this was another challenging month.

The weather has been kind to us though, demand has been notably declining over the last 6 months (and no, they don’t all appear to be deserting on mass…!).  I suspect this is down to seasonal variation, but that said, previous summers have always seemed busier. It is possible that all the credit goes to to the new way of working, but I remain skeptical, and think the sun might just have played a small role.

The system is evolving daily and, even despite our ongoing workforce shortages, is becoming more manageable.  We have learnt a lot over the past 6 months. We have uncovered several things that don’t work, but thankfully, have discovered others that do. We have brought the “routine for today” request forward, to a 3pm cut-off, to allow better end of day planning.

“I have not failed. I have just found 10,000 ways that won’t work”

                                                                              –    Thomas A. Edison.

In an attempt to ensure even distribution of workload, GP lists are evened out by the receptionists judgement once any GP gets to an agreed number of callbacks (currently 25). Patients who specifically request a particular GP for continuity reasons, are still accommodated, but those who don’t express a preference are given are more limited choice of GPs to keep lists balanced.

Interestingly, and contrary to popular belief, Dr Popular, and Dr Unpopular, does vary from day to day!

Our recent patient feedback survey was very encouraging. Very few patients expressed dissatisfaction with the new system. Many more, volunteer their delight, on a daily basis.   Over 90% of patients expressed ‘overall satisfaction’ with appointment outcome, and over 90% stated they liked the idea of being able to consult over the phone.
(Just over 80% even reported the receptionists to be ‘courteous and helpful’ ! 😉 )

Whilst this survey shows a huge leap in satisfaction from our previous survey, for it to be really useful, we need to do some more detailed ‘before and after’ comparative analysis, which I hope to share, once available.

Ups…

  • Agreeing appointment times, and durations, with the patient, which are appropriate to their problem needs.
  • Knowing what problem is coming through the door – allowing better planning, preparing a package of care, and structuring the appointment.
  • Patient education and self-care.  Directing people to over-the-counter or self help remedies is surprisingly so much easier when they are on the phone and sitting, remotely, in an office or workplace that is closer to a chemist/shop than it is to the surgery. Despite best intentions, it is all too easy to issue a prescription when they are already sitting next to you.  My telephone consultations often end with “I’ll tell you what, I’ll leave you a printout with some more information”.  This feels a positive outcome, which is clearly appreciated by many. Improved time efficiency allows for this. (Waiting for a printer to slowly churn out a 6+ page printout, from Web Mentor or Patient.UK, was always a painful experience in a pressurised 10min appointment slot!)
  • Our workload has never been so clearly visible.  The callback lists we keep are an accurate reflection of demand. All messages and patient contacts are now logged – whether a face-to-face is generated, or whether we are just phoning a patient about an abnormal blood test result. There is no hidden clinical workload.
  • Equity of workload – all GPs share the benefits of a quiet day, or the demands of a busy day, with absolute equality. No more horrendous ‘duty’ days for any single partner.
  • On the whole GPs, and patients, are more relaxed.  Despite the workload, GPs are more in control and have more time for casual banter together throughout the day.
  • Patient Satisfaction has improved enormously when compared to the old system.  Dr First Coulby patient feedback.  A handful of patients, however, express preference for the old system. These views are usually expressed by patients who are not comfortable with phone use, and we need to help them understand, that as long as they identify themselves to us, we can exempt them from this system.

…And downs

  • Weight gain and backache. I’m no longer getting out of my chair every 10minutes to greet a patient in the waiting room…. Note to self: Need to buy a treadmill.
  • GPs have become slightly more confined to their rooms. Less frequent visits to the reception office may feel unsupportive to the team. We have always been very visible in the past.
  • Room isolation is a potential danger. As our ‘callback’ list is continuously increasing, we must make that extra effort to take-a-break and meet for coffee etc. It is all too easy to allow the day to be a continuous flow of work if we don’t discipline ourselves.
  • Costs. Here’s a biggy. Our phone bill, as you might expect, has risen considerably. We are currently negotiating a new contact with an alternative provider which may mitigate things substantially, but it remains to be seen if any benefits in profit will be offset against this.
  • Divided team. ‘Divided’ may be a bit harsh. We are, now, a 5 GP partner team with 2 Nurse Practitioners (one yet to start). 3 of the the Partners, and our existing NP, love the system and find it very rewarding. A 4th Partner whilst still very keen, feels they need to work at it to suit their style of consulting. The 5th partner is still not keen on the system at all.  I can see this disparity will be one of the greatest ongoing challenges for our team over the next 6 months. Despite this however, we are unanimous on one thing – that we couldn’t contemplate a return to the old system. A better alternative has yet to present itself.

Number crunching
National statistics apparently suggest that you can expect 1% of your patient list size to contact you in any week. Our weekly demand is currently between 0.8 and 0.9% which is encouraging. This allows for a slight rise in the winter months and we should still be within average. (In february, when we started , our weekly demand was around the 1% mark). The next 6 months will be critical in determining the longevity and success of this system.

As things stand, with all appointment requests going through a GP or NP, I feel we are addressing patient needs, not wants.
However, if demand continued rise, over and above National patterns, then we would have to question if we are purely feeding an addiction.

The Bigger Picture

Over the next 12 months, we intend to analyse longer term patterns on prescribing data (especially antibiotics and over-the-counter preparations), complaints (clinical and non-clinical), QOF achievements,  referral patterns and any quality or disease outcomes on which we can collect data.

In order to make these results more meaningful and statistical, we hope to collate such data from all of the 8 of the Practices within our CCG who have now embarked on this system. We already have some encouraging preliminary data on WIC and OOHs attendances, but we must ensure that we are not simply burdening ourselves with the workload of others, at our own cost. Education and a subsequent control in demand in pivotal. Make or break, this is quite an exciting an innovative project, of which I am proud to be a part.

To summarise, I quote (and from more than one patient this month):

“Thank you so much, Doctor – no GP has ever explained all that to me before.”
That GP is me. I haven’t changed, but I do have more time.

But for now, role on August, and the red wine & cheese of The Dordogne.
My turn.   🙂

 

One Practice Journey…Month 5

“Accept the things you cannot change, and change the things you can”
       –  Reinhold Niebuhr

No one can argue that current ‘demand’ in the NHS is high.
We can argue until the cows come home, as to why, or who/what is responsible for this ever increasing demand.  But unless we think we can alter this demand in the immediate foreseeable future, maybe – just maybe – we should start thinking about how we can manage it.

What if it is time to adapt?

In  February 2013 we embarked on a new kind of appointment system. To find out more about this system and how we implemented it, please refer to the previous blog, “One Practice’s Journey – Starting Out”

******

June  Update.

I can’t deny it it.  June has been hard.
Keeping colleagues on board along the way has been challenging at times.

Why?

If you read the last blog about our first 4 months with Doctor First, you will know that we our newest GP partner left, at the end of May.

Seven clinical sessions down.

Having been left with 3.25 WTE partners, one of the 3/4 time partners decided to up their sessions to full time. This replaced  2 of the 7 sessions lost.

Five clinical sessions down.

We tried to keep upbeat. We needed to review our current situation and consider how best to develop the practice from here on in.  By now it was becoming apparent, that in contrast to our previous system, the appointments of which we were most short were Nurse Practitioner, not GP,  appointments.  After a lot of discussion and careful planning, we decided we needed to re-cut our cloth accordingly.  We unanimously decided that the best way forward for the both the patients and the team, was to replace these 5 GP session, with an 8 session Nurse Practitioner. It’s important to stress here, that this was not a financial decision. Replacing our 7 session GP with 2 GP + 8 NP sessions was a small additional financial hit, but for a variety of reasons, we felt it was worth it.

So far so good. Then the crisis hit.

Within 2 weeks of our GP partner leaving, and whilst all the above decisions were still on the table, our full-time Nurse Practitioner went on long term bereavement leave.

13 Clinical sessions down. Pow.

This is where Doctor First really struggles. The daily demand remains static and predictable, but the problems arise when the capacity to meet that demand is unexpectedly reduced. We can plan ahead for anticipated leave, by swapping sessions around and pre-loading the high demand days, but as soon as you add a bit of sick leave to annual leave, the problems start.

A Practice Manager from a neighbouring Doctor First Practice summed it up nicely:

I think it’s fair to say that when we have had a tough day, it tends not to be demand that has been the problem (as that remains fairly predictable) but supply – ie the absence of a doctor or two. One’s knee jerk reaction is always to blame demand but very very rarely has it been even 20 calls more than we would have expected.

For the past 4 weeks, there have been 2, or occasionally 3, GP’s in most days, sharing the workload of 5.  Locums would have been a welcome solution, but unfortunately, very few were available. We’ve patched up where we could with a few locum sessions dotted here and there, but the vast majority of days each GP was dealing with 50-70 calls. The days would start at 8.00am (or earlier).  Finishing by 7pm was a luxury. Many days went on until 8pm, or much later.

But, that said, the work did get done. All the patients who called were dealt with, and in fairness, I think any system would have been tested in these circumstances.

The Doctors

It has been very tempting to blame the enormous workload we have faced in the last 4 weeks, on the Doctor First system, but the truth is, we believe we have survived better than we would have done int he old system. Granted, by restricting the number of appointments to 18 per GP surgery, would have offered some GP protection – but at what cost? The phone lines would have been blocked, patients would have been turned away, and those too unwell to argue, or fight the system, would have been left to get worse.  The receptionists would be on the frontline of the wrath, fielding complaints and aggression resulting from the frustration. Instead, we had long and tiring days – but still left work feeling content and satisfied, knowing the work was complete and no sick patients had slipped through the net.

GP fatigue, however, has to be considered. Is the safety of both the GP and the patient compromised by this system?
I’m reminded of a Tweet made by Clare Gerada, Chair of the Royal College of General Practitioners, in the midst of this crisis:

Clare gerada tweet-2

I value Clare’s point, and she is undoubtedly right – and for all the right reasons – but whilst this might be music to the ears of an overly tired clinician at 5.30pm, when the 60th patient of the day calls, it’s a very difficult shout to direct that needy patient elsewhere.  Especially when they, their problems, and their family are so well known to you. Additionally, The GMC have no interest in the 59 delighted patients you deal with every day, but only the one who was turned away or brushed over through fatigue, on that one day. And, as we all know, the additional workload and emotions that ensue from a formal complaint, are far in excess of the 10 minutes it would have taken to see that patient and give them a proper service.
A vicious cycle is produced, as this unwelcome and additional workload, then takes your precious time and attention away from the rest of your patients, who need your focus.

Access versus quality is a very complex issue.

Capping Workload?

Other Practices I have spoken to have devised various complicated “capping” systems to deal with this kind of demand problem. I can see why this might be tempting, to overcome a short term supply problem, but such a system is no longer a demand driven service. Surely the telephone backlog is only be pushed on to another day…..just like the traditional appointment system, and so history repeats itself. Hey Presto – one problem has simply been replaced by another.

One local Practice did trial a ‘capping’ system in the early months of Doctor First, but soon gave-up. One of the GP’s told me it was “disastrous”. I do hope she will add a comment on the blog and share this experience with us.

One adaptation that we have put in place, is a request to patients that if they want to be seen the same day for a routine problem, they need to call before 3pm. New onset, or urgent problems will of course be dealt with up to 6pm. This seems to be working well.

Reception Team

Ok. So let’s be honest. They’re not happy either at the moment. The honeymoon period feels a bit like it’s over, for everyone! The reception staff feel they are buckling under the workload. We need to address this. I can’t help but wonder, if the GP’s have unwittingly transferred their workload stresses of the past 4 weeks to the reception team.  I certainly think I have been short with them at times and questioning of their distribution of calls. (Remember, patients are given the choice of who they see, but if no preference is stated, we have asked the reception staff to distribute calls in a fashion which keeps the doctors lists balanced). When you are working under pressure, it is human nature to think you are working harder than everyone else! Perhaps we have taken this out, unfairly, on our receptionists. However, there may be other reasons for their disharmony, which will need investigating.

The Patients

We have already have lots of very encouraging feedback from patients. Initially, most gripes revolved around understanding the system, and once explained, were resolved.
Obviously, the reduction in GP manpower and subsequent large callback lists has meant that patients ringing after 10am can be waiting up to 3hrs – or more – for a callback. Some callbacks are in excess of 4 hrs. Again, we need to keep reassuring them that they will still get seen if necessary.

In our old system, nearly all complaints received centred around the appointment/telephone system. These have subsided to almost nothing, but we have instead seen a very small number of clinical complaints. It’s early days, and I’m aware the recent weeks have been challenging, but if this pattern was to continue, then it is not  a compromise we will allow to happen.

Our post-implementation patient feedback survey was completed last week and the results will be available soon. We await them with anxious anticipation.

And so…

All in all, it’s been a challenging month. Lots of meetings, heated discussions and vented frustrations, along with very tolerant families waiting for us at home, have been essential to see us through.
However, there is some light at the end of the tunnel. We have been fortunate enough to appoint a second highly motivated and very competent, skilled Nurse Practitioner who can start in the not-too-distant future. Our wonderful, long-standing Nurse Practitioner may also be returning sooner than expected.

Today is the 1st July. And it’s a Monday. Each of the four GPs in dealt with around 40 patients. By 5pm I had managed all my patients and by 6.15pm completed all outstanding paperwork.
Just imagine if we’d had a full team in – with another two clinicians to share this work?

Demand does appear to be diminishing slowly week on week. I hope this is a reflection of ongoing patient education, and reassurance in a system that really does work for them.

Without doubt, June has been hard,  but I have my suspicions, that with another 13 clinician sessions each week, we would have been laughing.

The future is looking brighter once again.   🙂

One Practice Journey – Starting out…..

Doctor First Appointment system – A 21st century Solution?

“Accept the things you cannot change, and change the things you can”
       –  Reinhold Niebuhr

No one can argue that current ‘demand’ in the NHS is high.
We can argue until the cows come home, as to why, or who/what is responsible for this ever increasing demand.  But unless we think we can alter this demand in the immediate foreseeable future, maybe – just maybe – we should start thinking about how we can manage it.

What if it is time to adapt?

For more than 60 years now – long before the birth of the NHS – General Practitioners have been offering the same traditional style of service: Patient decides on need to see doctor. GP offers a time to be seen. GP sees patient. 
This has always been considered the gold standard, the very essence of the much coveted doctor-patient relationship, in UK primary care. 
But it is reasonable that this traditional style hasn’t really evolved with an ever changing 21st century National Health Service? Are we clinging on to the past too much?

“All great changes are preceeded by chaos”   –  Deepak Chopra

In February 2013 our NHS GP surgery embarked on a new kind of appointment system known as “Doctor First”.

I can only write about my personal experience, the highs and lows. It is my own views which I express, and not necessarily those of my partners. Other practices may have very different experiences.  I will try and update this blog monthly, to let you know how things are progressing, and if we are surviving! (The updates will be much shorter. Honest)

There are several similar systems to this being implemented Nationally, ‘Doctor First’ is just the brand-name of one such system.  Others I know of, which work in a similar vein, are ‘Patient Access’ and ‘The Stour Surgery System’.
  I’m sure there are more, but as I have no experiences of these other systems, I cannot comment on the similarities, or differences, between them.

It’s only early days for us, and we have a lot to still work out, but I’ll try and précis the gist so far.

How we got here:

We are a very busy sub-urban Practice, on the outskirts of Middlesbrough, with 4.25 whole-time equivalent GP’s, covering a list size of 7,300 patients. We have one Nurse Practitioner, and no salaried GP’s.

Over the 20yrs that I’ve been in the Practice, we have changed the appointment system dozens of times. We have desperately tried anything suggested in a quest to find a system that works for both patients, and doctors. We never have.

As a team, we are devoted to our patients. Sadly, this is not always obvious to them, as our appointment system has too often let us down.
We have always been convinced that we have extremely high patient demand. We now have the data to confirm this belief.  
Over the last 15yrs, we have lost 10 GP partners. Four of these were as a direct result of work stress, two left through physical illness, and four were enlightened enough to get out before the workload had chance to get them down! This high GP turnover has only served to compound our workload problems.

Previous appointment system:

Our most recent previous appointment system offered a mixture of same day ‘routine’ appointments, 48hr to 2 week ‘book-ahead’ appointments, and a ‘duty’ GP with reserved appointments every day, to see same day ‘urgent’ requests.
No patient, with a problem they reported as urgent, was ever turned away. We have always had a very low patient attendance rate at A&E or Walk-in-Centres.

What we did have, was patients who were very unhappy with the system. The usual 8am phone jam was a huge source of stress to them, and our receptionists. Many patients couldn’t get through, and gave up. Too often we never even knew who they were. Many were told that all ‘routine’ appointments were taken, and requested to ‘try again tomorrow’. The complaints about the system were high. The receptionists, who took the verbal abuse on the frontline, had very low morale.

We had no choice but to do something different. We had very little to lose.

I can’t pretend it wasn’t scary. We were terrified. 
It took an enormous leap of faith. To take down all barriers? To allow every patient to choose who, when, and how they are dealt with? To agree to see everyone of the day they call? 
Were we totally mad?

The First Steps:

After 4months of training, planning and education of staff by the Doctor First team, we eventually felt ready, and went ‘live’ on 1st February 2013.

The first stage of the Doctor First system is called ‘Clearing the backlog’.  This is to ensure, that at the point of ‘going live’, there is no outstanding, hidden demand, in the form of frustrated patients waiting to be seen.

This stage was pretty easy for us. Our advanced booked appointments were a maximum of 2 weeks ahead, so we had to stop advance booking of appointments for 2 weeks before D-day. Then we had to see everyone who rang in and requested an appointment, in order to clear any outstanding demand.
For these two weeks, all partners worked pro-rata 10 sessions (FTE) and we brought in 4 locum sessions each week, to help.
It was the easiest two weeks of my career. We were so over-doctored!

‘Doctor First’ – How it works:

All nurse and phlebotomy appointments go through a receptionist booking procedure as usual. Any patient who phones requesting ‘GP advice’, or a ‘GP appointment’ goes through the DF system.

The basic principal of DF is that the most senior clinician is the first point of patient contact. It is important to stress here, that the system works entirely on the patient’s choice – with regard to who they see, how they see them, and when they see them. They really have very little to complain about now!  Basically we endeavor to give them whatever they ask for.  Sounds crazy, and very alarming, but there is some intuitive logic to it, as I’ll go on to explain later.

At very least, they get instant (almost) access to a GP for advice.  This has an immediately calming/reassuring effect. Early on in the patient’s journey, they have already reached the person they most wanted to talk to, and this achieves an early sense of security.

Any patient phoning requesting medical input of any kind, gets same message: “Of course. Which doctor would you like to see?”
  For continuity, if they have previously been seen for the same problem, they are encouraged to see the same doctor, or Nurse Practitioner again, UNLESS of course, they prefer not to due to dissatisfaction for example.

They are then asked for a contact number, so that the doctor can prioritise, and deal with the most needy, quickly and efficiently. They are also asked if there are any times in the day which would not be convenient for the doctor to call them back. They are told not too worry if it takes time for the GP to call back, as they are guaranteed to be seen that day if they want.

When we call back we ask about the problem, and if appropriate give brief advice, before asking what time they’d prefer to come down. By this stage, 60-70% have already decided they don’t need to come down – they are happy with advice, a sick note or a prescription. Others are directed to alternative community healthcare services. At the end of the telephone chat, if – and only if – both the GP and the patient, are equally happy, and in agreement that they don’t need to be seen, then, end of.

We listen out for non-verbal telephone-cues suggestive of ‘red flag’ signs – pauses, hesitancy in agreeing to telephone advice, apparent lack of confidence in the advice, or a slight pause when asked at the end if they are happy with the advice.  Any of these signs – or if they ask to be seen – they then get offered a same day appt. No questions. They are offered an appointment later that day, at a time which suits them. Our appointment availability is such that they can nearly always pick and choose a slot time.

The call has to end with both the patient and GP entirely comfortable with the situation.  This is fundamental to the success of the system.

If an appointment is required, we encourage them to come down and be seen same day, but if they prefer another day, we ask them to phone back on the day they want. They can remind us we’ve already discussed the problem and we’ll agree a mutually convenient time on that day. This method allows for unexpected eventualities cropping up in their lives, or that of the GP, thus avoiding DNA’s and cancellations.  The same applies if they want to come down another day after work/ day off etc. We agree the time on the day.

If they really want/need to prebook a specific time – we let them. But this is surprisingly rare in our experience so far!

Advantages and Disadvantages.
For ease, I will break these down into Patient, Doctor and Receptionist advantages and disadvantages, but you will see there is much overlap – and advantages can also be disadvantages and vice versa!

Advantages:

The advantages for the patients are fairly obvious. They get appointments (or advice) fast, and at their convenience. They get continuity of care. If they are complex or ill, they get more time with the GP, and so a more holistic package.

If they are working, or have children’s school commitments, we can agree to see them before school finishes, or after work in the early evenings. We try to be pretty flexible, within reason.

On a daily basis, we get comments “thanks for seeing me/dealing with me so quickly”. The feedback so far is very encouraging.

The advantages for the GP’s are that we are more in control of our workload. We can book the right people in for the right slots. We can work more flexible hours (no such thing as an am/pm surgery any more) and can fit the appts in around visits/paperwork/meetings/coffee breaks etc.  We are seeing far less patients face-to-face,  but at least we know we are seeing the needy ones. As a result we can give them much more time and deliver much better quality medicine.  Each GP ‘sees’, around 10-12 patients in a day since we introduced this new system. Many are children who just need a 3-minute safety-net consultation, the rest are the complex patients, with potential red flag symptoms. The latter can be spaced at 30-40minute intervals so we have ample time to take a really thorough history, examine, dictate a referral, speak to the local hospital consultant, or whatever is required, all whilst the patient is still sitting next to us. A package of care is agreed, hospital advice or clinic reviews are arranged, and all in one sitting. It’s wonderful. I have spoken to more consultants on the phone in the last 4 months, than I have been able to do in years. The tailored packages of care that result from this, are a refreshing breakthrough.

It’s also much easier seeing/speaking to patients who have requested you by name – these patients, or their problems, are already well known to you. They already trust and have confidence in you. Consequently, they are more prepared to accept telephone advice, and in turn, if the GP knows the patient well enough to be aware of their limitations, he/she is more comfortable giving that advice.

The advantage to the receptionists is that they have no more confrontational battles. Within a couple of months of the new system, we saw a complete transformation of the receptionists. They became again, the happy, smiley people we had once employed, now relaxed and released from the wrath of complaining, and understandably frustrated, patients.
 Sadly, this rosy glow was not to last long as other issues arose.

However, their roles are now released freed-up time to do more administrative work/QOF data trawling, and thus allowing the GP’s to stick to being ‘clinicians’.

Disadvantages:

To the patient.  Not many. At the time of writing, we are 4 months into the system, and we have no formal/major complaints yet.  (We were use to dozens a day in the previous system, complaining about the phone lines, or that they couldn’t get an appointment).  Most of the patient chatter in reception is very positive and encouraging.

Theoretically some similar systems have apparently given rise to patients complaining they never get to actually ‘see’ the doctor. As mentioned above, if they want to be seen, that’s an indication to see them.

We’ve had a handful expressing minor concern at how long they’ve had to wait for the doctor call back on occasions. We hope in time, when they are more confident in system, this will be less of an issue.

One patient has mentioned that they ‘do not like answering the telephone’, but these sorts of issues can be discussed and resolved on an individual basis.

Contrary to the beliefs of some, Doctor First doesn’t discriminate against people who are not good on the phone, for whatever reason. These patients will be identified by themselves, or by the GP, and will simply get offered, or choose, a face-to-face appointment.  However, it is true that the success of the system does indeed depend on having a majority of patients who are happy with telephone consultations. I can imagine this would present inherent problems in a Practice with a high population of non-English speaking patients.

The disadvantages to the GP.
  It IS hard work. For the GP’s, the work is undeniably intense.

By lunchtime, my eyes are sore from staring at the PC EPR/appts screen.

Whilst the mornings are hard, the afternoons usually lighten up.
Doctor First Data repeatedly shows that 2/3 of a GP’s workload comes in before midday.  So, although tired by 1pm, you’ve pretty much cracked the day.
At least you don’t have to embark on an 18-patient face-to-face afternoon surgery, at a time when you are already tired, and the consequent struggle to keep everyone to their 10minute slots. Doctor First suits my tired afternoon brain – I always struggled with the p.m. surgery, and worried how safe I was.

I’ve usually spoken to around 30-40 patients by 1.30pm, but may have only seen 4-5 of them.
 Despite this, it doesn’t really feel like working in a call centre, as some have suggested, because the patients to whom you are speaking, are well known to you. The conversations are, therefore, very comfortable.

When all GP’s are in, I’ll speak to about 10-15 more people in the afternoon and see another 4-6 (some of whom were booked in the morning but requesting an after school slot).

During GP leave periods, it’s a different matter.
The demand for clinical input remains constant regardless of any reduction in workforce. These spells provide the biggest challenge. The same volume of calls are shared amongst fewer GP’s. Making up to 70 clinical decisions a day is hard, and the days are long.

Over the Easter holiday period, and for a couple of weeks since, when GP Partners were off, I have been working 14hr days, and have been beginning to wonder if this really is sustainable. That said, 12hr days were the ‘norm’ for me in the old system, and 14hrs were not unheard of during busy spells. Such times are always challenging – for any system.
Another Practice, piloting Doctor First locally, admitted that whilst hard, they still find holiday cover less stressful and less demanding than their old system – despite a lower patient demand than ours.  I’m inclined to agree.

One thing we have all noticed, however, is that we are becoming more ‘conditioned’  to this style of working, and are finding it becomes easier as we get more experienced at it.

The disadvantages to the receptionists
.  This is really interesting.  We didn’t anticipate any of these at all, but a couple of problems have been highlighted.

The major problem we are currently facing is the late finishing time at the end of the day. In these early weeks, whilst everyone adjusts to the system, the doctors have frequently been working late, and bringing patients down long after the receptionists day is due to end. This is particularly a problem when the workforce is down through GP absence. It has resulted in the need to pay overtime for those staff members willing, but others have been reluctant to stay back.  Commitment, loyalty and a vocational sense of duty is proving an invaluable quality here. However, this is causing a rift in the team, and we have safety concerns to consider if reception staff are unable to stay back until all patients have left the building.

We are currently working on solutions that are acceptable to all, but it’s not proving easy.

On a lighter note, the Office Manager has reported that receptionists are starting to feel a bit ‘lost’! They feel their skills and training are not being used to their full advantage. They are keen to have some control back and use their own sensible judgements for certain ‘clinical’ requests, such as, for example, same day prescription requests.  Currently, all clinical requests are directed to the doctors, so this may indeed need tweaking a little.

The funding issue /CCG /Private company support

I am often asked if we really needed to employ a private company like DF, or could we just have done it by ourselves?  In all honesty – I don’t think we would have embarked on this, nor succeeded, without the support of Doctor First. They seemed to know and pre-empt all the pitfalls, but more importantly held impressive and reassuring data on other Practices who had done it and survived! Without that reassurance, I don’t think we’d have ever had the confidence, or the necessary understanding of the system, to take the plunge.

Middlesbrough PCT, now Middlesbrough CCG, invited several companies to tender bids, and present their case. As a result of this process ‘Doctor First’ were selected.
Given that the PCT /CCG were offering to fund it, the decision to proceed was a no-brainer for us. We had nothing to lose.  If we’d had to fork that money out for ourselves, I guess, if I’m honest, we could never have justified the cash to do so. However, we now regard it as money well spent.

The practice have incurred small financial costs (such as additional locum sessions in the preparatory 2 weeks), but larger time investments – especially in the preparatory weeks when partaking in data collection, training, logistics & solutions meetings with the Doctor First team. A lot of this time however, can now be off-set against the time no longer taken for dealing with complaints from regarding the old appointments system!

The Doctor First team have inspired us, helped us, re-trained (and re-motivated) our reception team, and taught us a great deal about patient demand/appointment systems along the way. They have provided us with some really useful data.

I think one of the most important aspects we have learnt, is to run with their expertise and advice – no matter how counter-intuitive it has felt at times! on occasions, it has been very hard to resist the temptation to alter things slightly. One of the first 3 practices in our Middlesbrough pilot has now pulled out. I have been told, that very early on – they adapted the system to what they thought they needed. It didn’t work.

The one thing that has amazed us all, is just how accurate all the Doctor First forecasts have been. Everything they said would, or wouldn’t, happen has been just as they predicted. We have started to realise just how predictable patient consultation rates are over a working week. Our only gripe, is that they advised us to use their own ‘standard data’ rather than the data we collected, as they believed our data may not have been collected accurately. They assured us their data had proven reliable in multiple practices.  We rearranged our working patterns to ensure our weekly GP-sessions covered the predicted demand for each day. It turned out, as we expected, that our patient demand was higher than average for comparable practices. The minimum GP sessions advised by Doctor First, turned out to be not enough.

Doctors First believe they can give accurate demand predictions, almost day-by-day, for every month in the year. To the extent, for example , they believe they can accurately predict, what our appointment demand will be on the Wednesday before Easter, 2015!! Fascinating stuff.

The drive for the PCT/CCG is to improve patient access and services, and reduce the load on Walk-in-Centres, and A&E, which was thought to be created by GP-appointment overspill. It will be some time before the data is available to confirm whether this ambition has been realised.  Middlesbrough, had very poor patient access survey results. They initially offered funding to 3 Practices prepared to pilot this, with a pledge to fund all others if successful.  To date, 8 Practices in Teesside have now “gone-live” with 4 more practices signed up and preparing.  It will be interesting to see how we all fair over the next 6 months…

The future:

Doctor First data suggests that nearly all their Practices have reduced the number of sessions per full-time equivalent, because they are working so much more efficiently. This they argue, frees up time for alternative income generation, or new service provision.  Personally, we are along way off seeing this yet – it remains but a pipedream!

The role of the Nurse Practitioner is proving more worthwhile than ever. Many of the patients who are most difficult to assess on the phone, are the very patients that fall within her remit – rashes, throats, ears, joints etc.

We always had a problem filling the NP appointment in our old system. Patients would always choose the GP as a first default. In the new system, after speaking on the phone, we can reassure them of her skills and competence to deal with their problem. We are fortunate to have an excellent NP and most are more than happy to see her if we suggest it.

The next aim is to use the freed-up receptionist time and train them in QOF data collection and admin to trawl in income, leaving GP’s freed-up to be ‘doctors’.  The Doctor First team hold impressive stats and data on Practice savings/profits through this system. We will see.

Patient education is an extremely important aspect of the system.
Previous health-seeking behaviour patterns of our patients, stem, I am sure, from the inadequacy of our previous systems.  By rationing the appointments available, we had ourselves created a sense of urgency and panic.
We hope that in the long term, education and reassurance that patients will be seen when they need to be seen, will gradually start to impact on demand.
Our ‘demand’ figures are very high when compared to similar practices for both size and demographics. Whether this is an historical problem from encouraging doctor-dependency over the years, or whether this is a more specific demographics issue is not clear, but we hope with ongoing understanding and education, we may be able to make a difference to future demand, as the years go by. ….

We will see. All fingers crossed.

One Practice who has been operating a similar system for over 4yrs, recently advised me, that after years of training, many patients were now ‘self-triaging’  and appropriately requesting telephone appointments.

In Summary…..

On a personal note, I certainly feel I’m working much safer now; more efficiently, and more effectively.

At the end of each day, I know I have seen everyone who really wanted to be seen, so there is no going to bed anxious that I’ve breezed over someone simply because I didn’t have a spare appointment to offer.

I also worry, how many vulnerable patients were never known about in the old system. It allowed the strongest, or those with the loudest voice, to get priority.  The weakest, most frail, elderly, or quietest would give up at the first hurdle – getting through on the 8am phone-rush.

The new system seems fairer. It is more balanced, both for the patient and the GP.
It no longer depends on which of the two, is feeling strongest on the day. It depends on entirely on clinical need.

More importantly, know I can deliver 30-40mins of high quality medicine to those patients that need it most.

In the old system, large numbers of patients complained that they could never get an appointment.  Others were in four times a week seeing different doctors. I still can’t fathom how they managed to work the system with such reliability.  The new system ensures that appointments are still availability by mid-afternoon, if a needy non-frequent attender happens to phone up.

On the whole, the doctors feel less stressed and more in control of their workload. They feel more satisfied and relaxed at the end of the day, despite still working long hours.

This is with one exception.

Sadly, we have lost our newest partner, a very competent and caring clinician, through Doctor First.

We took on a new partner a couple of months before we embarked on the new system. Despite them embracing the concept of Doctor First from the outset, and being very much committed – not only to the team, but also to the philosophy of the new system – they just felt it wasn’t for them. After trying desperately hard to make it work for 2 months they still found themselves longing for the old system – in their words “for a ‘normal’ surgery” of 18 pre-booked patients.

Together, we considered lots of options, perhaps whether there was room for a hybrid middle-ground with GP’s opting in or out of the system, but in the end, and with heavy hearts, a mutual agreement to go our separate ways was agreed.

It’s not for everyone.

In particular, I think that newer, junior partners, who know patients less well, are probably at a disadvantage, and of course, there are doctors, as well as patients, who are less than comfortable with telephone consultations.  No one hat fits all.

Admittedly the system may seem threatening to those uncomfortable with phone based systems, but patients at least, can be reassured and offered a face-to-face alternative.

Doctor First gives the ability for GP’s to triage priority and be in control of their workload. The old system gave no control, and either poor or no triage at all. Any triage that did take place, began from a negative stand point, once all the appointments had been taken.  This traditional kind of ‘triage’, aimed at limiting access once no appointments were left, was very stressful.

Doctor First eradicates the need for patients to ‘game’ the system.  Patients do not have to justify whether their problem ‘deserves’ an urgent or routine slot.  If you are ill, or need to be seen, you will be – and in most cases by the GP who knows you best.

All in all, it just seems very intuitive. Right for patients and right for doctors… “Put the most senior clinician on the frontline – not the most inexperienced or least qualified.”

This system has potential, but be warned, it’s not for the faint hearted. It requires robust GP’s, and full team commitment to it.

Four months in, and all the pre-existing partners firmly believe it is the best system we’ve tried so far. Whilst it is still far from perfect, and we still have challenges we need to work through, for the time being at least, we feel could never return to the old style system….

Watch this space…..   😉