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