“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”
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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:
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. 🙂
GPs blog 
well done, all of you. Keeping patient are central when your own well-being is stretched. But don’t try to do the impossible, ( if possible)
Heather,
Thanks so much for sharing this. It’s really interesting to hear your description of how this worked and I’m quite inspired by your dedication.
AM
I asked my Diabetic nurse i she had head of Doctor’s First,she said they were trialing it in Bristol he doctors were one but though it was inpersonal, She had to phone for her self but could not speak to her doctor had to speak to doctor that treated like child,Have told her about your trial she isn’t on twitter so can’t get her to follow for updates from claude @Monecel
I know June has been a challenge but patients have approached myself as chair of the PPG saying that they are pleased with dr first It is reassuring to know we have a dedicated team across the practice
I agree that once you start dr first system it is the break in supply which causes the problem.
Unfortunately the plea of tired exhausted GPs will fall on deaf ears of the patients and any regulatory body .
I manage my day by dealing with most pts by 1pm .
When I start my afternoon surgery at 4 I have had a little drive in the picturesque Middlesbrough to see someone who was too ill to come and see the GP and wanted a home visit .I must thank my pts as that gives me an opportunity to listen to radio 2 at 3 pm! You soon start seeing the good in everything .
Start afternoon at 4 pm which is mainly mopping up the work from morning and any new, late calls from our pts.
Have managed to do more QOF work with tel contacts as made a habit of checking it before ringing a pt.
Capping was good for a while but just transferred the work to another day . I must say that a lot is common sense . Yesterday when someone rang to discuss a problem of 6 years, I still had a telephone chat but booked them to see me a week later . I asked they were expecting to be seen the same day, and they replied “oh gosh no, I have not even done my hair today . I just wanted to prebook .”
If we can work some way of managing a mix of prebookables after discussing with the dr first it will be magic .
My day off today and the big question is to run or not to run or go for a facial …. I deserve it after speaking to 50 folks and seeing 20
I know June has been a challenge it is nice to know we have dedicated doctors and staff good work
DR FIRST – just about sums this system up. What happens to the patient who works in a shop or a factory who cannot wait around for the doctor to call them back? What about the patient who is not forceful enough to get their point across or explain fully how they feel at the triage stage? What about the patient who is triaged for a problem that is decided by the doctor does not require a visit yet a visit could show something more sinister that the patient was not aware of? What about the elderly patient who walked to the surgery to try to see a doctor because he felt so ill, yet was sent back home to wait for a call; walked back in his door to the telephone ringing and was asked to go back to the surgery immediately? What about PATIENT FIRST? Doctors quite rightly earn very good salaries for the work they do, but this reflects the fact that they will be working under a certain amount of stress and duress so I do not feel the cart comes before the horse. No patients means no practice means no money. Doctors should be there for the patients needs not the other way round!
Thanks for those comments Christine.
I agree absolutely with your final sentence, and that is exactly what I believe this system offers.
In a traditional appointment system, each doctor can only realistically deal with around 36 x10min appointments each day – with phone calls, visits, handling results and correspondence on top of this. Once those 36 appointments are booked up (as is often the case by 8.30am in many surgeries) patients are often told “please try again tomorrow”, or asked “is it urgent for today?”. The latter question is quite off-putting, and sadly, it is often the most needy who will quietly back down and retreat. The ability to get an appointment is dependent on being one of the loudest shouters, or the most persistent callers.
In contrast, our new system allows every single patient who wants to speak to a doctor, on any particular day, to do so.
To put that into numbers – each GP in our practice used to see 36 patients a day. We now deal with up to 60 patients per GP per day – all of whom have the choice to be seen, but almost two-thirds actively choose an alternative option. The initial patient feedback was overwhelmingly positive and supported patient satisfaction.
We plan to repeat the same feedback questionnaire this month (1yr on) and if the satisfaction levels have dropped we are unlikely to persevere with this system, which is certainly much harder work on the doctors, our hours are longer than ever, and the number of clinical decisions we have to make each day has doubled. The sole purpose of this system is to improve the service for patients. (The term “Dr First” by the way – refers to the patient speaking to the doctor, first, before a receptionist – but it’s a bit of a misnomer in my opinion as that would depend on having sufficinet doctors to be answering the calls as they come in).
– Patients who work full time can pre-book an easy morning or late evening appointment – this just needs to be agreed between patient and GP.
– The small number of patients who can’t take day time calls (we have patients who work in prisons, or shops who don’t allow mobile phones) just need to make the GP aware of this, and they can be put straight through when they call in.
– Patients who walk-in to surgery don’t have to walk home – they can choose to sit and wait for their turn if they prefer – but they have the options to wait in the comfort of their own home IF they chose to.
– Patients should not need to be ‘forceful’ in order to be seen. Every patient should be asked if they are happy with the agreed plan. We listen out for pauses, uncertainties, and any other non-verbal cues which suggest another worry on their mind. If they are not happy, or the plan is not by mutual agreement, then the system has been incorrectly applied.
You ask “what about…?” all the above issues.
What about all those patients with serious symptoms, or severe depression, who never even got the chance to speak to a GP because every time they rang, all the appointments had been taken?
What about those who only wanted a repeat prescription, or some simple advice, and didn’t want to take time off work, but were told by the receptionist that they’d have to make an appointment?
What about worried relatives, nurses, or hospital consultants will vital information to share – who could never previously get through to the GP?
I worry about all of them.
Gosh, I find it really hard work. Exhausting in fact. But I do it for my patients, and for no-one else.
I really hope that next weeks satisfaction survey shows they are getting the service the deserve. If not, I’ll be the first to backtrack.
What is to be done about patients cannot use the phone because of hearing problems, many people have this problem but don’t have or really need a text phone.
Hi Michael, thanks for asking this question – it’s a common concern. We have a handful of deaf patinets – some of whom rely on sign language or lip reading, but many more elderly people who simply ahve impaired hearing and find the telephone difficult for any more than a brief conversation. This isn’t a problem 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 and 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 actullay have free appointments available for them every day, all day, unlike the old system when all appointments were taken by 8.10am!). They just book and agree a slot time directly with the GP (instead of the receptionists, in the old system) or come to the front desk and book it if they prefer.
Hope that helps?
Thanks for taking the time to read and comment.
Heather.