“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.   🙂

 

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