“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.

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