“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