In February 2013, under pressure to provide a more sustainable GP service for both our patients, our staff and our GPs, our Practice embarked on a telephone consulting system which put a senior clinician (GP) as the first point of contact for all patients. The patient together with the GP who knows them best, decide on the most appropriate course of action and the suitable timing of any appointment required. Over the last 2 years, there have been ups and downs, but mostly ups. My previous blogs highlight the journey, and attempt to dispel some of the commonly held myths about such a system.

In addition to my GP work, I work as a GPwSI (GP with Special interest) in Cardiology at the local Acute Trust Rapid Access Chest Pain Clinic (RACPC). This role gives me lots of insight into what is going on, both within the Trust, and across the local GP practices. It’s quite an eye-opener, and indeed a privilege, to see things from both sides of the fence.

I would like to share an all too frequently encountered case scenario with you.

See how many ‘sub-optimals’ you can spot.

Recently, in the RACPC, I saw a lady who had developed on/off niggling left-sided chest pains one afternoon a week earlier. Overnight they had become much more severe and persistent. She waited until 8am the next morning to phone her GP for an appointment.  She tried phoning constantly between 8am and 9.30am but the line was engaged.

By the time she got though, she was told all the appointments for the day had gone. She was advised that if she felt it was ‘an emergency’, she could be offered a call-back from the ‘duty’ GP who would discuss her problem, and agree to see her if necessary.

She waited until late afternoon but no call came. Her resting chest pains were constant and persisting, and her anxiety was increasing, so she took herself to A&E.

At A&E, her cardiovascular system was examined and had an ECG, CXR and blood tests (including Troponins) which were all normal. She was discharged after 12 hours assessment, with a label of ‘possible angina’, and an out-patient referral was made to the RACPC.

I saw her there the following week.

By the time she attended RACPC, her pains had eased considerably, and were barely present. It was noted she had no risk factors for ischaemic heart disease and no exertional symptoms. The pains were usually triggered in bed, or when sitting. They were however exactly mimicked, and reproduced with severity, by palpation of anterior and posterior the chest wall – over the costal margins. (A simple examination which had not been undertaken in A&E).

A diagnosis of chest wall pain was made and she was discharged without further investigation.

This lady went through a protracted process, at a cost to her and to the NHS, for a diagnosis that may well have been made swiftly and accurately by her GP with no need for further investigations, no anxiety-inducing labelling, and no onward referral. But the system was overload and there were no appointments left. She became one of an ‘unknown’ demand volume – those that want to see a GP, but can’t, and are never really logged as potential workload.  I’d also like to bet her GPs weren’t enjoying a relaxed, lazy day and slipping off home promptly at 6.30pm with smiles on their faces…

But, I couldn’t help but feel, that if this lady had been a patient at a GP telephone-consulting Practice (and assuming the ‘999 ambulance’ protocol had not been triggered) she would have been given a priority callback by her usual GP,  and would have had the benefit of immediate and appropriate advice, along with the reassurance of a confirmed appointment slot for later that day; at a time that suited her.

Now A&E are no less and no more stretched than Primary care, but they are naturally more risk averse. As such they are more likely to investigate, and more likely to refer on. This is understandable and probably entirely appropriate, because the statistical likelihood of ‘serious disease’ in any population is immediatley raised the moment they step inside a hospital door.

Some Background figures

Last year, the RCGP estimated, that around 34 million people would fail to get a GP appointment. Estimates suggest, that this year about 1 million more patients will attend A&E because they can’t get a GP appointment.  Over recent years, the historical attendance data at A&E has been mapped by the Kings Fund.

Nationally, there are around 300 million GP consultations a year, and around 20 million A&E consultations. 

So consider this…
1 million more patients attending A&E this year, only represents about 0.3% of our GP workload being unable to get to see us.  To us in GP land, this sounds a very small problem.

But looking at it another way, as GPs are seeing about 15 times more patients than A&E, if 0.3% of of those are unable to get an appointment, then this translates into a very large problem for A&E.

What’s more, GP consultation rates are also on the increase – GPs are undertaking 40 million consultations/year more now than they did in 2010.

In short, the argument stating all patients are going to A&E anyway, so let’s put all the GPs there clearly doesn’t follow.  Quite the contrary. Certainly in core hours (8am-6.30pm) this could have a disastrous outcome.  Co-location of some services (eg out of hours) on the other hand, may be beneficial.

For those interested, there’s more useful stats in these posts:

So – A telephone appointment system is the answer, Yes?
Then why the blog title? 

Well here’s the thing.

A telephone consultation/appointment system is not a cheap cop-out. It’s also not designed for dossers who want to see fewer patients, fob the rest off, and then go home early.  If done properly (and that’s key) it’s hard work and long hours, but delivers a high quality service to the patients, and comes from the one person who knows them best. It’s also a service placed geographically at their convenience, and offers flexible appointment times to suit their lifestyles.  And since cost comes into everything, this has to be more cost-effective than a Secondary care based service, as General Practice is well recognised to be a highly cost-efficient option to our NHS.

It also needs GPs. Which we just don’t have enough of at the moment to make this work. Recruitment and retention of GPs is at an all time low. It seems new doctors are not going into hospital careers either, but many are choosing to work outside the UK, or seeking alternative employment outside the NHS.

On a personal note, since we adopted this way of working just over 2 years ago, our continuity-of-care rates and patient satisfaction surveys have never been higher. Additionally, for those GPs who suit it (and it doesn’t suit every GP)  it provides high GP satisfaction too. BUT – it needs properly funding – or at very least remunerating – for the extra workload burden which is mopped up in Primary care.  The A&E and Walk-In-centre attendance rates in core hours (red line) for our Practice, dropped significantly when we introduced this service in Feb 2013:

WIC attendances - early data         A&Eattendance afterintroDF

On a reassuring note, since we ‘opened the flood-gates’ and abolished the artificial barrier of a restricted number of appointments per week, our demand for GP/NP advice hasn’t risen at alarming rates. In fact – so far as we can see – the early data from early year 3 is looking encouraging.

The chart below maps the total number of our patients requests per week, for either GP or NP input. This is from our list size of 7,500 patients.

Annual demand 2012-2015

What’s more, a predictable pattern of demand seems to be evolving.
Predictability always makes any workload strategies easier manage.

So – All that glitters may not be gold.   But it might still be something precious.  

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Special thanks to John Bye for his help sourcing data for this blog and (as usual) for allowing me to paraphrase him at times.. 😉

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