How analysing appointment data helped us free up GP time
Dr Joyce Robertson explains how the Peterhead Practice used tools in the Productive General Practice pilot to adjust skill mix and improve patient access.
Peterhead is a large practice in a town near Aberdeen, with 12 GPs covering over 20,000 patients. I suspected we had inefficiencies in our day-to-day workflow, and knew from previous experience that in a large practice small changes often have big outcomes.
Like many other practices, we were keen to respond to the rising pressure being placed on us to deliver services.
We wanted to retain personal lists, which we felt contributed greatly to continuity of care. As continuity of care is also linked to the patient experience, we felt this was important to consider when obtaining and analysing data as part of the Productive General Practice (PGP) pilot.
PGP is a programme designed by the NHS Institute for Innovation and Improvement. Developed with GPs from NHS Scotland, it focuses on recent research by the King's Fund and Dr Stewart Mercer, chair of primary care research at the University of Glasgow, which found continuity of care improves the quality of care as well as practice productivity. Scottish practices like ours can register to use the programme free of charge and English, Welsh and Northern Irish practices can sign up through the NHS Institute for a fee starting from £2,100.
The GPs and practice manager at Peterhead were starting to question whether it was sustainable to maintain personal lists while trying to support the delivery of a house call service.
On any given day, there could be two GPs visiting patients at the same time and in the same street or nursing home. The equivalent number of patients that could be seen during one surgery is three to four times greater than the number seen in house calls during the same period. But the home-visiting service is vital for our frail and vulnerable patients.
Our main aim was to create a more appropriate appointments system – so if an appointment could be done by a nurse, it should be, so that GPs were freed up for non-acute problems and long-term conditions.
This would mean better use of our GPs and nurse practitioners, and in the long run the practice could then take on more enhanced services and be more responsive to opportunities.
We also wanted to explore whether we could organise management of house calls differently, possibly by initiating a rota whereby GPs were allocated a day and/or time to undertake house calls. This would mean patients requiring house calls would be seen by any GP.
What we did
Peterhead Practice started implementing PGP modules in September 2011. First, information was gathered looking at appointment activity and capacity.
We ran a staff survey, a survey of patients to collect their views on the services provided and a quantitative survey of appointments and personal lists. The GPs and staff completed a questionnaire that identified how happy they were about innovation and change.
The data we gathered was then analysed, summarised and presented back to the team in graphs using PGP tools and data analysis apps.
Before any change was made to our systems, it was crucial for us to gather data to support our assumptions and ideas for the future. Informal feedback from our patients had indicated that there were difficulties with obtaining appointments at the surgery. Patients had said they were not always able to see their own GP at the surgery.
The patient experience survey, however, did not suggest this was the case, and showed that patients were in fact pleased with all aspects of patient access.
Towards to the end of the process, we started to discuss ways of ensuring patients requesting an appointment could be seen by their registered GP in order to maintain an appointment system based on personal lists.
GPs reported that demand on their time was increasing, so it was imperative patients were able to get an appointment with their registered GP.
This is usually difficult unless the GP in question is continuously available – when they are not, patients are seen by other GPs who may be unfamiliar with their case history. This in turn leads to appointment time being squeezed and repeat appointments being booked.
We went on to use the same methodology and the principles contained within PGP to undertake an analysis of the process and the demand for house calls.
We also looked at the appropriateness of each call to determine whether the request was being made for an ongoing condition and whether the request could have been handled by another healthcare provider.
Having gathered and analysed our data, we realised there was a great deal of predictability within our service and the data collection exercise had made organising and managing the service a great deal easier.
Using the quantitative survey of appointments, we looked at what the total number of appointments available would be if GPs only saw patients and had no other commitments – such as prison visits, cardiology clinics, administrative work and so on.
Then we looked at how many appointments were available after the commitments were added. Looking at the data from the two-week period, we found that 30% of patients who had requested and were given an appointment were not seen by their registered GP – equating to just over 200 appointments.
By removing all other commitments and redirecting that capacity into the appointment system, the total number of available appointments increased from 899 to 1,377 per week.
Out of the appointments that were not deemed to be appropriate to be seen by a GP, we broke the information down to show how the appointments could have been managed.
We found that 33% of patients seen by GPs were either inappropriate appointments or could have been seen by another healthcare professional – almost always a nurse practitioner.
The data provided our team with the necessary evidence to support what patients had been saying informally.
Requests for house calls are a significant demand on GP time. We identified that 83% of house call requests were made between 8am and 10am, with Monday being the busiest day for requests and visits.
The exercise also showed that 73% of home visit requests were for ongoing conditions, while 13% could have been dealt with by a district nurse.
House calls were being delivered on a personal list basis. Given the capacity needed to deliver the service, we had questioned whether personal lists for house calls were a luxury we could still afford.
Could we manage resources more effectively by introducing a system of triage? This would direct requests accordingly, but without jeopardising quality or continuity of care.
The potential time savings identified only reflected face-to-face time with patients. The average time spent in face-to-face house call consultations was 20 minutes. Along with travel time, a GP on a house call spent around half an hour with each patient.
If we could effectively reduce house calls and demonstrate continuity of care would not be lost by moving to a shared house call service, it would release time that could be spent on improving patient and staff experience at the practice.
We now plan to develop skills and expertise within our own team to allow them to start managing and shaping the current demand.
Our next steps will be to:
• develop the nurse practitioner, practice nurse and triage nurse roles
• extend training of practice nurses to include contraceptive counselling and to take over fitting of coils and implant clinics.
Developing roles will allow us to put in place a system of triage to manage both our appointments and house calls.
We chose to look at appointments and house visits in our PGP exercise and, although there was not a specific module within PGP to deal with this, we adapted the existing tools to our purpose.
We have, as a result, planned our future workforce to include more nurse practitioners, with the aim of triaging appointments and house visits more appropriately. This should free up GP time for more complex face-to-face consultations.
We hope to train up our workforce in the next six to 12 months.
Dr Joyce Robertson is a GP at the Peterhead Practice in Peterhead, Scotland