The problem
We are a busy suburban practice on the outskirts of Middlesbrough, with 4.25 FTE GPs covering a list size of 7,300 patients. We have one nurse practitioner, but no salaried GPs.
Over the 20 years that I’ve been in the practice, we have changed the appointment system dozens of times. We have always been convinced that we have extremely high patient demand. We now have the data to confirm this.
Over the last 15 years, we have lost 10 GP partners. Four of these were as a direct result of work stress, two left through physical illness, and four were enlightened enough to get out before the workload had chance to get them down. This high GP turnover has only served to compound our workload problems.
Our most recent previous appointment system offered a mixture of same day ‘routine’ appointments, 48-hour to two-week ‘book-ahead’ appointments, and a ‘duty’ GP with reserved appointments every day to see same-day ‘urgent’ requests. We have always had a very low attendance rate at A&E or walk-in centres. What we did have though, was poor satisfaction with the system. The 8am phone jam was a huge source of stress both to patients and our receptionists.
Getting started
The PCT invited all the practices in the area to attend a Doctor First (DF) presentation, following which, we decided to try undertaking it. We felt we had no choice but to do something different, but the team was apprehensive about the system, which is based on the principle of seeing every patient the day they call.
After four months of training, planning and education of staff by the DF team, we went ‘live’ on 1 February 2013.
The first stage of the system is called ‘clearing the backlog’. This is to ensure, that at the point of ‘going live’, there is no outstanding hidden demand, namely frustrated patients, waiting to be seen.
This stage was pretty easy for us. Our advanced booked appointments were a maximum of two weeks ahead, so we had to stop advance booking of appointments for two weeks before launch day.
Then we had to see everyone who rang in and requested an appointment, in order to clear any outstanding demand. For two weeks, all partners worked pro-rata 10 sessions (FTE) and we brought in four locum sessions each week, to help, so due to high staffing levels it was the easiest two weeks of my career.
What we did
A quick note on how the system: all nurse and phlebotomy appointments go through a receptionist booking procedure as usual, but any patient who phones requesting ‘GP advice’, or a ‘GP appointment’ goes through the system.
The most senior clinician is the first point of patient contact. It is important to stress here, that the system works entirely on the patient’s choice. Any patient phoning requesting medical input of any kind, gets same message: ‘Of course. Which doctor would you like to see?’ For continuity, if they have previously been seen for the same problem, they are encouraged to see the same doctor or the nurse practitioner again, unless for some reason, they prefer not to.
They are then asked for a contact number, in order for the GP to prioritise and deal with their call efficiently. They are also asked if there are any times in the day which would not be convenient for the doctor to call them back. They are told not to worry if it takes time for the GP to call back, as they are guaranteed to be seen that day if that is what they want.
When the GP calls back he or she ask about the patient’s problem, and if appropriate gives brief advice before asking what time they’d prefer to come down.
By this stage, 60-70% have already decided they don’t need to come down - satisfied with advice, a sick note or a prescription. Others are directed to alternative community healthcare services. This is also an ideal time to direct patients to appropriate self care and over-the-counter remedies, to save them coming down, if appropriate.
At the end of the telephone chat, if - and only if - both the GP and the patient agree the patient doesn’t need to be seen, then the consultation concludes.
We listen out for non-verbal telephone-cues suggestive of ‘red flag’ signs.
If the patient asked to be seen or shows any cues they then get offered a same day appointment, no questions asked, at a time which suits them. Our appointment availability is such that they can nearly always pick and choose a slot time.
The call ends with both the patient and GP entirely comfortable with the situation - this conclusion is fundamental to the success of the system.
If an appointment is required, we encourage them to come down and be seen that day. If the patient would prefer another day (after work, on a day off), we ask them to phone back on the day they want. They can remind us that they’ve already discussed the problem with a GP or NP. This aims to avoid DNAs and cancellations.
Challenges
We’ve had a handful of patients expressing minor concern at how long they’ve had to wait for the doctor to call back on occasions. We hope in time, when they are more confident in system, this will be less of an issue. Notably, people who are not good on the phone, for whatever reason, will be either self-identified or identified by the GP and will simply get offered or choose a face-to-face appointment.
However, it is true that the success of the system does indeed depend on having a majority of patients who are happy with telephone consultations. For the GPs, it is hard work running this system. The work is undeniably intense. There is no doubt this is already getting easier as the months go by, and we adapt to this new way of working. Under the new system, I’ve usually spoken to around 30-40 patients by 1.30pm, but may have only seen four or five of them. When all the GPs are in, I’ll speak to about 10-15 more people in the afternoon and see another half a dozen, some of whom were booked in the morning but requested an afternoon slot.
During GP leave periods, it’s a different matter as the demand for clinical input remains constant regardless of any reduction in workforce. These spells provide the biggest challenge - making up to 70 clinical decisions a day is hard, and the days are longer.
Sadly we lost our newest partner, a competent and caring clinician, since using the DF system. Despite them embracing the concept from the outset and being committed, not only to the team, but also to the philosophy of the new system, they just felt it wasn’t for them.Together, we considered lots of options but in the end, and with heavy hearts, a mutual agreement to go our separate ways was agreed.
A couple of unexpected challenges for the receptionists are that, firstly, they are currently facing is the late finishing time at the end of the day.
Secondly, the office manager has reported that receptionists are starting to feel their skills and training are not being used to their full advantage - they describe it as feeling a bit ‘lost’.
Outcomes
Middlesbrough PCT, now Middlesbrough CCG, offered the contract on an open market - Doctor First was selected and given that the PCT/CCG offered to fund it, the decision to proceed was a no-brainer. If we’d had to fork that money out for ourselves, we could never have justified the cash to do so. However, we now regard it as money well-spent.
The practice has incurred small financial costs (such as additional locum sessions in the preparatory two weeks, the cost of training, meetings, and closing the surgery for training), but the larger time investments are more worth remarking on (such as the preparatory weeks when partaking in data collection, training, logistics and solutions meetings with the DF team). A lot of this time however can now be offset against the time saving from the reduction in complaints. At the time of writing, four months after the launch, we have no major complaints yet. We were used to dozens a day in the previous system.
Patients are now happier because get appointments (or advice) fast, and at their convenience. They get continuity of care. If they are complex or ill, they get more time with the GP, and so a more holistic package.
If they are working, or have children’s school commitments, we can agree to see them before school finishes, or after work in the early evenings.We have also reduced our DNA rate to virtually nothing.
GPs are more in control of our workload. We can work more flexible hours (no such thing as an am/pm surgery any more) and can fit the appointments in around visits, paperwork, meetings and coffee breaks. We are seeing far fewer patients face-to-face, but at least we know we are seeing the needy ones.
As a result we can give them much more time and deliver better quality medicine. Each GP ‘sees’, around 10-12 patients in a day since we introduced this new system. The rest are the complex patients with potential red-flag symptoms. They can be spaced at 30-40 minute intervals so we have ample time to take a really thorough history, examine, dictate a referral, speak to the local hospital consultant, or whatever is required, all whilst the patient is still sitting next to us.
Patients who have requested you by nameare more prepared to accept telephone advice, and in turn, if the GP knows the patient well enough to be aware of their limitations, he/she is more comfortable giving that advice.
The role of the nurse practitioner is proving more worthwhile than ever and receptionists are now released to do more administrative work, allowing the GPs to stick to clinical work.
The future
The next aim is to use the freed-up receptionist time and train them in QOF data collection and admin to trawl in income. The DF team hold impressive stats and data on practice savings or profits through this system, which we have yet to test for ourselves.
One practice who has been operating a similar system for over four years, recently advised me, that after years of training, many patients were now ‘self-triaging’ and appropriately requesting telephone appointments.
It still early days, and it remains to be seen what the longer term holds. This is an evolving process for us, but the early impressions are very promising.
Dr Heather Wetherell is a GP in Coulby, Cleveland.
If you are interesting in following the progress of the introduction of this appointment system, you may be interested to read Dr Wetherell’s blog, updated monthly
