GP Access Manifesto v5 (1)

Enabling DEmanD-lEDgEnEral PracticE:How gPs can solve their capacity problem, improve patient care, and rediscover the joy in their work

Enabling Demand-led general Practice 1

introduction

“i get to see everyone i need – it’s great,” she says.

“nobody waits too long for an appointment, even for routine things like a blood pressure check, and i can regularly review my patients.”

“there are no queues in the surgery” – Wallington medical centre in Surrey – “and only two Dnas a month, on average.”

“Some days i don’t even fill all my appointment slots. i leave every day on time, on the dot.”

For most GP surgeries in the UK, this is stuff of fantasy.

gPs are buckling under a deadly combination of unmanageable workloads and declining budgets. On average, gPs turn away one in eight patients who ask for help each day. gPs are rarely able to prioritise patients according to need or give them the time they deserve.

as a result, gPs are blighted by a feeling of lack of control – over their time, over which patients they see,over their professional lives.

“”

When Dr Eleanor Barnard gets to work in the morning, she knows she won’t be turning away any patients who need help.

What you are about to read is a manifesto for change.

It is meant to bring hope to those who believe that there is nothing we can do to return control to our GPs; that there are no solutions that work, and that the system is too big, too established, too difficult to turn around.

It is meant to inspire those who find the idea of change overwhelming. The reality is that Dr Barnard is not alone.

She is part of a small but significant group of over 80 practices across the country that have broken with the traditional system of booking patients and found a new lease of life.

Serving deprived and wealthy areas, with partnerships and salaried gPs, ranging in size from 3,000 to 23,000 patients, they are delivering outstanding and sustainable outcomes. these include:

• Patients consistently accessing a gP on the phone within an hour

• a drop of 50% – 80% in patients missing appointments (Dnas)

• improved continuity of care (typically 10 – 15%1)

• a reduction in a&E attendances. We’ve measured 20%, now being independently researched in the tele-First programme by ranD/cambridge University.

• gPs able to spend anything from 1 to 30 minutes with a patient – not all boxed into 10-minute slots,though the average face to face duration is the same

• an enormous increase in productivity, as gPs see or speak to more patients each day

• Work spread more evenly throughout the day. these doctors take lunch breaks!

all this, for a tiny investment: Just £1-£2 per patient per year – no more than 0.05% of the £116.4 billion nHS budget – to save far more in costs.

there’s nothing secret or mysterious about what these practices are doing. they’re becoming “demand-led”.

Here’s what that means – and how every surgery can repeat this feat. Yours, too.


1 as measured by Usual Provider continuity (UPc)

1 What is ‘demand-led’generalPractice?

The idea behind a “demand-led” system is simple.

Patient demand for help from the healthcare system is highly predictable, meaningthat the GP surgery can plan to meet it and offer same-day access. No one is toldto come back tomorrow, or next week, or go to a walk-in centre because all slotsare full. They all get the help they need.

this is radically different from the traditional system, where what matters is not how many patients need appointments, but how many slots are available (“supply-led”).

Once that fixed number of slots is filled – usually within minutes of phone lines opening – patients arerebuffed or redirected. For the rest of the day, practices do not respond to demand but instead try to divert it.

most attempts to reform our supply-led system have focused on turning the patient away from theprofessional they really want to see or talk to – their gP – and sending them to a pharmacist or nurseinstead. in many cases patients end up self-referring to a&E, or giving up altogether on seeking medical attention.

Demand itself is poorly understood. While most surgeries know that there is a rush of phone calls everymorning, particularly on monday, they probably can’t explain how it ebbs and flows the rest of the week.

basic information such as the number of consultations carried out in general practice is missing; the estimates are still based on data from 2008.2

the result is a rigid system, where gPs struggle to fit their patients into 10-minute slots, treating them in the same time frame no matter how serious or complex their symptoms.

this supply-led framework goes back to 1948, when access to a gP was dependent on means and theobvious solution was to provide more gPs. but it never evolved into understanding demand or into a system sufficiently flexible to handle the inexorable growth today.

But both are easy to do.


2 is general Practice in crisis? nuffield trust, november 2014

2Patients are so predictable

In reality, patient demand for GP services is completely, utterly, boringly stable and predictable.

after four weeks of monitoring, the surgeries we’ve worked with can tell within a range of 10% exactly how many patients are going to phone every single day. Even hourly rates are predictable.

that’s right: if you ask how many phone calls the receptionists will field on tuesday at 11am or thursdayat 4pm, they can provide a reliable working estimate.

the surgeries that have successfully become demand-led record and then harness the data to organisethemselves far more efficiently, ensuring there is a good fit between demand (patients requestingappointments), and the number of staff on hand to help them.

The model they follow is ‘MEPRA’: Measure, Predict, Respond and Adjust.


1 MeasureFirst we need the data to measure when and what type of requests come in. Extracting remotelyfrom the clinical system means this is not a chore, but produces all the information we need, by day,hour, even minutes, and it’s effortlessly updated.

2 PredictWith just a few weeks of data, it becomes easy to predict demand on any given day so that capacitycan be planned around it. Did you know that in a typical practice, 28% of demand is on a monday?there may be local differences, but this means adjusting the rota for receptionists and gPs – perfectfor part-timers.

3 Respondas demand comes in on the day, the surgery staff must handle it rapidly and appropriately.

the key here is to give gPs the tools to treat patients differently, according to their needs. not everyone needs the same amount of care and attention. not everyone needs a 10-minute, face-to-face slot.

With a more flexible system in place – see next section for more details – doctors can help a far larger number of patients quickly.

4 AdjustOver time the surgery will learn valuable lessons about how demand fluctuates and how best to meet it, and be able to optimise the way they work.

as the surgery responds better to demand, so demand will shift again. Once patients learn thatthey do not have to call at 8.30am in order to see their doctor that day or that they do not need to book slots two weeks ahead just in case their cold hasn’t gone away, they stop doing it. Patientbehaviour changes as anxiety demand falls and the supply arrangements must change as well.

that’s why MEPRA is a cycle – a continuous cycle of improvement.

this does not mean the surgery’s staffing arrangements are constantly in flux. as response to demand improves, generally demand smooths, regularises and is easier to manage.

indeed, although MEPRA may appear daunting at first, practices we have worked with tell us it is ultimately far less work for everyone in the surgery.

Finally, doctors are in control of their schedules – instead of constantly battling a backlog.


3How do wehandle demand?

Let’s get back to the “Respond” part of our model.

How do we ensure that each patient gets the attention they deserve, quickly, without hiring dozens more doctors – and while making life easier, not harder, for the doctors already in the practice?

the key is not to force everyone into the same face-to-face 10-minute slots, but to give the appropriatetime and type of attention to each patient, according to their needs.

that’s where technology comes in – at the moment, phones and internet.

i say “at the moment” because it’s important not to get too hung up on the type of technology we use.the technology is a tool that enables us to become demand-led – it isn’t the crux of the exercise.

Here's how surgeries with the askmyGP online system handle demand.

Patients seeking help from their gP enter their details and their symptoms online. they then answer very simple structured questions with one-click answers, creating a medical history in a gP-friendly reportformat. they also see self-care information precisely related to their symptoms, and may decide that is all the help they need.

a doctor at the surgery – they can name which one – takes seconds to scan the report and can respondquickly with the best course of action. they may ask reception to call the patient in, usually the same day,or they may phone the patient directly.

One third of demand is non-medical – perhaps asking for test results, organising a referral, or looking for an answer to a simple question. reception may answer directly, or may send a message from the gP.this level of efficiency ensures that the doctors’ face-to-face time is reserved for those who most needtheir attention.

the beauty of the system is that it is “asynchronous” – that is, the doctor and patients can access thesystem at different times, when convenient for them. they don’t need to find a time when they are bothfree to meet, or play telephone tag.


gPs save time because around two thirds of patients can be dealt with remotely, yet clinical quality isimproved as many more questions can be asked by the askmygP system than most gPs have time for.the average seven minutes to complete a history is all in the patient’s own time. 14,000 submissions haveproven how well the system works in the UK, where it has been pioneered in london, the West midlandsand Edinburgh.

Patients catch on fast, with a shift of around 45% moving online within four months. indeed, the earlyresults in the UK have been so encouraging that we now offer it as standard.

the online questionnaire builds on the success of the phone system, which has already been implemented by dozens of UK practices.

A telephone-led system follows three simple steps.

1 The patient calls the surgery. they may ask for anyone to help, or name a specific doctor.

2 The doctor calls them back, usually within the hour, and works out how to help them, resolvingaround 2/3 of issues on the spot.

3 The GP calls the patient in for a face-to-face whenever necessary, and certainly when there is any doubt. Patients can choose when to be seen, but nine out of 10 choose a convenient time on the same day.

When the practice has a good understanding of demand, it is easy to achieve a call back time below an hour, and some are below 15 minutes on average. calls take around five minutes, though a fewpractices are down to four minutes. We can measure these response times directly from the clinicalsystem, using our navigator analysis suite.

by far the main time saving comes from the repeated finding that two thirds of patients neither need nor want to be seen. the problem is resolved remotely, completely revolutionising the gP process.


4…but won’tdemand gothrough the roof?and otherobjections

The change I’m advocating is enormous, so it’s not surprising that there are many fears attached, particularly in an NHS culture where change is frequent, often cumbersome, and fruitless.

Here are some of the concerns i commonly hear:


“if we are hyper-responsive to demand, won’t demand go through the roof?”

“if we allow patients to name the doctor they want, won’t the burden be uneven?”

“is it safe to diagnose some patients on the basis of a phone call or online questionnaire?”

“if doctors have to triage every patient themselves, won’t they become glorified receptionists?”

“i don’t believe the evidence, the face-to-face model is the only one that works, as it always has.”

these are all legitimate concerns that must be addressed seriously – you can read my responses here3.but in my experience, they are rarely heard after a gP surgery has made the switch as none of these fears are realised.

“

”

in our experience, 78% of gP practices that adopt a demand-led system make the change successfully,with all the benefits we have described. Of the remaining 22%, many end up with a hybrid system, and a small number revert completely to a supply-led one.

the most common feature of those that succeed is clear commitment from leadership.

like all change, moving to a demand-led system can be hard, and some parties won’t like it, at least at first. receptionists, doctors and patients must all be guided through the process and given a chance to get used to a radically different way of working.

if those at the top are not determined to persevere through those first weeks and months, when everythingis new and the system is not yet fully optimised, the change is put at risk.

Those that persevere reap the rewards.


3 Our evidence shows that demand is flat, and in many cases actually falls by 10-15% over the first year to 18-months. Once patients are confidentthat the doctor is within easy reach, they don’t call “just in case”, they only call in time of need.

We measure the gPs’ view on whether a consultation “should have been self-care”, and it remains about 3% on average, before and after the change.

nor are the “popular” doctors more burdened than others. in reality, just 23% of patients in the surgeries we work with choose a named clinician, and while some have a preference it isn’t always for the same doctor. Speed of access to a gP – any gP – seems to be far more important.

the doctors manning the phones quickly come to appreciate that it does not disempower them by turning them into receptionists, but ratherempowers them by allowing them to prioritise and control which patients they see face-to-face.

is it safe? gPs consistently explain to us that the system is safer, because all patients have access to a clinician and are not turned away by a medically untrained receptionist. the gP always has the option to bring the patient in for examination.

telephone triage has been the backbone of out-of-hours services for many years, and is built into the 2015 bma – nHS Employers agreement.neither telephone triage systems nor online access have any effect on medical defence insurance, and the reduction of a&E attendances providesfurther evidence of safety over the long term.

5Dnas? What are those?

One surgery that exemplifies commitment to the process is Rydal group practice in Woodford Green, Essex. It has truly internalised that MEPRA is a cycle, and continually works to improve its response to demand.

the surgery, which has six gPs serving 12,500 patients in a suburban family area, first changedits booking system in 2012 after the duty doctor started calling the list of people who had rungthat morning and discovered that 50% of patients could be dealt with over the phone.

initially, rydal pre-booked phone appointments throughout the day but was soon battling a backlog.


4 For all rydal statistics, see http://gpaccess.uk/evidence/askmygp-pilot-study-30-demand-moves-online

““We ended up having to ask people to call back tomorrow, which they don’twant,” says Dr Ed Diggines. “it was mirroring the face-to-face system.”

the real problem was that rydal was not yet demand-led. it had instituted the technology, but withoutmeasuring demand, or responding to it in real-time.

that was the next step (and when i came on board).

“now i know that 6.5% of my list will come in any week, with a 10% margin of error,” says Ed. “On monday, 26% of that 6.5% will come in, and 18% on the other days. 60% come in the morning, 40% in the afternoon.

“the system is now so finely set up, you’ll get a senior physician phoning you back within 30 minutes, no matter what you’re asking about.”

in march 2015, the practice started offering online questionnaires, because some patients were not getting through on the phone.

Within three months, 40% of demand had moved online.4

88% of demand is during opening hours (and the gPs meet the rest, too). there is a good spread of calls throughout the day with no 8am rush.

Only 30% name the gP they want, and even the most popular gP gets just 9% of enquiries, so no one is overly burdened.

On average, rydal gets back to online patients in 27 minutes and four out of five patients say they like the new system.

“the feedback is that we’re now very accessible”, says Ed.

as for the doctors, they are working as hard as ever – but far more efficiently, and giving the bulk of their time to the neediest patients.

the fact that nHS does not reward increased productivity is a frustration.

but they are forging ahead, planning to extend the phone system to six practices in neighbouring boroughs.

ask Ed what life was like before becoming demand-led, and he says he can hardly remember.

“i used to hate it when patients told me they couldn’t get an appointment,”he eventually recalls, “but even more, i hated it when i got people in my room with no idea why they were there – 10 minutes to review a letter from a specialist, or to discuss results that weren’t in yet.”

“they used to make appointments on the basis of what might happen. if they got over their sore throat, they’d Dna.

“in our current system, that doesn’t happen anymore.”


”

6the demand-ledfuture

I first stumbled across demand-led practices by accident. I was working with a Primary Care Trust, phoning GP surgeries who had particularly low A&E attendances to figure out their secret.

i soon discovered that several of them had independently invented a new way of triaging patients, in which the first response to patient demand was always a phone call from the doctor. because their owngP was so easily accessible, most patients had no reason to go to a&E. but then one of the receptionists– i still remember her name, Sam – added the following sentence: “i love working here. i’m not fighting off the patients.”

It was a eureka moment.

not only was the rapid-response system keeping patients from making unnecessary trips to a&E, it was keeping them from making unnecessary trips to their doctor’s surgery, as well. the only patientsdoctors were seeing face-to-face were those whose needs could not be resolved over the phone.

I was so struck by this powerful idea that I have been working to spread it ever since. And now I want to pass the baton on to you.

Demand-led general practice works. it is already being successfully implemented in surgeries across the country. the technology which fuels the system works, and is evolving all the time.

It’s good for patients. It’s good for receptionists. It’s good for doctors. So,

if you are a gP who can’t bear to see patients turned away each day;

if you are frustrated because so much of your time is taken up with minor complaints that do not needface-to-face attention;

if your receptionists are stressed because they are perceived as barriers to access by your patients;

if , like so many of your peers, you have thought of abandoning the profession;

…Have hope. realise that change is possible. better triaging will lead to “more joy in [y]our work”.5

realise, too, that not changing carries a price – and a significant one too.

We already have the knowledge and the practice. All we need to do is to scale it up. It’s in your hands.


5 general Practice adaptation, a better nHS blog post, June 9, 2015. https://abetternhs.wordpress.com/2015/06/09/general-practice-adaption

about Us Harry Longman is the founder and chief executive of GP Access, a company with the simple vision “to transform access to medical care”.

So far, it has helped over 80 practices transform their work through its consulting interventions, and is enabling online access for patients nationally through its askmygP platform.

Formed in 2011, it grew from a community of pioneering gP practices around England that want to develop and make known their discovery of a better way to provide access for patients to gPs.

While independent, gP access works with nHS organisations for their benefit, as well as for patients, gPs and practice staff.

an engineer by background, Harry led research while working in the nHS which uncovered the benefitsgained by the inventors and early adopters of the acc ess method. He then brought the practices together,leading to a conference sponsored by the Department of Health in June 2011, and the mandate to foundthe company.

We are a member of the NHS Alliance and the European Forum for Primary Care.

Solve the capacity problem at your GP surgery

if you, too, are buckling under the strain of patient demand and want to regain control, the next step is to contact us:

Email Harry [email protected]

Phone GP Access 01509 816293

Visit our website www.gpaccess.uk

Read our Case studies www.gpaccess.uk/case-studies/practices

Examine Our research www.gpaccess.uk/research

Check out Harry’s blog www.gpaccess.uk/blog


Documents

GP Access Manifesto v5 (1)