Primary Care -reducing demand in practice (part 1-)

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“Only very exceptionally do patients seek help when they do not need to. Some are ill-informed and some are not very bright but they still need to be seen and looked after. Hardly anyone gets up in the morning and thinks it will be fun to go to the “doctor’s”. GP

In the London Primary Care Quality Academy we are working on reducing demand. Whilst we know that this takes a redesign of the whole system of primary care, many practices are immediately concerned about appointment systems, and struggle to lift their eyes beyond this immediate pressure.

This blog looks at the very best way to organise in general practice. The next blog will address in more detail more radical ways of organising in Primary Care.

Step One – Understand your Demand

You need to know how many appointments you need every day. Sounds obvious but many practices have no idea.

We do this in the London Primary Care Quality Academy in some cases using historical data from open access systems, but mostly using online diary forms. The advantage of the latter is we co-design these with practices to secure the best approach for them.

Screen Shot 2017-07-25 at 12.12.16The webforms are:

  • A one page web form for GPs and reception
  • Completed after each appointment or reception contact
  • Tracked for one week

The GP / nurse form includes:

  •  first estimate of the size of “moveable” demand at the practice

The reception form includes:

  • Flow and nature of appointment requests – by hour of day, by day of the week
  • Distribution of requests (days ahead requested)
  • Proportion of named(continuity) requests that we manage to satisfy

These diaries produced excellent data for the practices in the academy to be able to compare between themselves and to see data within their own practice .

Examples of outputs

  • A high level view of appropriateness of appointments that come through to GPs – this provides a long-term ambition for re-allocation and reinventing how demand is handled at the practice

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  • Variation in judgments of the above by GP – a basis for deep discussion about how demand is handled at a practice

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  • The shape of demand coming into reception – its timing, nature

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  • Variations in demand at reception by time of day – how does this vary and how does our ability to allocate appointments vary after the morning peak?

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And how these requests for appointments are handled:

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You can do this data collection manually using receptionists armed with tally charts and calendar.  You can look at data from open access systems, which measure actual demand because they never close access for example GP Access.
Doing this comparably with other local practices means you can start to review how you allocate appointments, and manage demand. This really helps practices understand their own culture and stretches their options.

Its really helpful to review the nature of the demand (same day) as well as the volume.

There will usually be a pattern of most activity on Mondays and Fridays with less on Thursdays – the pattern will usually be fairly consistent (i.e. predictable rather than volatile). Where practices have different patterns (say busy on a Tuesday) this is usually about supply not demand, i.e. the availability of professional staff and the learned response from patients. Of course most practices know they are busy in terms of calls first thing in the the mornings but not all know how busy. Practices who have worked on addressing this, move to a more even spread of demand during the day.

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Step Two – Match Supply to demand 

Having worked out how many appointments you need each day you match supply to demand. First thing to do is clear your backlog so that when you go “live” with a new system you have a clean appointment sheet – you can do that via a blitz with locums or by everyone doing a bit more over the course of a month – its up to you.

(a) Open Access mixed appointment system – doing today’s work today.

Many practices have a duty doctor or other ways of giving everyone an appointment on the day they want it – the key is to do “todays work today” and not ask anyone to call back or book them in later in the week because you have “run out” of appointments.

The best way to match supply to demand is through an open access system, otherwise you’ll still end up sending people away when your variation exceeds supply, or you find when and as you see more and more complex people so your appointments get longer.

Example Tower Hamlets CCG

As an example, on Monday 10th July there was a spike in demand across the whole system. Unpredicted and unexplainable: 38% higher than predicted demand, and the highest attendance in history at Royal London A&E. Special cause variation. The cause? Unknown. But if we had a closed, demand-matched system, we’d now be in bottleneck mode. So this works when people are prepared to pull extra hours in case of occasional surges. And these do happen.

We also know that if people know they can get an appointment with the practice, they manage their own demand better. They don’t get anxious about getting into the practice and will wait, sometimes realising they don’t need the appointment. A walk-in option generates better demand management, and it appears has the potential to reduce demand.

Example: A walk in service reduced demand in Robin Lane Health and Wellbeing Centre. Their research showed that:

  • Guaranteed consultation and type of accessibility offered reduced patient anxieties regarding access
  • Attention given to patient education during attendance enables patients to try alternatives in order to self-manage in future
  • Improved efficiencies by facilitating a teamwork environment where clinicians draw on collective experience at point of patient Screen Shot 2017-07-23 at 20.51.49attendance.

The walk-in service was introduced in 2012 and this was the impact.

 

 

 

 

Matching supply to demand also requires a mixed appointment system with a range of appointment types, and at best an open access on the day walk-in service.

(b) GP variation

It helps to know average throughput per GP, and length of time each GP spends with each patient, partly because when one goes on leave, you can lose 13 or 27 slots depending on who that GP is. There are reasons for this, and variation can be reduced to standardise consultations, but only to a certain extent. What works here is a lot of transparency around throughput, and high trust that everyone is working to their best abilities, even when there is large variation in output. Overall knowing this variation helps professional peer review and improves everyone’s practice.

Screen Shot 2017-07-23 at 20.46.12Here is an example of the variation in one practice. Often GPs don’t know how they vary in relation to their peers.

In our experience 1 WTE GP can do circa 7 sessions of 18 appointments – 126 per week.

 

Step Three –Triage Appointments & Skill Mix

We now have supply matching demand – but its not necessarily efficient or a good use of your GP time, the most expensive resource. Often practices have a system which channels everyone to the GP creating unhelpful patient expectations. In this system the GP will see lost of self-limiting conditions, letter requests, sick note stuff etc.

Overall be proactive in managing demand there are lots of ideas here 

So what can we do to be more efficient? Telephone consultations have not shown to reduce demand, but are more efficient; demand for face-to-face consultations was reduced by 39% by GP-led telephone triage (Jiwa at al 2002), and can reduce DNAs to almost zero (NHS Innovation and Improvement 2007).

Here are some of the steps that are generating a better flow, and managing demand.

  1. Phone consultations are more efficient than face to face consults – a face to face is 10 minutes, a phone consult takes as long as it takes, if a patient needs 3 minutes you can get straight onto the next one, if a patient needs to be seen face to face and cant be dealt with on the phone you can call them in. Done well, and it does take time and training, you should end up only calling in around 30% – 40% of patients. Some practices ask all patients to speak to a GP first – the big advantage is that it puts the two people who want to speak to each other in contact as soon as possible. For it to work well the GP call needs to respond in no more than 2 hours after the patient calls the practice. If your supply meets your demand then there is no reason why this isn’t achievable. Not all practices do GP call back for all patients – often it’s an option which patients take up through choice. Either way evidence shows that a GP can deal with around 25 patients in 3 hours rather than 18 – a significant gain. This is different than triage. In this system the caller (patient) decides if they want a telephone appointment. Some GPs will call patients, and then bring too many patients in for face-to-face appointments, so you need to work on phone skills, both in terms of dealing with patients on the phone and closing the conversation quickly. Using locums well here is very important. Get the most senior people to focus mainly on phones and complex presentations which require continuity, and have locums working on acute single presentations. Overall you do need to review how the calls are going. Here is an example:Screen Shot 2017-07-24 at 17.20.39Screen Shot 2017-07-24 at 17.21.36
  2. Good Reception Triage. Some calls shouldn’t even get as far as a phone consult, a good reception triage should meet the needs of at least 30% of calls without a GP call back. These include people calling for repeat prescriptions, hay fever, sick notes and medication issues. Tower Hamlets triage in colours: callback from admin, from nurse, from HCA, from pharmacist, from micro team. Good reception triage requires a good script and agreed protocols for matching the right condition/issue with the right member of staff. Without this reception triage is just adding a block in the flow of appointments.

Jubilee Street Practice developed their triage protocols through an audit process

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However to put this in place there needs to be training for all staff, and regular review otherwise the process collapses (Murdoch et al 2015).

At the same time as introducing triage, take a look at how to secure better telephone access. Here is an example of impact from Tower Hamlets:

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  1. Skill Mix. There is a big overlap here with skill mix. Practices are finding a real benefit in appointments covered by GPs, Nurses and Pharmacists. Pharmacists can deal with medication issues, HCAs and nurses can deal with many people with long term conditions especially if it’s a care plan issue. Everyone should be working to the maximum of their license. There is a useful exercise you can do with the whole team going through a sample of consultations and asking the team who would have “best” dealt with it and using that discussion to identify protocols to share with receptionists and GPs.
  2. Reduce follow ups. This can be a big area where you can gain some capacity. It seems that follow-ups have the highest DNA rates. We suggest no follow-up appointments. People should be being supported to manage their own conditions. GPs can have a “just in case” approach (e.g. antibiotics – “come back and see me in 3 weeks” rather than “make another appointment if it doesn’t clear up”). People with complex and long term conditions are often recalled for annual reviews by disease register which means they are called back perhaps 3 or 4 times a year when they could be called in once for a more holistic assessment which would save everyone’s time. None of these work for the GP or the person. Data is key, you need to pull off the number of follow ups each GP does and then work towards no follow-ups. One way of working with people with longer-term conditions is to support them through applications such as eConsult where they can let the practice know how they are managing.
  3. Reducing DNAs. In our experience DNAs drop when access gets better but text reminders can also help. Some practices identify repeat DNAs and take them off the list (three strikes and your out) but this just pushes the problem onto a neighbouring practice.The best approach is same day appointments (and as we saw above) and/or a walk-in service. For advance appointments book ideally no more than three days in advance, so that planned care still gets planned close to the date, and not in advance. Then guarantee the appointment, so that on the day you need to be seen, and on that day specifically, you will be seen. This really reduces DNAs to below 5%

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Step 4: Going Live

When you have determined the demand and therefore the supply (and range of appointment options), and have cleared any backlog, and have developed your protocols and trained ALL staff, you go ‘live’ armed with your new rota and knowledge of what’s coming through the door knowing that supply matches demand every day.

This process may show that you have sufficient appointment supply or not. Often practices do have enough capacity – they just allow backlogs to build, they aren’t strict with annual leave and practice absence (if a GP isn’t about you have to find a way to provide their appointments that day) or simply each GP isn’t doing sufficient appointments. Usually the new system takes a few months to bed down.

“No system is better than the intelligent person who manages it in real-time. Doing this is a necessary and difficult skill. Some doctors have it, as do some practice managers and receptionists. The ability to see things going pear-shaped at an early stage is absolutely crucial. As is the initiative and authority to do something about it.” GP

Example: Clarendon Surgery in Salford found that in the first month it was taking 3 hours to get to 90% call back, but over the next two months this reduced to nearly two hours and with further refinement half the patients where called back in less than 2 hours), and now has a system that enables 90% of patients to be called back within 55 minutes, with 54% within 20 minutes or less and 71% in thirty minutes or less. Another ‘major outcome of this phase was that the initial ‘flood’ of calls at 8.00am began to be spread across the day, making it much more manageable.”

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You can find out more here

The Whole Package

Here is an example of impact of this whole approach to appointments from Tower Hamlets:

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Sustainability

Implementation requires practices to:

  • Prepare properly with training for all staff
  • Develop robust protocols based on peer review and audit
  • Clear the backlog before starting the new system
  • Generate feedback and use that to adapt the system
  • Secure the impact they need and measure it

Without all of these staff become dissatisfied and patients ‘game’ or develop workarounds. If the system isn’t working within 3 months, clinicians, reception, management and patients will give up, and the whole thing collapses. So taking short-cuts doesn’t work.

Where there is full and careful implementation, with reviews and changes to adapt to feedback, staff and patient satisfaction increases and the approach is sustained (but is also adapted as needs change and capacity changes, based on feedback).

You can find many resources to support these changes here on the RCGP site 

Next time: reducing demand through a whole system model of primary care  working with communities.

References

Jiwa, M., Mathers,N., Campbell, M. (2002) The effect of GP telephone triage on numbers seeking same-day appointments. British Journal of General Practice. 52 (478), pp390-391.

Murdoch, J., Varley, A., Fletcher, E., Britten, N., Price, L., Calitri, R., Green, C., Lattimer, V., Richards, S., Richards, D., Salisbury, C., Taylor, R., and Campbel, J. (2015) Implementing telephone triage in general practice: a process evaluation of a cluster randomised controlled trial. BMC Family Practice 16:47

NHS Innovation and Improvement (2007) Stour Access System: a new way to manage GP appointments Better for GPs, better for patients, better all-round.

Prof Becky Malby, David Groom, Virginia Patania, Tony Hufflett, Nick Downham. The London Primary Care Quality Academy.