1. Dealing with increasing demand in general practice - our experience The Elms Medical Centre - Merseyside Dr Chris Peterson, Elm Medical Centre, Liverpool

2. Patient Access The Elms Experience 8200 Weighted list size 9700 Toxteth Liverpool 5.5 WTE GPs 8.5% of list contact practice every week 3. Why did we do it? Increasing demand high demand practice Falling morale Grumbling patients A fundamentally bad model Hiding behind poor access. 3 4. Same Day Access Why Bother? Patients Council (2010) of 4000 respondents 82% said they attended AED because they could not get an appointment with their GP Liverpool Insight work (2011) - 49% of patients said they would use AED if they could not get satisfactory access to their GP Review of 2012 GP patient survey against the Liverpool GP specification AED indicator suggests that in practices with few pts attending AED in hours vs. practices with more patients attending the ease of phone access is similar with 77% saying phone access was fairly or very easy vs. 79% respectively However patients getting same day appts were 58% vs. 23% respectively suggesting the easier that a pt receives a same day appt the less likely they are to go to AED Better continuity results in reduced use of secondary care services (Richard Baker Leics. University and Stour PA practice) Evidence suggests that 50% of patients who end up seeing a doctor didnt need an eye to eye consultation (PA) 80% of patients offered a same day appointment will take that appointment (PA) 19.5% of complaints taken forward by Liverpool PCT from April 2011- to March 2012 had an access component to them 4 5. What did we have 1? 2 week wait to see a partner Average 6 day wait to see any doctor All pre-bookable slots gone everyday Most book on the day slots gone Patients ringing at 8am 5 6. What did we have 2? High DNA rates Nightmare on call days Frustrated doctors Miserable reception staff Unhappy patients Minimal Proactive management of capacity 6 7. What have we got now? Benefits for the partners Control over the appointments Knowledge that we are on top of our workload Proactive management of our appointments/ capacity Less impact if a doctor off sick Frequent unfilled appointment slots 7 8. What have we got now? Benefits for the Elms MC No backlog Minimal DNAs falling secondary care utilisation Control over patient selection for registrars Receptionists who can say yes Patients who dont need to see a doctor dont see a doctor 8 9. What have we got now? Benefits for our patients More timely assessment of Mental health problems Some cancer presentations Patients who need to see a doctor see a doctor Easy access to advice High reported patient satisfaction 80%+ of patients seen the same day Median time to see GP 83 minutes 9 10. What had we tried before? Everything: Open access Routinely bookable Book on the day appointments Telephone consultations Nurse practitioners On line booking Hybrids of the above 10 11. Preparation 1 Read about Patient Access in Pulse 2010 Made contact with Harry Longman late 2010 Utilised winter pressures money - PCT Scrutinised our appointment data Consulted with the staff 11 12. Preparation 2 Engaged Harry and PA Picked a date Advised the PPG Notified the patients Stopped taking advanced bookings Went live April 16 2012 12 13. Patient Journey Patients rings surgery Receptionist takes details (if patient agrees) GP rings patient back Patient has face to face appointment arranged or Other solution to problem provided 13 14. Drop in waiting time to see GP All data from The Elms, charts by PA Navigator From launch date, drop in waiting days to see GP from 6 to 1 15. GP call back median time is 12 minutes 16. Median time to be seen following call is 71 minutes. Median 71 minutes, data from 4 full weeks 17. Secondary Care Utilisation Liverpool GP Specification Liverpool PCT funded Primary Care at 151/152 PCTs 6m funding to get practices to minimum of 90 Variety of KPIs Proxy measure of access = in hours AED minors attendances 17 18. AED in hours attendances 18 19. AED in hours attendances 19 20. Alderhey 20 21. Alderhey 21 22. Patient view; Patient Satisfaction data Family and friends recommendation; Excellent 40% Very good 21% Good 20% CFEP UK Surveys IPQ Report 24548/3025 23. Patient view; Patient Satisfaction data Q2) Telephone Access 73% - G VG Ex 23% - P F Q3) See Practitioner in 48/24 hours 86% - G VG Ex 10% - P F CFEP UK Surveys IPQ Report 24548/3025 23 24. 70% of patients rate the new system better, 3.7% worse (note: n = 27) Independent qualitative research for Liverpool PCT by GfK shows what matters most to patients is speed and continuity. 25. Patient view: Patient Satisfaction data Q4) See Practitioner of choice 38% - G VG Ex 48% - P F However Q12 continuity of care 77% - G VG Ex 13% - P F CFEP UK Surveys IPQ Report 24548/3025 25 26. Patient view; Patient Satisfaction data Q5) Booking advanced appointments 46% - G VG Ex 38% - P F CFEP UK Surveys IPQ Report 24548/3025 27. Patient Dissatisfaction 1. Advanced booking 2. Ability to see doctor of choice (continuity) 28. Advanced booking Issues ; Part time workforce Poor patient engagement Failure publicising new system Unrealistic expectations of our patients? 29. Continuity. Patient view; individual continuity GP view ; treatment continuity Where GP felt continuity important it was achieved in >97% of contacts Elms upheaval recruitment issues older partners We can work towards better continuity 29 30. Patient view: What Do Patients Think? Qualitative Survey October 2012 Speed of access to problem resolution Individual continuity (LTC patients) Speed trumps continuity for the majority of our patients. 30 31. 72% of demand is acute. Access has not increased demand All data from The Elms, charts by PA Navigator Very small, only 2%, considered by GPs as self care. Floodgates have not opened. 32. With largely acute demand, continuity considered by GPs as important in 35% of cases and achieved in 32%. All data from The Elms, charts by PA Navigator 33. Continuity has remained stable through the change. Measured statistically, % of patients seeing same GP. All data from The Elms, charts by PA Navigator This means that on multiple consultations, a patient has about 60% chance of same GP 34. Impact on Clinical Capacity This model of delivering appointments provides Same Day primary care access at about 20% lower clinical capacity than would be needed using the traditional model of reception booked primary care Here is how.. 34 35. Impact on clinical capacity Activity 2010 vs. 2013 August & September 2010 and vs. June & July 2013 Average telephone calls - 190 vs. 600 Average face to face - 860 vs. 420 Total contacts - 1050 vs. 1020 35 36. Impact on clinical capacity Activity : Phone Calls Weekly phone calls 2010 vs. 2013 190 vs. 600 @ 4 minutes each = 760 minutes vs. 2400 minutes = 12.6 hrs. vs. 40hrs. 36 37. Impact on clinical capacity Activity: Face to Face Weekly face to face 2010 vs. 2013: 860 vs. 420 @ 10 minutes each = 8600 minutes vs. 4200 minutes = 143hours vs. 70 hours 37 38. Impact on clinical capacity Activity: Hours per week overall difference 2010 vs. 2013 hours per week: Hours = 156 vs. 110 Because phone calls take less time than face to face we need less hours. 38 39. Impact on clinical activity; Backlog Elms back log conservatively was 300 appointments when we changed over This represented a weeks work for 2.5 WTE GPs yet to be done Currently minimal back log. (Minor surgery and baby checks excepted) 39 40. Overall demand has drifted down by 12%. Early rise in contacts With rapid response, demand drifts down 41. Downsides 1 Exposes a lack of capacity Need to flex up when things get busy Got to do today's work today Not everyone enjoys triaging Not everyone is effective at triage Triage can be intense and unpredictable Negative GP view of advanced booking Some patients dislike the lack of control 41 42. Downsides 2 Receptionists can dump on the triage list You must keep on top of your phone answering Reduced opportunistic activity Hearing language and telephony issues Patient perception of continuity Change in relationship with some patients De-personalisation of the encounter is not for everyone 42 43. How did it go? 1 Badly!! We didnt consult meaningfully enough Some doctors not fully on board Some doctors dont like triaging Some doctors are less good at triaging We didnt cater for initial surge in workload 43 44. How did it go? 2 We didnt match capacity to demand Full details as to why if needed Reception dumped everything on to the triage list We were too long ringing people back We didnt keep on top of the phone demand The sessions had no break in them 44 45. How did we make it work 1 Partners took up the slack Continuous change and adaptation Certain principals became apparent You must map out demand in real time Plan triage at 4 minutes per call 45 46. How did we make it work 2 Must keep up with the triage in real time Better to have triaging and seeing appointments separated Lunchtime cut-off We are still tweaking - possible limited condition list for reception booking 46 47. Week plan- updated regularly Session Triage needed Appts needed Mon am 120 45 Mon pm 75 60 Tues am 90 45 Tues pm 60 30 Weds am 75 30 Weds pm 40 30 Thurs am 75 30 Thurs pm 60 30 Fri am 75 45 Fri pm 60 30 47 48. Our Golden Rules 1 Know your hourly demand for triage calls Know your average daily appointment demand morning and afternoon Proactively match your capacity to your demand- especially with triage Keep up with triage in real time Where possible have doctors either triaging or seeing in any one session not both 48 49. Our Golden Rules 2 Most appointment requests come during the first 2 hours so dont provide appointments too early Triage time 4 minutes per call Triage rate 15 per hour Appointments 6 per hour Provide an end to the sessions 49 50. Our Golden Rules 3 Play to the strengths of your team Sacrifice F2F for triage and add extra f2f after Do not give away the next sessions appointments You decide what continuity means Have an escalation plan 50 51. Questions & Answers 51