Tackling one of the NHS’s biggest issues: GP access

Content

GP access: the need for change

One of the major issues facing the NHS today is GP access. Stories of increasing waiting times and booking systems that are full at 8.00am every day are common. Surgeries are struggling to cope with an ever growing demand for appointments. This is the story of how one surgery in Salford used innovation in service delivery to improve.

This is leading to GPs being unable to see patients quickly, stress for patients who are trying, and often failing, to be seen by a healthcare professional, and stress for staff having to say “no” to patients and working long hours but not seeing all the patients they need to. A lack of timely access for patients can have a number of knock-on effects, including:

  • Poor experience for patients and carers
  • Poor experience for primary care staff
  • Increased health inequality due lack of health promotion opportunities
  • Increased use of secondary care such as hospitals

A ‘typical GP Practice’

Faced with the same issues, Clarendon Surgery in Salford decided something had to improve, as access was now impacting on the service their patients received. Clarendon Surgery could be called a ‘typical’ GP practice; it has 9,000 patients, three partner and four salaried GPs, three nurse practitioners and is a teaching and training practice.

“The staff couldn’t cope with the volume of calls, the patients couldn’t get through and sometimes the phone system would crash from the sheer number of calls we had coming through in such a short space of time. Our surgeries were fully booked, if you hadn’t made an appointment by 8.30am all the slots were filled, the waiting room was packed, we were making telephone calls, and patients still couldn’t get an appointment.

“From a staff perspective, we had a high non-attendance rate for appointments, it was a miserable environment for reception staff, we GPs were stressed and for everyone just ‘working harder’ wasn’t having any effect. We had to do something different.”

Dr Jeremy Tankel


The transformation process

The critical change that transformed access for Clarendon Surgery was a new telephone appointment system. Previous studies have suggested that GP-led telephone triage can reduce demand for face-to-face consultations by up to 35-50%1 , can reduce DNAs to near zero2, and is an acceptable alternative to a request for a same-day appointment for over 80% of patients3. The implementation process for this new system involved preparation of staff and systems, a “big bang” switchover, measurement and monitoring of performance and several cycles of identifying and testing changes to improve and refine the service.


The ‘big bang’

Opting for a full, rather than transitional, implementation of the telephone appointment system allowed Clarendon Surgery to focus their efforts on a successful launch, without the added inconveniences and issues that would come with trying to gradually change from the old system.

To achieve this, a number of updates to practice infrastructure, staff training and appointment management took place before the ‘big bang’.

“As it was going to be a fundamental change to the way we deliver care, before we went live we put a lot of effort into retraining for administration and clinical staff.

“There were also practical improvements that needed to happen such as installing more phone lines, new telephones and headsets. We had to stop taking advance bookings as it was a ‘big bang’ switchover.”

Dr Jeremy Tankel


Finding their feet: The early months

In the first month of the new system going live it was taking three hours for 90% of patients to receive a call back. With a number of tests of change over the next three months this was improved to perform at nearly two hours. These improvements were achieved through a number of factors, including:

  • Realising that not all patients can be treated over the phone, if telephone consultations looked as if they were going to take longer than five minutes then these were patients who needed to visit the surgery
  • Staff, having never used a system like this previously, became more confident and experienced
  • Patients began to change their behaviour and started to trust the new system. Any patient who expressed concern or dislike of the changes spoke with a clinician or the practice manager who found out their concerns and experiences so the practice could learn from feedback

The 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.

Getting it right: identifying and testing changes

Clarendon still didn’t feel that two hours was a good enough time, so from April to May 2013 more improvements were introduced, including:

  • Individual call back lists for doctors in the morning
  • A communal call back list in the afternoon
  • A break between 1.00-2.00pm where no calls were taken

Again, patients and staff responded positively to the changes. In this period, half of patients were called back in less than two hours.


Pushing the boundaries: Refining the service

The surgery felt that the system still had potential to work even better, without just relying on goodwill and hard work, so they tested and implemented:

  • Giving doctors individual call lists in the morning and afternoon (removing the communal list)
  • A break between 12.00pm and 2.00pm where no calls were taken, except on Mondays when they were busiest
  • Additional doctor time allocated on Mondays to cover the extra demand Graph shows improvement over time for patients being called back

Now the practice has a system that enables 90% of patients to be called back within fifty five mins; this is a two hour improvement since the start of the project, 54% of patients are called back within twenty minutes or less and 71% in thirty mins or less.

90-called-back-within-graph


Sustained success

Most importantly of all, this fantastic improvement has been sustained. Patients are happy that they can call up and know when they will be treated, and the surgery is now out-performing other practices in Salford:

  • 93% of people now find it easy to get through to the surgery on the phone compared to 73% across Salford CCG
  • 92% of people got an appointment to see/speak to someone last time they tried compared to 84% across Salford CCG
  • 93% of people are satisfied with the surgery’s opening hours compared to 78% across Salford CCG
  • 87% of people would recommend Clarendon Surgery to friends and family compared to 76% across Salford CCG

Not only are patients getting a better service, this system has also improved life for practice staff.

“Staff no longer had to say ‘no’ to patients. They no longer had to say ‘we have no appointments, call back tomorrow’. You can hear the surprise in people’s voices when you say would you like to come in for an appointment today. But it’s not just about satisfaction.

“I’ve got no doubts that a telephone appointment system is a safe system. When you compare it to a system where you can’t get through to a doctor at all and therefore care is being ‘rationed’ by non-accessibility; I don’t believe that is a safe system.

“Personally I think we’re now offering a better service.”

Dr Jeremy Tankel

Download the full case study here.


References

References

  1. Jiwa, M., Mathers, N., Campbell, M. (2002) “The effect of GP telephone triage on numbers seeking same-day appointments”, British Journal of General Practice, 2002; 52, 390-391
  2. Brown, A., Armstrong, D. (1995) “Telephone consultations in general practice: an additional or alternative service?” British Journal of General Practice, 1995 Dec; 45(401): 673-675
  3. NHS Improvement (2008) “Stour Access System: a new way to manage GP appointments” [online] http://www.institute.nhs.uk/images/documents/ CareOutsideHospital/Stour%20Access.pdf