Originally published on the Centre for Health and the Public Interest Blog. Please visit their excellent website http://chpi.org.uk/ for detailed papers looking seriously at health-policy that relates to the public interest.
The government has laid out its ‘Plans to Improve Primary Care’, focusing on GPs. Few GPs will read this tediously repetitive, wordy document, full of un-evidenced assumptions – that IT, home care and schemes to avoid hospital admissions will save money. Gimmicks like a named GP for patients over the age of 75 reveal how little they understand which patients most need continuity of care and the ‘Friends and Family test’ has not been shown to have any effect on quality. Labour’s response, apledge that patients can book to see a GP within 48 hours is a political target that has nothing to do with clinical need and will be fiddled, fudged and ignored. Such gimmicks from both sides will not help patients and will only add to the frustrations and lack of trust towards government among the profession.
What could the future of General Practice look like, realistically – taking into account patient needs, increasing demand, and policy and financial pressures?What follows is a description of what is already possible. I am not aware of any practice that works exactly like this, but some practices are very close. You will see that one aspect is the way appointments are organized. One GP surgery’s experience of changing its appointment system has been written up in a blog by GP Heather Wetherell. Evidence of confidence in this kind of system can be seen by commercial organisations like Doctor First and Patient Access that help GPs make the change. Another aspect is patients’ access to their GP records. Amir Hannan, Brian Fisher and Patients Know Best have pioneered ways for patients to access their GP records. Many practices are incorporating these changes. They are being driven by GPs in response to patient needs, increasing demand and policy pressure.
The Future of Primary Care – a possible scenario
Five doctors, all GPs, and two nurse practitioners are sitting in a large room wearing headsets. They are separated by booths so that neighbouring conversations cannot be overheard by patients. Two of the GPs have a trainee listening-in through a second headset. It is a Monday morning and they are managing the demand from a practice with thirteen-thousand registered patients. The calls come through to the receptionists who add them to a single list that appears on the screens in front of the GPs. Patients who are distressed or have serious symptoms like breathlessness or chest pain are highlighted. Patients who are unable to use a phone or cannot speak English still come in to the surgery. On a Monday morning they handle about 250 calls, see 40 patients face to face and do 3 visits. Other days tend to be much less busy. Occasionally a patient is put on hold and the doctor or nurse asks one or more of their colleagues in the room for advice.
The nature of a clinical encounter is far more suited to a phone-call than email because of the quite intense nature of listening, questioning, clarifying, mutual understanding and reassuring that goes on. In a consultation, narratives are explored and created. This is far more suited to a conversation than an email exchange. Email still accounts for a tiny proportion of interactions. On the policy advice of mostly young, fit men, there is a risk that the government will squander millions on secure on-line consultation technology that will lie largely unused. Such is the nature of healthcare schemes dreamed up by fit, young men.
Calls take anything from a minute or two to half an hour or more. The written documentation has to be thorough and records are audited regularly by listening to the calls that have been recorded and reading the notes. I’m found guilty of writing too little and it’s a useful bit of feedback. My practice improves.
Every few minutes one of the doctors or nurse practitioners gets up and goes into the waiting room to call a patient that they have invited to come in to the surgery. They lead them into one of five consulting rooms and are with them from 2 to 30 minutes depending on the patient’s needs. Average consultations are about 12 minutes, but the doctors and nurses have the advantage of knowing in advance why the patient is attending. The problem of patients failing to attend appointments has almost been eliminated.
Four or five times a day a doctor goes out to visit a patient at home. Around here where I work in Hackney, most doctors do their visits on bicycle or foot simply because it is the easiest way to get around. Dealing with demand by phone has reduced the need for visits, perhaps because patients are more confident of getting through to a doctor when they need to.
Every patient will be registered with their own doctor, and if they are on duty will be called by them. Both doctors and patients value continuity of care. Patients will often wait to call on a day when they know their own doctor will be on duty. If they cannot, and their problem is complex or longstanding, another doctor will ensure it’s safe to wait and arrange for the usual doctor to call back. Out of hours calls and A&E attendances have also significantly reduced.
The practice has invested several thousand pounds setting up the call center and telephone bills have increased significantly, but they have saved on space by reducing the number of consulting rooms, and are sending far fewer letters. In a few years they hope to recoup their costs.
The service runs from 8am to 6.30pm Monday to Friday with later evening booked appointments. Once access improved, demand for late appointments diminished and hours were cut to save money. GPs are usually working until 8 or 9pm to finish their admin. When the surgery is closed, local practices share the workload using a similar model working shifts with the local social enterprise which comprises 34 GP surgeries. Patients can speak to a local GP at any time of day or night, but most prefer, and are encouraged, to speak to their own GP for reasons of continuity and safety. The ability to access every patient’s electronic record is still a pipe dream that extends back and forwards into the mists of time, littered by untold billions of wasted pounds. Fortunately most patients can access their own records and though many of the most vulnerable are unable or unwilling, it helps somewhat.
Doctors work shifts with protected time set aside for administrative tasks, teaching sessions and meetings. Their shifts are advertised so that their patients know when they are available. Patients are surprised to find out that each full-time GP is responsible for over 1500 patients, takes over 50 phone calls a day and spends over 2 hours a day on admin and up to 6 hours a week in meetings, teaching, etc. Every month the practice publishes data showing how many patients have been seen and how long they waited for their call to be answered and for the doctor to call them back. They also publish an anonymised summary of patient complaints and the actions they are taking in response. Complaints have reduced from several a week to a handful each month and patient satisfaction has increased from just over 70% to over 90%.
Planned care for chronic diseases like heart-disease, diabetes, asthma, contraception and antenatal care is still booked in advance with the practice nurses and midwives face to face. Patients needing blood tests, ECGs and breathing tests are seen by nursing assistants, some by appointment and some by a walk-in service. The nursing assistants are also trained as receptionists and when the phones are busiest, they work in reception. Patients are also offered minor surgery, physiotherapy, psychology and antenatal care. Patients from local GP surgeries who do not offer these tests because they lack the space or resources can come to a neighbouring surgery than has the facilities. A contract has been set up so that practices that are willing and able to offer services which others cannot, will be paid to do so. This way, patients do not have to go far for their tests and can stick with their local GP who they know. Local surgeries are supported and share resources and expertise. The contracts are repeatedly contested by private companies like Virgin and Serco, but thanks to campaigning by local patients we are able to keep the services in GP surgeries where patients actually want to go. The time and costs involved in tendering for the contracts is burdensome and takes clinicians and money away from patient care.
There are downsides.
Making the changes is very stressful, as described by Dr Heather Wetherell. In many cases practices eventually change when present systems have become intolerable and those that are working in them are already stressed. The changes are designed to improve the experience for patients rather than those that are looking after them and for some doctors the added pressure of major change is too much. Nevertheless, practice staff do feel satisfied knowing that they can help every patient that needs them, appointments are never wasted, complaints are down and patients are happier. Receptionists no longer have to tell patients they cannot see their doctor for 2 or 3 weeks. Doctors are working even later into the evenings than used to be the case in order to finish their administrative tasks and the pressure to answer a never-ending queue of calls is relentless. Finding suitably experienced nurse practitioners is extremely difficult and understaffing is a serious problem. It takes about 6 months for the new system to bed-in and inevitably, some patients are angry and confused to start with despite efforts to explain the changes.
If a doctor or receptionist is off because of sickness, pre-booked appointments rarely have to be cancelled as they are now, but the work has to be covered by the remaining staff and the time taken to return calls from patients increases significantly and everybody who can ends up staying late. Resentment towards those who cannot stay late has to be managed. It is very difficult for doctors to plan work after their shifts are supposed to finish.
It doesn’t suit some patients who cannot use the telephone because of speech and language barriers, cost, etc. – some don’t have phones, and some don’t like using them. Allowances are made to ensure that these patients can book appointments directly and because of the flexible appointment system they can be seen on the day if necessary. Making a diagnosis on the basis of what I see when I meet a patient face-to-face remains an important part of my job and I’m worried about patients now being able to choose to see me.
With the exception of A&E, other parts of the NHS are being forced to restrict access to cope with serious and prolonged underfunding. A system of GP access that is demand-led means that GPs cannot restrict access and so will take the strain when other parts of the system do. A letter from senior NHS managers in the Guardian highlights the dire situation now. Of particular concern are changes to the GP contract that could see up to 100 GP practices, including ours, close. We are set to lose up to £200,000 a year, equivalent to 2.5 full time GPs or 300 appointments a week.
This could be The Future of Primary Care, but we do not have enough GPs to meet patient demand. The risk is that GPs will put up barriers to protect themselves from demand they cannot possibly hope to meet.
It is vital that we remind those in power that ‘despite being an oft-repeated command to dying institutions, the ability to do more with less is an inherent impossibility.’
How to destroy General Practice. Margaret McCartney. BMJ June 16th 2014
GP numbers tumble in England as recruitment crisis bites. Guardian June 14th 2014
Almost 40% of GP training places unfilled in some places in the UK Pulse June 14th 2014
Plans to shift hospital care into the community doomed as district nurse numbers tumble. Guardian June 17th 2014
Something is profoundly wrong with the NHS today. Clare Gerada. BMJ Careers June
Save Our Surgeries: campaign to help surgeries threatened with closure under the new GP contract.
RCGP Put Patients First Campaign.
The Doctor will Skype you now. A few words of caution about not seeing the patient face to face.
Three papers I use to teach trainee GPs about phone consultations:
You missed out pre-consultation software and placeshifted GP’s. A couple of those GP’s will be remote, one at home with the kids, the other semi retired working from Majorca. Locums may never have to travel.
100% telephone triage is very bad news. The loss of the ‘soft knowledge’ we gain from our patients and their families when seeng and chatting to them (what they dress like, who are they with etc) is vastly underestimated. This more phone-based purely transactional primary care will just increase inequalities and social isolation. We also lose many more of those critical door handle moments
It is also putting too much pressure on GP’s, the burn out rate will spike further as junior doctors shun a future call centre life (as they are already).
Jonathan, I am not sure, after having read your article, whether what you describe in “The Future of Primary Care” is what you are actually doing in Hackney or what you might find yourselves doing in Hackney if you implemented this way of running General Practice.
The idea that one can deal with an increasing workload whilst maintaining quality and safety but with fewer resources is rather like thinking one has solved the riddle of perpetual motion. Friction will always foil your attempts.
We’re not working this way, though I imagine we might be at some point. There are simply not enough GPs or nurse practitioners to make it work at present and I’m still uneasy about not allowing patients to book directly if they wish. I’m pretty reassured by Heather’s experience though …
Have to agree with Gus – but the beauty of the system we use is that by allowing much greater use of, and access to, telephone consultations by those who activey ‘want’ them (around 60-70%) then we free up face-to-face consultations for the rest. Indeed, in our experience, it is this latter group (30-40%) who are more likely to be those ‘door-handle-moment’ patients. All we have done is create a ‘distillate of need’ and generated more GP time for those that really need it.
The job is immensely more satisfying. The patients are happier, more relaxed, and well educated in selfcare – yet know they can see the GP (of their choice) whenever they need.
This is exactly what we have developed over the last 3 years with the latest addition of patients being able to rapidly request a call back online. I beleieve we have created a model which is as efficient as it can get in this direction but has left us with a few problems in addition to the ones you describe:
1) massive un addressed funding discrepancies across the UK mean we have to operate locally at more than 2500 patients per doctor and as a 12000 patient practice have a turnover less than an 8000 patient practice elsewhere. We therefore operate on the edge of ideal with the dream situation of longer face to face appointments not materialising and actually a tendency developing to shorten appointments because we have spoken to them already. Consequently long term condition expertise doesn’t develop and referrals for conditions like Parkinson’s which could have been managed further in the community continue to go to the hospital. Our relative inability to make the phone system work compared to other practices was a mystery until we discovered this.
2) All of our doctors feel less like doctors than they did 3 years ago, feel they have become the front face of a trivialising process playing lip service to an increasingly insecure and unsupported society rather than exploring greater medical complexity as in US and Australian Chronic Disease Models. In addition to the demoralizing impact of this we have a group of patients who are more vulnerable than out nurse led LTC clinic can reach and they continue to bounce back and forwards between the hospital and their home, often bypassing our system all together. CCG colleagues tell us reducing this has a far greater financial impact than diverting some minor illness away from the UCC through rapid access and although I haven’t seen peer reviewed evidence of the 38% hospitilisation reduction Chen med claims for vulnerable patients I would be interested to understand this further.
3) some doctors have become almost phobic of telephone calls, one has retired early and another is about to
4) Despite achieving an average phone back time of 12 mins and a 90% same day GP face to face appointment there has been no financial reward for this and a significant phone system investment
5) Sensible blog posts like this and reasoned responses based on years of tweaks and data gathering seem to have little resonance in the debate on developing the NHS either with the CCG and NHS England or with GP colleagues
6) we have developed significant IT improvements to make life more convenient for the patients and allow them to talk to us and collect prescriptions etc remotely but access to diagnostics and interactions with the hospital are still in the dark ages with a high % of our time still spent chasing the hospital for results.
7) As you mentioned in a demand led system there is no where to hide when there is sickness or holiday. Regardless of staffing you are providing unrestricted access and extra staffing in the form of long term slack, locum staff or extra hours needs to be found if you don’t want performance to suffer
In conclusion if all General Practice was tariff based or at least speed and continuity were awarded financially and if all practices developed access systems similar to this I believe the needs of 90% of access would be solved overnight. In addition I believe there is a need for additional funding, relocated from secondary care, to develop a greater proactive, planned chronic disease practice based model with all the other professionals including social care genuinely co funded and co located around the GP.
I also believe that there is sketchy evidence for any of what I’ve just said and that the profession needs to be on the one hand much more open minded and the other hand much more rigorous in gathering evidence about the way forward. Otherwise my experience has been that our inertia puts us at the whim of politicians and management consultants and most of our time as medical leaders is spent unpicking the misconceptions of the people with control of the money. Even hospital consultants weigh in to this debate with very little comprehension of what is happening in the community. Leadership based on strong internal evidence gathering capability is a desperate need in General Practice.