General Practice - Appointments, Capacity and Choice

Talk to anyone about the thing that irritates them about General Practice and the first thing they mention is appointments. It’s not just the patients! The staff also feel the pressure on appointments.

How can we increase capacity in General Practice so that there are enough appointments when there are a falling number of GPs?  What is ‘enough’ appointments anyway?

There are those who say we should also increase choice for patients in where they go for primary care – “more surgeries” is the cry.

The digital solution

There are several websites or Apps, such as http://askmygp.uk/ that allow people to enter their symptoms and answering some questions allows the GP to work out the best way to help.  These may advise the patient as to who is best p[laced to help them. This may create some spare capacity so that those who need to see a GP, such as people with complex needs, can do so.

The ‘do it on the phone’ solution

Instead of seeing a GP or other healthcare professional the patients the consultation will take place on the telephone or via Skype or some form of webcam interaction or by email. There are a number of solutions available to manage phone calls such as http://gpaccess.uk/ & http://www.digitallifesciences.co.uk/

Both of the above solutions could also be considered the ‘managing the demand side’ solutions.

The Changing traditional General Practice or more GP surgeries solution

(‘more of the same’)

This solution is about increasing the number of GP surgeries so increasing the number of appointments and increasing choice for patients.

So how do you go about developing a new surgery? You need to raise the cash to buy or rent a suitable building. You need to recruit the relevant staff. That means a full multi-disciplinary team to provide a 21^st century service. The cost of a building for 6000 patients could be around £1.5 million but could be more if an extended team is required.

 This investment has to come from somewhere.  There is the Prime Minister Innovation Fund (now with a smart new name) that was for existing practices if they developed 7 day working. There has not been any funding for new builds from central government for the last 25 years or so. If there is a new housing development and if the local planning authority is up to the mark such a new building could come from ‘planning gain’ and built into the cost of the development. However the developers would only build the bare minimum – based on 1990’s requirements.

However there is still the problem of revenue costs which has to currently come from the NHS. Unless, of course, there is a change in the views of the public on private healthcare or health insurance.

Finally there is the problem of recruiting the staff. GPs and nurses are hard to recruit or retain at the moment.

The nuclear solution

One way of increasing appointments with a GP is to do the reverse.  Patients will only see a GP after they have been seen by another health care professional, (a nurse, a pharmacist or an emergency care professional).  They would refer patients onto a GP as appropriate in the same way as a GP refers to a consultant.  Thus the GPs would see fewer patients.

Other solutions

• Reduce unmanageable & unsafe workload
• Improve perception of General Practice as a career option for junior doctors & nurses.
• Reduce administrative & regulatory burden.
• Return to self-management of minor illness.

There is a final solution 

There could be real and meaningful investment to restore the percentage of the NHS budget spent on General Practice back to the 10% it used to be.

So how will these solutions increase choice and capacity?

Really the only solutions to do that are ‘the more of the same’ solution of increasing traditional general practice by increasing the number of practices.

This is highly unlikely given that there is no investment in new building and real problems in recruiting new GPs.  If the government does not invest will private investors take that role?  Again, in my opinion, I think that is unlikely as there is no profit to be made from general practice at present.

Would a community enterprise or other not for profit organisations invest in general practice?  That is an interesting question.

So sadly I can see no way to increase choice for patients.

Similarly the only way for general practice to survive is to manage demand rather than increase supply.

#GPincrisis

Urgent prescription for general practice

Impact of a shortage of GPs

In many parts of the country GP surgeries are having trouble recruiting Doctors and Practice Nurses. 

What impact is this having on patients and the care they receive?

My guess:

·        There will be a shortage of appointments, so patients will have to wait longer to see a GP.

·        Telephone lines will be even busier so it will be harder to contact the surgery.

·        Patients will be asked (forced) to see someone other than a GP.  This may be a Practice Nurse or a pharmacist.

·        More locum staff may be employed.

·        Practices may close completely.

·        Surgeries will close their lists to new patients.

·        Branch surgeries will be closed.

New patients will have to join another practice which may be some distance away from their home.

This will put pressure on these other practices as they get more patients joining the practice and the cycle continues.

It’s the patient experience, stupid!

I have always thought that the main role of local Healthwatch was to collect the experiences of patient using the health and social care services.

But one of their board members is quoted in the minutes of their November board meeting as saying

 “Healthwatch Bucks could make a business case for the integrated collection, analysis & reporting of patient feedback across health and social service provision in Buckinghamshire”.

http://www.healthwatchbucks.co.uk/sites/default/files/board_minutes_11th_november.pdf

So why does this board member think Healthwatch Bucks needs to make a business case to do what it is contracted to do anyway?  By using the words ‘business case’ he is suggesting, in my opinion, that they should seek funding to do this job. 

They should be doing it now as part of their primary function, not asking for more funds!

I wonder if he has seen what Healthwatch Buckinghamshire says on its own website.

This statement is included as part of their ‘What we do’ section on the Healthwatch Buckinghamshire website

“Collect data and stories about the good and the bad, so we can use evidence based criteria to influence commissioning and policy.”

They expand on this theme in their ‘What will Healthwatch do’ section of the website:

“….seek the views of people about their needs for, and their experiences of, local care services.”

“Examine the quality of local health and social care services.”

“Make the views of local people known, and reports and recommendations about how local care services could or ought to be improved, to people responsible for planning, providing, managing or scrutinising local care services.”

http://www.healthwatchbucks.co.uk/

Even the CCG has something to say on the issue:

In their draft paper on the Review and Development of our (AVCCG) Commissioning Intentions they say:

“(the CCG will) Work closely with Healthwatch to expand the feedback we receive on patient experience from direct observation and feedback from patients, clinicians and the public including those from hard to reach communities. “.

http://www.aylesburyvaleccg.nhs.uk/wp-content/uploads/2013/10/GB-2013-10-4b.pdf

It is high time Healthwatch Buckinghamshire stopped talking and got on with its primary function.

Go out and collect the experiences of patients and carers of health and social care service provision.

Conversations between patients and hospitals

Some hospitals and the newly created Clinical Commissioning groups are finding it difficult to engage in a meaningful and effective way with patients and the public. 

These are my thoughts on how they could hold a conversation with the public rather than 'engage' with them.

• Go out to the people – don’t expect them to come to meetings.  It’s the same old faces, like me who go to public meetings.
• Use language suitable for all
• Keep it simple
• Keep events small and short
• Don’t give too much information at any one time
• Leave time for reflection
• Be prepared to repeat and revisit issues
• Hold a conversation
• Use patient leaders/champions
• Feedback is essential. Explain how the input from patients has been used and has influenced change
• Be informal, don’t lecture/broadcast.
• Use staff, not managers/executives (?)
• Be bold, take risks, do something different.
• Social media is very powerful but it is a conversation. Those of us who use twitter get irritated if all we get are broadcasts and publicity messages. 

How to improve healthcare in your area

How to Improve Healthcare in Your Area.

Patient and Public Involvement in Healthcare

I find that patients are, on the whole, only too happy to discuss their experiences of using the health service. In fact often it is hard to stop them talking and I cannot take notes fast enough!

Yet they find it hard, as individuals, to get their opinions listened to by Hospitals, PCTs and Social Care providers and commissioners.

Perhaps part of the problem is the bureaucracy and apparent inflexibility of these organisations. They like to do things in formal ways, by holding consultations and engagement meetings. Most patients prefer a face to face, informal conversation.

Patients also want quick feedback.

Then there is the language!

Public and Patient Involvement (PPI) has its own jargon, like many of things that happen in the NHS.  There is ‘engagement’, ‘consultation’ and ‘involvement’. They seem to mean different things to different people. In fact to most patients they mean little. They are words that managers use and are found in all the strategy documents and reports published by hospitals and the government.

Patients just want someone to listen to them and then to take some action so that services are provided or improved. One of the things that patients feel is important is to have some feedback from the organisation about how it is using the information it receives from patients.

This is what the government has said (see bullet point 6) about giving patients a louder voice through the Health and Social Care Act 2012:http://www.dh.gov.uk/health/files/2012/06/B3.-Factsheet-Greater-voice-for-patients-300512.pdf

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Involving Individual Patients

Patients, at an individual level, have always been involved in managing their own health.  This took place, either through self-management of their illness or during the consultation with a health professional. Between them the patient and doctor or nurse will work out what is best for the patient.

There are times, however, when the patient would still say “What do you think, Doc?”  But in every consultation there should be some form of joint decision making about what should be done to improve the patient’s health and wellbeing.

There are other ways that patients, as individuals, can influence how healthcare services are delivered.

Choice.

We all, as patients, have the right to choose where we receive our hospital treatment. The hard part is finding out which hospital provides the best treatment for our condition and for us as a person. But by making a choice we are influencing those who make the bigger decisions for all patients. So ask your GP about the quality of the service you need.

Patient Advice and Liaison Service (PALS).

If a patient or carer has concerns about something then one way of letting the organisation know is through the PALs officer.  This service has been around for a while now and the PALs officers are there to provide information about services but also to sort out minor concerns and problems that patient’s experience.

The PALs officer is able to pass on the concerns to senior management who should sort it out or provide explanations.

Regular reports are made to the hospital board on the number and types of issues that come to the PALs department.  The idea is that this provides information on services that may need to be improved in some way.

Writing to MP and local press.

This is always a good way of getting the attention of the Chief Executive.

Ask questions at Hospital Board meetings.

This is not easy for some people and I suggest that you write down your question and ask the chairman to read it out.

Ask questions at your local Council Overview and Scrutiny Committee.

Again some people might find it easier to ask the chairman to read out your question.

Complaints.

People are often hesitant in making formal complaints. They are concerned that if they cause a fuss something might be written in their notes about being a ‘trouble maker’.

However every complaint has to be investigated and a report is seen by the Chief Executive. A sub-committee of the board will also see the investigation and should make sure that actions are put in place to ensure that no harm comes to future patients. Regular reports are made to the board in public on the causes of complaints and the actions taken to stop similar things happening again.

Sadly, sometimes the only way to make sure that services are improved is by making complaints. 

The NHS needs to make it easier for people to make complaints. There are organisations, such as ICAS (see below) that support patients, their carers and relatives, in making formal complaints about the care they have received.

The Independent Complaints Advocacy Service (ICAS). ICAS provides advocacy support to people who wish to make a complaint about the service - or lack of it - that they have received from the NHS.

Finally patients and carers can also influence the way their healthcare is provided by joining one of the many groups that exist in the community and becoming part of a network.  Networks of people tend to have a louder voice than an individual.

There are lots of organisations and groups in the community that can help patients and members of the public to influence the authorities. The hard part is to find them and then to find the time to be active.  Often local councils will have lists of such organisations.

Join your local GP surgery Patient Participation Group.

If you have a long term medical condition you could join the local user group (or set one up). These groups are often used by the authorities to provide ideas for improvements in specific services such as stroke, diabetes, mental health, disabilities and other conditions.

There are local & national charities and other voluntary sector groups who support patients and carers and who can start campaigns to improve care services.

Foundation hospitals will have members who elect a board of Governors who can influence the executive board of the hospital.

Hospitals and PCT (and hopefully the new Clinical commissioning Groups) have patient experience groups or forums.

Online groups.
There are plenty of online groups that can both provide support for people with long term conditions and others like Patients Opinion (https://www.patientopinion.org.uk/ ) who provide a way of raising your concersn in a user friendly way.  Hospitals do respond to these online comments so hopefully they also act on them.

There is the Local Involvement Network (LINk), an independent local volunteer led responsible for collecting the views of the patient and passing them onto the authorities.  They also have the right to inspect NHS and social care funded organisations providing care. The LINk will evolve into Local Healthwatch in April 2013.

Local Healthwatch will have a greater involvement in this sort of activity and will be recruiting members to undertake some of the work. Look out for information in your area.

Other voluntary sector organisations take an interest in health and social care issues.  The Women’s Institute in Buckinghamshire recently ran a campaign to improve stroke services. http://www.bucksfwi.org.uk/index.php/wi-campaigns/bucks-activities.html

Influencing the Clinical Commissioning Groups

The government has placed great importance on the need for the new Clinical Commissioning Groups (CCGs) to undertake “Meaningful engagement with patients, carers and their communities.” as part of their authorisation process.  They are also required to “…to involve the public on any changes that affect patient services.”

This means that they should be asking all people about their experiences of the health care they have received and also asking how they can be improved. Ideally patients and the public should also be involved in designing the changes to services as in this example:

http://www.improvement.nhs.uk/audiology/presentations/national_audiology_conference_july2010/Workshop2_presentation.pdf

It will be interesting to see how CCGs engage and involve individual patients in decisions about patient services. In an ideal world GPs will have time in a consultation to discuss with patients and carers the issues and priorities that face the CCG.  Then they should have time to collect together all the comments made during the working day and pass those onto the CCG. The CCG then will look at all the comments from all the GPs, analyse them to help their decision making.

In my experience I fear that scenario is unlikely!

So ask your GP and your local Clinical Commissioning Group how they will involve the patients and the public in any changes that affect patient services.