6. Understanding your community

This chapter looks at what good access is, simple demand assessment and capacity planning techniques, and how to ensure adequate staff levels for call handling.

6.1. Five steps to improve access for patients from black and minority ethnic groups

In 2001, the black and minority ethnic (BME) population was 4.6 million and this number is likely to have increased. The 2007 GP Patient Survey showed that some groups reported significantly less satisfaction with access to their local surgery. For example, Bangladeshi patients were 20% less happy with access than white patients.

Professor Mayur Lakhani’s review into access to and responsiveness of primary care services for BME patients, No patient left behind: how can we ensure world class primary care for black and ethnic minority people?, outlines the need for a culturally sensitive primary care service. It focuses on delivering better health outcomes for all, through managing difference and providing personalised services that suit the needs of BME patients.

Here are five steps to help GP practices better meet the needs of BME communities. These changes reflect existing good practice in the NHS and can apply to all providers of primary care.

Making a difference

This short guide builds on Professor Lakhani’s report. It outlines five simple steps to help GP practices better meet the needs of BME communities. They are a lever for improving access, patient experience, value and appropriateness of care. These changes are taken from existing good practice across the NHS and apply across all providers of primary care.

1. Knowing your patients

Monitoring ethnicity and preferred language, plus all other diversity pointers, is a good start. Data can be analysed to identify which are the main groups in the practice population. Creating and maintaining a local database of patient ethnicity and preferred languages, and using this information when designing services, is vital if practices are to become responsive and address health inequalities.

 

2. Improving communication

Good communication between BME patients, healthcare professionals and service providers is vital in improving access to primary care. This does not necessarily mean paying for expensive translation services. Good practice shows that one can use resources that are readily available in the community, such as collaboration and sharing resources with local councils, bilingual staff and telephonic interpreting where appropriate. Improving communication can be as easy as researching where local English for speakers of other languages (ESOL) classes are held and directing patients to these.

Top ten tips to improve communication

1. The Multikulti website provides accessible, accurately translated advice and information in community languages. It includes information on how to register with a GP, NHS primary care and provisions to complement GP services.
2. A wide range of information on some of the most common diseases is often translated into the main community languages. These resources are easy to download or print, or can be ordered. Diabetes UK has developed a toolkit to enable community and religious leaders to host diabetes awareness sessions for people from the South Asian communities. It includes a handbook, a presentation on understanding diabetes and food, and speaker notes. Alzheimer’s Society and Asthma UK also have a range of information translated into various languages.
3. NHS Direct provides a confidential interpreter service in various languages. To use the interpreter service, call NHS Direct on 0845 4647.
4. Language Line works with organisations to provide a 24-hour telephone interpreting service that connects you to a qualified interpreter in less than a minute. This is cheaper than face-to-face interpreting and is easily accessible. SignTranslate is an internet-based translation program that converts English to British Sign Language (BSL) and can also be used for 12 foreign languages.
5. Websites can be translated using translating software. (Please note that the translation service may not provide a perfect representation of the English text.)
6. It’s possible to recruit a bilingual worker if there’s a ‘genuine occupational requirement’. For example, it would be a genuine occupational requirement to employ an individual to provide services to people from a particular racial group, defined by nationality or language, which only a bilingual person could do effectively.
7. Information about local ESOL classes can be found at www.direct.gov.uk and researched by your area or postcode.
8. Information on NHS Choices is provided in 12 community languages www.nhs.uk.
9. Language cards with the phrase ‘I speak …’ contain both the translation and the English text sitting side by side on a poster and are a simple way for patients from non-English-speaking communities to indicate their language.
10. Multi-lingual appointment card – www.communicate-health.org.uk – enables users to type in details of an appointment in English and translate the text accurately into community languages.

3. Involve and engage

Evidence suggests that strong partnerships and links between healthcare providers and community groups can greatly improve access to primary care for BME groups. An effective local healthcare system should be designed to meet the needs of BME communities. It is a part of their legal duty to promote race equality, PCTs need to consider BME issues when commissioning and developing new services. Involvement and engagement in the design of services, as a part of a wider strategy concerning increased patient autonomy and patient-centred decision-making, is needed in order to enable continuous improvement across the whole community.

4. Raise awareness

Training can be effective in improving engagement between patients and GP practices. Front-line staff and receptionists are key to patient access and it helps to have knowledge and awareness of issues that affect BME patients when accessing primary care services. Developing receptionist/navigator skills among staff and training front-line staff in cultural capability are effective ways to better guide patients through primary care and offer culturally sensitive services.

5. Reflective organisations

Given that all health organisations run people-to-people services, the quality of staff that GP practices employ is of paramount importance.There is no compromise on the overriding objective of employing and developing the best talent available. However, this means using the local talent pool as well. It is important that careers in local health services are accessible and attractive to suitably skilled local people. Any good recruitment strategy must rely on having a reputable presence in the local community. In the internet age, however, this historically important area often remains overlooked.

6.2. Improving the experience of people with hearing loss

The experiences of people with hearing loss using primary care services often include frustration, confusion and, critically, some patient safety issues. Practical solutions exist that are simple to implement for little or no cost. The focus of the solutions is on awareness and practice process change. It is supplemented with a simple but powerful IT-based communication tool which is available free to GPs.

 

The challenge

 

There are about 9 million people with hearing loss in the UK – this is one in seven of the population. On an average day in the consulting room, a GP will see several of these people as patients.1 In the same day, the reception team in an average-sized practice will have managed 40 to 50 interactions with people with hearing loss. The experiences of these patients have been captured2 and make for challenging reading.

 

Here are some examples from some recent research undertaken by SignHealth:

• Of the clinical consultation – patients leaving the surgery with no idea what is wrong with them and others leaving the surgery with little or no understanding of their medication and then taking the wrong amount.
• Of the appointment and reception systems – difficulty or even inability to get an appointment by telephone. Some patients suffering stress, embarrassment and missed appointments, partly due to waiting rooms operating ‘listen for your name’ systems.

1 Royal National Institute for Deaf People (RNID) (2004),GP guidance for deaf patients

2 SignHealth (February 2009), Deaf and disabled people’s experience of primary care

1. Appointment booking

There are three potential ways to improve the appointment booking experience for people with hearing loss: maximising the potential of existing landline telecoms, harnessing mobile telecoms and implementing an online capability.

Maximise the potential of existing landline telecoms

Make sure practice staff are aware of Text Relay. This service allows communication between textphones and telephones. Text Relay is a national telephone relay service, letting deaf and hard of hearing people use a textphone to access any services that are available on standard telephone systems. A practice does not need any new or special equipment to use Text Relay. The link between the patient and the practice is a highly trained Text Relay operator, who provides a discreet and confidential service.

Text Relay is a national service and operates 24/7. Practice staff can also use Text Relay to contact a patient by dialling 18002, followed by the patient’s contact number.

What does it cost?

For outgoing calls from the practice to a UK landline or UK mobile number, the call should cost you no more per minute via Text Relay than it would for a voice telephone call – although it may take longer. Because calls from a textphone can take longer, some telecommunications providers offer a refund on textphone calls.

Training

Practice staff need to know how to answer and make calls using Text Relay. Everyone who might answer a telephone in the practice should be able to recognise an incoming call from a patient using Text Relay.

Surveys show that this is not always the case in a busy practice with multitasking staff. A quick solution may be to ensure that every staff member knows that when a call is received from an automated voice, ‘Please hold for an operator-assisted call from a textphone user’, they should pause to allow the connection to be made and the relaying of the patient’s words. Practices will need to think about how any out-of-hours services need to be briefed in order to take Text Relay calls. However, practices should bear in mind that automated telephone systems can be problematic for deaf and hard of hearing people. These systems cannot be accessed easily using Text Relay, particular where the different options are read out quickly.

Surgeries should take into account the fact that it will take longer for a Text Relay call to be connected. For example, many surgeries offer a same-day appointment if you make contact at a particular time in the morning. Phone lines are often very busy at these times and require the patient to redial many times – something that places patients using Text Relay at a disadvantage. Therefore, surgeries might consider offering a bespoke telephone or minicom number offering direct access to deaf patients.

Full instructions for Text Relay are available at: www.textrelay.org/files/Typetalkleafletv7.pdf

Harnessing mobile telecoms

Patients with hearing loss can use text messaging (SMS messaging) to book appointments. It is a relatively inexpensive option to set up, but careful consideration is needed to ensure that processes, roles and responsibilities in the practice are agreed and communicated.

The key tasks for a practice are to:

• dedicate a phone number to receive the messages and publicise it to patients;
• secure the equipment or applications to receive the messages and ensure reasonable visibility if the equipment is shared with other tasks. A PC or terminal in the reception area is ideal. Suitable applications are available free from many of the usual mobile contract providers; and
• ensure practice staff know how to receive and send messages, and whose job it is to check for incoming messages on a regular basis.

Implementing an online capability

Providing an online capability need not be as complicated as providing real-time access to the live appointments database, with all the potential issues around security and interfaces to the clinical system. A simple email account, set up to receive emails from patients, may be a good compromise between increasing access for patients and increasing complexity for practice staff. As with SMS, the technology exists and is inexpensive.

However, a practice would need to think carefully about confidentiality and data security issues before setting up an email facility. Just as with SMS messaging, the practice would need to address new processes, roles and responsibilities. (See section 2.2 Internet appointment booking for more details.)

2. Increase staff awareness

All front-line staff members should have basic deaf awareness training, but preferably the whole team should be involved. In order to maximise efficiency, practices can get together locally and arrange a single training session for staff from each surgery. There are a number of charity and third sector organisations that provide this sort of training.

3. The waiting area

Practices should consider fitting an induction loop in their reception areas. Ensure that the logo informing patients that the loop is fitted is easily visible and has not been covered with notices and stickers.

The loop should be tested and maintained on a monthly basis. The responsibility for this should be agreed and communicated between staff, and a record should be kept of each time the loop is tested. In addition, a sign should be displayed encouraging patients to report if the loop is not working.

The ambient noise level in a waiting area is often low; by contrast the reception area is often very busy with telephone calls and multiple conversations taking place. The need for the practice team to demonstrate deaf awareness can be appreciated by anyone by standing in the quiet of the waiting area for a few minutes and then walking up to the busy reception desk.

All practice staff should make an arrangement with a deaf or hard of hearing patient, when they first check in, how they will notify them when it is their turn to see a doctor or nurse. The traditional system of calling out patient’s names is clearly limited.

Practice staff should be helped to realise that it takes no more than a few seconds to walk out into the waiting area and make direct eye contact with the appropriate patient. Patients with hearing loss worry about missing their turn and can find sitting in the waiting area very stressful. The practice team can really improve the patient experience by demonstrating their deaf awareness through their actions.

Some practices have visual systems to indicate the ‘next patient’ message. These can range from sophisticated screens linked with the reception system to simple pegboards with numbered and coloured tags. If a practice is considering changing their system, some thought should be given to how it will be used by patients with hearing loss.

Although it might be tempting to believe that a visual system caters completely for the needs of those with hearing loss, feedback suggests that this is not the whole picture. The patient needs a visual signal to tell them to ‘go to a consulting room now’ and not just ‘it’s your turn next’. Patients with hearing loss report that they tend to watch these systems intently, determined not to miss their turn or avoid an embarrassing situation. But they often miss the ‘your turn now’ signal. If the receptionist confirms with the patient when they first check in that ‘someone will come and tell you when it’s time’, then the patient can avoid a stressful wait, staring at the visual system for what might feel like a long time.

Alternatively, deaf patients could be issued with an alerter system on arrival. This would be linked to the visual system and would vibrate each time a name appeared on the system, letting the patient know when it is their turn to go into the consulting room.

4. Communication support

Practices will be used to providing communication support, such as sign language interpreters, under local arrangements. Where possible, practices should use a qualified language service professional. However, these arrangements can be challenged by availability, especially at short notice.

An alternative might be to use SignTranslate:

• SignTranslate is an internet-based translation program that converts English to BSL and also can be used for 12 foreign spoken languages.
• The program is free of charge for all GPs in England, currently until the end of July 2009.
• SignTranslate is already used in the NHS by doctors who need to be absolutely sure that their diagnosis and prescriptions are properly understood.
• The program can be accessed through any internet browser.
• It is also accessible directly from internet links within EMIS practice systems.

As long as a patient can see the screen in the consulting room, the clinician can click on context sensitive questions that are provided on screen. They are translated instantly to BSL. It is fast, robust and very cost effective. Clinicians would need to spend only a little time becoming familiar with the on-screen layout before using the system with patients. Practices will need to evaluate if SignTranslate would add to their communication support options. A good place to start is the demonstration area of SignTranslate at: www.signhealth.net/login2.asp

5. Deliver a personalised experience

In order to deliver a personalised experience for patients with hearing loss, a patient’s written and electronic notes should clearly record the person’s disability. The notes should also record any associated adjustments required and the patient’s preferred communication method.

For this information to be of value in improving the patient experience, it should be accessible in such a way that it does not have to be ‘re-discovered’ each time the patient contacts the practice.

Key resources

RNID GP resources:

www.rnid.org.uk/information_resources/information_for_health_professionals/

Text Relay information:

www.textrelay.org

RNID deaf awareness training:

Email: training.services@rnid.org.uk

SignTranslate information:

www.signtranslate.com/freegp.php?page=freegp

6.3. Improving the experience of people with sight loss

An average practice will have around 150–200 patients with significant sight loss. Service improvement needs for patients with sight loss have been consistently identified in the UK. There are simple practical approaches to improving the experience of these patients, many focused on staff awareness and the patient journey. This section should be read together with section 6.2 ‘Improving the experience of people with hearing loss’ since many of the issues, tips and suggested improvements apply across both groups.

The challenge

GP practices are providing primary care services for 309,300 blind and partially sighted patients.3 If we include patients with significant sight loss, this number increases towards 2 million.⁴

The needs of patients with sight loss have been identified through several surveys and studies conducted in a range of general practices across the UK.5,6 The two surveys referenced in this guide were made in 2005 and 2009, four years apart – and with exactly the same issues identified in each. Clearly, there is still scope for improvement. There are some simple and very low-cost approaches that a practice can consider in order to deliver worthwhile improvement in patient experience.

Making a difference

There is a great consistency in the messages and conclusions of patient surveys. In the context of this guide, they indicate three areas of opportunity to improve the patient experience:

• improving the experience of attending the practice
• improving the experience of the consultation
• needs of the patient with sight loss outside the consulting room. These improvement needs are from the perspective of the patient with sight loss.

Practices will want to re-frame these improvement needs in order to plan and take practical steps towards addressing them. This re-framing process translates these three areas for improvement into four areas of potential activity through which practices may deliver the improvement:

• staff awareness
• information and communication
• physical environment
• using information to deliver a personalised experience.

3 NHS Information Centre, People Registered as Blind and Partially Sighted 2008 England
4 R. Tate et al The prevalence of visual impairment in the UK (2005), London School of Hygiene and Tropical Medicine
5 GP Access and Responsiveness Project for Severely Sight Impaired and Sight Impaired People (2009), Action for Blind People
6 Enhancing Care Provision for Blind and Partially Sighted peoplein GP surgeries (2005), The Guide Dogs for the Blind Association

Four Steps: How to make it happen

In this section are practical suggestions in the four activity areas through which practices may deliver improvement:

• staff awareness
• information and communication
• physical environment
• using information to deliver a personalised experience.

1. Staff awareness

Patients with sight pick up information as soon as they walk into a practice by reading signs and name badges. They observe the behaviour and context of staff and other patients.

Practice staff may become accustomed to this situation being ‘normal’ and may benefit from sight loss awareness training. This will enable them to work out how their practice needs to operate, and what their own behaviours need to be, in order to improve the experience of patients with sight loss.

Receptionists, healthcare professionals and other staff should introduce themselves by name and the position they hold in the practice. They should also talk through the procedure that they are conducting or about to conduct, even if they are just looking for notes or telephoning through to a consulting room. A ‘commentary’ on what is happening really helps a patient with sight loss.

An added benefit of awareness training is the potential for practice staff to understand how simple changes to the operational environment and process may greatly improve the patient experience. For example, if a sight loss patient needs to fill out paperwork it is usual for reception staff to help them. They should be given privacy and not be asked to verbally provide personal or medically confidential information at the reception desk.

The reception staff might feel that the reception area is appropriate if they can see that it is separate from the waiting area and there are no more patients waiting. However, the sight loss patient may lack the comfort that this visual information provides. A move to a more private area tells the patient that the receptionist understands the patient’s needs and is acting accordingly.

Practice staff should be trained in sighted guide techniques, such as offering their arm to safely guide the patient to a seat or other destination. When guiding a patient to a waiting area, staff should never back a patient into a seat, but always guide them to it and describe it to them. This means telling them if it is a dining chair, low sofa or an office chair for example. Staff should understand how to seek verbal permission before touching a blind person, to avoid alarming them by touching them unexpectedly.

Awareness training is available from a number of national and local organisations. Several of the national organisations are listed at the end of this section. Practices should consider combining awareness training for patients with sight loss with that for hearing loss patients.

Many of the issues are similar, and combining the approaches offers improvement to an even wider patient group as well as making better use of staff training time.

2. Information and communication

For a sighted person, a general practice may appear to be overloaded with information: notices and posters, leaflets and booklets; sometimes even touch screens and video information screens in waiting areas. Very little of this material is of use to a patient with sight loss. Practices should consider conducting a simple audit of their material to see what they have available for patients with sight loss. Many of the organisations currently providing practices with information will have suitable formats for sight loss patients available. Practices need to take time to identify what is needed and request it.

A sight loss patient may have little access to information about a prescription they have received in a practice. When they take the prescription to a pharmacy, the standard patient information leaflet in the pack may be of little use. Practice staff should be aware that the Royal National Institute of Blind People (RNIB) operates a freephone Medicines Information Line. By calling the Medicines Information Line, the practice can request patient information leaflets in large/clear print, in Braille or on audio CD. Any member of the practice can make this call for the patient – the number is 0800 198 5000.

3. Physical environment

Patients with sight loss are continually faced with issues relating to access to the physical and social environment. Some practices are located in purpose-built buildings but many are located in older or converted buildings.

Such settings can be made more accessible by means of better lighting, appropriate signage, and the use of tactile and auditory cues, especially hazard markers and way-finding devices. Signage should be at eye level, well lit, in large font, and in contrasting colours.

The layout and contents of many busy practices often ‘evolve’ as time goes on. It may be worth looking at the physical environment of the practice again after awareness training. Look out for obstacles in the waiting room, such as children’s toy boxes, pamphlet stands or furniture. Practices might consider involving some of their own sight loss patients and patient organisations in this review exercise.

The NHS Institute of Innovation and Improvement has produced a simple process and set of resources to help this sort of review, called experience based design. This helps capture patients’ experiences of a service as the foundation for making improvements. The experience based design resources are available on the NHS Institute’s website; a link is provided at the end of this section.

4. Using information to deliver a personalised experience

In order to deliver a personalised experience for patients with sight loss, a patient’s written and electronic notes should clearly record their sight loss. The notes should also record any associated adjustments required and the patient’s preferred communication method.

For this information to be of value in improving the patient experience, it should be accessible in such a way that it does not have to be ‘re-discovered’ each time the patient interacts with the practice.

Key resources

Visual awareness training from Action for Blind People.

Visual awareness training from the RNIB.

Experience based design resources are available from the NHS Institute.

RNIB Web Access Centre.

Speech enable your website using Browsealoud or other speech-enabling software.
Browsealoud: 0800 328 7910 or email: info@browsealoud.com

6.4. Five top tips to support a person with learning disabilities

1. See the person not the disability

At the practice, find the best way to communicate, picking up on non-verbal communication. For example, look at facial expressions, gestures and body language. Keep information simple and brief.

Avoid using jargon. Consider working with national or local groups to establish a procedure that establishes the best way to work with people with a learning disability. Ask if a health action plan exists.

Check how many people with learning disabilities are registered with the practice. If your practice has a high number of people with learning disabilities, then you may want to join a scheme to work with a primary care learning disabilities facilitator. Listen to family carers and support workers to highlight particular access needs.

2. Manage appointments correctly

Train staff to offer the maximum, appropriate help. A person with a learning disability may have difficulty with crowds, lack of space and long waiting times. Not understanding the social conventions of reception and waiting rooms may cause distress.

Consider offering them one of the first appointments of the day or one at a quieter time. Think about offering double consultation times or booking an appointment on the hour (which might be easier for the patient to remember). Some patients may need encouragement to speak up and explain why they need a consultation.

This will help the GP or other clinical professional ensure that they have a full picture. If there is a requirement for more than one type of consultation (eg with a doctor and a nurse), you should co-ordinate the appointments so that the patient only needs to make one visit.

3. Effective communication

Speak to the person first and only then check with the carer if something is unclear. Be sensitive to the person’s feelings and be encouraging. Ask open questions or change the question round to check if you get the same response.

Don’t assume that the person has understood a particular fact or piece of information. Check whether someone needs help to find their way around the surgery. Ask what help is required and try to provide it. If necessary, guide the patient from the waiting area to the consultation room.

Don’t just leave them at the door, but introduce them to the doctor so that they feel secure and welcomed. If a consultation is delayed, offer an explanation; otherwise the patient may get anxious and agitated.

4. Use appropriate information

Provide information in an appropriate, agreed format. Consider the patient’s needs first. Check how they wish to receive information. Should it be sent to them or to a carer or family member?

Be aware of any additional medical conditions, such as poor sight, when providing or sending out information. Consider working with the local Community Learning Disability team or Patient Participation Group to develop formats for standard letters. Do not assume that a patient can or cannot use a particular format such as the phone. Check with the patient first.

5. Training and development

Staff may not always know the best way to communicate with and support people with learning disabilities.

Link with local groups and societies to work out a plan for training and keeping staff knowledge up to date. Seek a champion from your team to lead on this aspect of the work.

Consider compiling a folder or checklist for staff, including pictures for patients to point to if they cannot explain in words. The website www.easyhealth.org.uk has a vast number of accessible leaflets for people with learning disabilities and healthcare staff. Stay calm and don’t rush the patient; they may get flustered or upset.

Link to other awareness training such as hearing or sight loss awareness training. Consider providing a general awareness training exercise for all your patient-facing staff. Explore opportunities for rewarding and publicising extended training through national vocational qualifications, certificates, local newspaper features and photographs in the surgery, etc. Remind patients to help staff by being clear about how they wish to receive information. Ask them to communicate what help and assistance they require.

6.5. Auto alerts on GP systems

Good communication is a major part of the patient experience and practices will wish to treat all patients equally and respectfully. An auto alert system can be used to make receptionists and other members of the practice team aware of a patient’s particular needs and respond accordingly. For example, if someone with hearing loss is attending the practice, then the receptionist can make sure that he or she looks at the patient when they talk. This helps lip reading.

How does it work?

Most GP systems provide auto alerts or flags that ‘pop up’ on the computer screen when a patient’s details are accessed. Some preparation may be required to ensure that your supplier has activated the auto alert function. If in doubt, contact your system supplier.

Collecting patient information

Agree a process to collect the information, for example:

• At initial registration, or during visits, ask the patient if they have any condition or requirement that needs particular help or assistance.
• If a patient asks for your help, make sure you note it.

Groups of patients that could be considered for auto alerts

Sight loss

Everyone with a sight loss is not totally blind. Some people have residual sight, which means that they may be able to see light or dark, make out shapes or read material that is printed in a large font size. They may have problems getting around the practice or seeing traditional signs and room numbers.

It’s important to stress that they may also not be able to see a visual alert system that tells them when it’s their turn to see the clinician.

Hearing loss

Some patients may have a small amount of residual hearing. Therefore, people with hearing loss communicate in different ways: hearing aids, BSL, lip reading, etc. Make sure you use the right method for each patient, otherwise everyone will get frustrated.

Learning disability

As with hearing loss, patients with learning disabilities have a vast range of requirements. Good communication is vital. Recognise that people may get easily distressed in a surgery and will need to be kept informed of any unexpected changes. Partnership working is crucial with families, carers and advocates, and patient-centred planning.