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2. Managing and meeting demand
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.
2.1. Skill mix
Demand for patient-led services is forcing practices to think carefully about the mixture of skills that their team possesses. The principle of employing staff who can provide the best, most effective care for patients, is set out in A Health Service of All the Talents: Developing the NHS Workforce, and emphasises the importance of:
- team working across professional organisations and boundaries;
- flexible working to make the best of the range of staff members’ skills and knowledge;
- streamlining workforce planning and development, which stems from the needs of patients, not of professionals;
- maximising the contribution of all staff to patient care, doing away with the barriers that state that only doctors and nurses can provide particular types of care;
- modernising education and training to ensure that staff are equipped with the skills they need to work in a complex and changing NHS;
- developing new, more flexible, careers for all staff; and
- expanding the workforce to meet future demands.
Achieving a range of skills can help practices cope with an ageing population, address developments in the management of long-term conditions, meet contract requirements and help support practice-based commissioning.
Benefits
- Access to a healthcare professional may improve.
- Frees up higher grade staff’s time to concentrate on therapeutic tasks.
- Improving access will lead to improved patient satisfaction, helping to achieve the targets set by the PCTs.
- Regular skill mix reviews can provide development opportunities for staff.
Drawbacks
- Patients may have concerns about lower grade staff taking on new roles.
- Cost-effectiveness of the changes can be difficult to establish. A revised skill mix is not necessarily more cost-effective than more traditional care models.
- A skill-mix approach can blur the role boundaries between staff, which may threaten professional identity – this could have an effect on teamwork.
- Investment in training for the increase in role duties may be required.
Costs
These will vary depending on your need to employ additional staff or alter the contracted hours of your current staff.
The Wanless review suggested that up to 70% of the work done by a GP might be allocated to a general practice nurse (GPN). Healthcare assistants (HCAs) are also valuable posts being introduced in general practice, enabling nurses to take on more complex duties. For more information on how to safely and effectively introduce new roles, see the Working in Partnership Programme’s (WiPP’s) GPN and HCA Toolkits.
To get in touch with other practices that have made changes to their skill mix, see the WiPP Database of Good Practice.
Step-by-Step Guide: Skill mix
1. Firstly, undertake a skill-mix review. Use a diary to log the different tasks staff routinely do (see Workload Analysis Tool). Group the tasks into broad categories, such as 'administration'. Compare the tasks with the job descriptions of the staff to identify cross-over and duplications. Mapping this out with your team can help identify where skill gaps exist. Download the template .
2. Make regular competency assessments to identify development needs, and ensure staff can then be directed to work at the right level, making full use of their skills. Download an example.
3. Communicate with staff – ensure a lead GP or practice manager discusses details of the skill mix and capacity plans with all the team at the practice.
4. Communicate with patients to understand their views about likely new roles and responsibilities (See Patient engagement Section).
5. Support the integration of any new role. A new role must be clearly understood.This is a key consideration for both the practice team and patients. Ensure patients understand the reason for the change, and what this means to them.
6. Monitor and review any changes. Set out what you hoped to achieve at the start, and gather feedback from staff and patients to assess the impact. Download a template.
2.2. Internet appointment booking
Allowing patients to create, amend and cancel their appointments online is becoming a popular alternative. It can be particularly convenient for patients when the practice is closed or telephone lines are busy.
Benefits
- Gives patients 24/7 access.
- Quick and easy to use, popular with patients who have busy lives.
- Can be popular with older people and those with hearing loss or a learning disability.
- Patients receive automated booking confirmations – no need to reconfirm by telephone.
- Reduces incoming calls and so relieves workload for reception staff.
- Appointments can be cancelled easily, reducing ‘did not attends’.
- Some suppliers estimate there is a 67p saving from each appointment booked online.
- Practices can choose how many appointments they want displayed, and are therefore able to be booked online.
- Some systems allow patients to send a message with their booking to tell the clinician what their consultation is about. Many offer additional options such as repeat prescriptions.
- Log-in details can be revoked if a patient misuses the service.
- Many systems also allow patients to view and order repeat prescriptions online, providing additional convenience for patients and making practices more efficient.
Drawbacks
- Not everyone has access to a computer.
- Some patients may need a lot of training to use the system.
- Patients may be concerned about the security and confidentiality of the information.
- Requires some staff time.
Costs
Costs vary. This depends on whether it is an extension to your existing system or an update of an old system. Contact your GP system supplier to discuss your options.
Step-by-Step Guide: Internet appointment booking
Consult
Have you checked with your Patient Participation Group to see whether there is an appetite for booking appointments online? What do your reception staff think about it? Are they happy to manage the system?
*GP systems
There are a range of software solutions that work across many GP clinical operating systems. Many of the GP Systems of Choice (GPSoC) suppliers offer similar appointment booking services:
- Egton Medical Information Systems Limited (EMIS) offer online appointment booking through EMIS Access. Around 1,500 practices are using this. An average of 45,000 appointments are being booked online each month. Depending on the software, patients can also access the system using digital TV, or on their mobile. Practices using EMIS LV5.2 or EMIS PCS can use EMIS Access straight away – provided you have configured your software correctly. To do this, download one of the two easy-to-follow configuration guides. For more information or further support contact 0845 123 4455 or email fieldoperations@e-mis.com.
- CSC Computer Sciences Limited offer online appointment booking through their SystmOnline service. It is an integral part of SystmOne. Practices can get started straight away by calling The Phoenix Partnership (TPP) on 0113 20 500 80. More information available here.
- In Practice Systems (InPS) offer something slightly different. Vision Patient Partner is a 24-hour telephone appointment booking system that integrates with Vision’s appointments. This allows patients to manage their appointments at any time.For more information contact 020 7501 7440, email sales@inps.co.uk or visit their website.
- Practices using Practice Manager 2 from Microtest can make use of the e-Appointments facility. To place an order, or to request a demonstration, contact 0845 345 1606 or email sales@microtest.co.uk. For more information visit their website.
- FrontDesk work across many GP systems including EMIS LV and PCS, InPS vision, iSoft Synergy and Premiere. They offer a range of modules such as online appointment booking, appointment reminders, check-in screens and patient call displays.
Training
Think about your staff receiving software training so that you can both make best use of the operating system. Training usually costs money, so contact your software supplier directly to check. Do make sure your patients know how to use the system. This may also require some training.
Communications
It is vital that you ensure all patients are made aware of the new system. Many suppliers offer promotional materials – such as posters and patient leaflets – that you can download from their websites.
Useful links
Read for yourself what patients are saying at: www.digitalspy.co.uk.
*Please note that this is not an exhaustive list of GP systems or software applications.
2.3. Home visits: duty clinicians and collaboration with other practices
For some practices, a cost-effective solution could be a doctor dedicated, for example, to providing home visits or telephone consultations. This may be preferable to doctors both running regular surgeries and carrying out home visits. This can be taken forward by collaborating with other nearby practices.
Benefits
- Where there is a dedicated duty doctor to make home visits, emergency patients can be seen more quickly than they would at the surgery. And they can benefit from longer appointments.
- Practices can reduce the number of emergency walk-in patients. These cause congestion in the waiting room and extend doctors’ working hours.
- By reducing visits to the surgery, home visits can also cut the risk of infection and local hospital admissions.
Drawbacks
- Home visits can cost time and money if the practice doesn’t have a dedicated duty doctor for home visits. A GP can see between two and four patients at the surgery in the time it takes to visit one patient at home.
- Better care can often be provided at the surgery. This is because there is specialist equipment and tests can be carried out more easily than at home.
- Home visits can be very disruptive for surgeries. This can lead to dissatisfaction among those patients making practice appointments, but subsequently kept waiting because of an emergency home visit.
Costs
It can be expensive for practices to carry out home visits, because they take much longer than appointments at the surgery. Practices who have combined to provide an acute visiting service have found the service pays for itself (see above).
Large practices might think about making one of their doctors available every day for home visits. This does not add any extra cost, and is popular with patients and doctors.
Step-by-Step Guide: Home visits
Step 1
Are your surgeries currently being disrupted by requests for acute home visits? Is this having a negative impact on patients, who are waiting longer for their appointments when their doctor is called away? What is the effect on the doctors, who are called away from their routine surgeries?
Step 2
How long do patients who request home visits have to wait to see a doctor? If it’s more than an hour or two, is this leading to higher rates of hospital admissions? Is it causing patients distress, or is it having an adverse effect on their health?
Step 3
Think about the different options for providing a dedicated GP for home visits during each practice day. He or she can respond quickly to requests for acute home visits, without disrupting the practice or the patients in the waiting room. You could introduce a duty doctor system: one practice GP who has no booked appointments for the day, leaving him or her free to meet home visit requests quickly. Another option is to collaborate with other practices, by hiring an external doctor whose sole purpose is to make home visits.
Step 4
Before going to patients’ homes, talk to them on the phone to find out if visiting them is the best course.
Step 5
Make sure all reception staff and practice managers are familiar with the practice’s policy on home visits, so that requests are channelled effectively.
Step 6
Are you introducing an acute visiting service or duty doctor system? Think about other activities the doctor could be doing while he or she is not making home visits. These might include visiting nursing homes or making follow-up calls.
2.4. Appointment reminder systems
Millions of GP and nurse appointments are missed every year. This amounts to millions of pounds worth of wasted NHS resources. There are many ways in which you can reduce your ‘did not attends’ (DNAs) and help to educate patients on their responsibilities. One of the most effective is a simple system that sends the patient a text message, a day or two beforehand, to remind them of their appointment.
Benefits
- Systems have been shown to reduce DNAs by up to 50%.
- Most products are compatible with most GP systems.
- Messages can be personalised.
- Systems are secure and confidential.
- Can be used for targeted health campaigns, eg informing patients of flu jabs or smoking cessation clinics.
- Can be used to engage with hard-to reach patients, including the young and socially excluded.
- Multi-lingual – most systems include language templates so that your messages reach non-English speaking audiences.
- Systems can send one-off messages to individuals or groups of patients.
- Reduces administration costs for printing and postage.
Drawbacks
- Relies on the practice keeping up-to date patient mobile phone numbers.
- Some patients may not want to be contacted by the practice.
- Not a complete solution – this won’t eradicate DNAs totally.
- Some patients don’t know their mobile numbers, while others forget to tell the practice when they change their number.
Costs
There are many suppliers, and costs vary. Some systems that use Connecting for Health’s NHSmail system are free. Some GP system suppliers are also now beginning to offer such functionality within their software.
Tip
If you use delivery reports, this enables reception staff to check if a patient has received the message or whether their number might need updating.
Allow patients to text back to cancel their appointment to free up the telephone line.
Step-by-Step Guide: Appointment reminder systems
1. Consider value for money
Would the alternatives – posting information to patients or a marketing campaign to reduce DNAs – cost more?
2. Test with your patients
Would they be happy to receive text messages from their GP practice? Do the majority of your patients have mobile telephones? Do you have mobile telephone numbers for all your patients? Who will maintain the details?
3. GP systems
Check with your existing GP software supplier to see if:
they already offer a system that can be easily added to yours; and
the system you are considering is compatible with your software.
4. Training
Make sure your staff have the appropriate training to get the best out of the system.
5. Impact
Make sure you monitor and evaluate the impact of the system. Have DNAs been reduced?
2.5. Telephone consultations
It’s Telephone consultations can be cheaper and quicker than seeing patients face to face, but they carry risks. In the right circumstances, they can increase efficiency, improve access and boost patient satisfaction.
Benefits
- There is increased efficiency. • By talking to patients before they make an appointment, doctors can ensure they only see people who would benefit from a face-to-face consultation.
- Waiting times and appointment systems can be better managed, leading to greater patient satisfaction and lower staff stress levels.
- Patients have another channel through which to access primary care. This is particularly useful for people with reduced mobility or very little spare time.
- Telephone consultations can increase the opportunity for a patient to consult their preferred doctor, reinforcing the relationship, to the benefit of both parties.
Drawbacks
- Doctors rely on visual cues for diagnosis and these are absent in phone consultations. This could lead to a greater risk of wrong diagnosis.
- Phone calls are dependent on the setting, with both parties influenced by their surroundings and mood. Patients won’t necessarily share the full details of their health problem. Doctors won’t always interpret what they say correctly.
- People who don’t speak English as their first language are not always confident at self-expression. Decision-making is difficult for the GP. Involving interpreters is complicated and costly.
- While some patients appreciate telephone consultations, others regard it as a blocking tactic.
- Telephone consultations can result in higher phone bills – up to 25% higher.
- Not all conditions are suitable for phone management. Some will need a personal examination.
Costs
There are minimal costs involved in introducing a telephone consultation system. Phone systems need to be up to date, with increased capacity and more than one line into the practice. Computer systems should permit internal messaging and fast retrieval of patient records. Phone bills will rise in proportion to the increase in telephone consultations being made.
Telephone consultations by GPs in normal practice hours serve a variety of purposes:
In clinical management
- Assessing a new clinical problem and recommending appropriate action – such as a home visit, surgery appointment, hospital visit or self-care.
- Offering a second opinion or taking over management from a colleague.
- Giving advice – particularly when the patient is well known to the doctor.
- Multi-tasking, eg conducting a surgery while on call for emergencies.
- Following up a clinical problem.
In practice organisation
- Arranging repeat prescriptions or medical certificates.
- Giving the results of investigations.
- Fielding a complaint or other feedback.
- Speaking to third parties about a patient, eg relatives or social workers.
Expert Advice
Royal College of General Practitioners (RCGP) guidance on telephone consultations in primary care
- Practice teams should regard the telephone as a means of improving access and personal care, rather than as a barrier.
- Patients should be involved in any plans to develop or change the telephone-based services a practice provides.
- A practice should have one incoming telephone line per 2,500 registered patients, and the flexibility to open further lines at busy times.
- All incoming and outgoing telephone calls with patients and carers should be noted in medical records.
- Doctors should be flexible regarding consultations so as to meet the needs of patients who prefer the phone.
- Doctors might consider telephone follow-up as an alternative to some face-to-face consultations for common conditions such as depression and cancer.
- An article from the June 2009 issue of The British Journal of General Practice concluded that ‘Used appropriately, telephone consulting enhances access to health care, aids continuity, and saves time and travelling for patients. The current emphasis for acute triage, however, worried clinicians and patients. Given these findings, and until the safe use of telephone triage is fully understood and agreed on by stakeholders, policy makers and clinicians should be using the telephone primarily for managing follow up appointments when diagnostic assessment has already been undertaken.
Tips
When to use the phone
Some health problems cannot be dealt with in a phone consultation – for example, those where the doctor needs to see or touch the patient. Some things that might be dealt with by telephone could include the following, though there may be circumstances where even these conditions are deemed too dangerous to diagnose or deal with over the phone:
- coughs and/or breathlessness
- earache
- sore and/or discharging eyes
- rashes and other skin problems
- spinal pain and injuries
- other musculoskeletal pain and injuries
- diarrhoea
- cystitis in women
- emergency contraception
- vaginal bleeding in early pregnancy
- anxiety and depression.
What to say
Although there needs to be flexibility in the structure of telephone consultations, several key stages can be identified:
- Identify yourself and the caller/person being called – the patient whenever possible.
- Gather information, including social context and clinical history.
- Address the biomedical aspects of the problem and the patient’s perspective.
- Give a diagnosis or interpretation of the patient’s problem, with an explanation.
- Signpost the point at which a triage or management decision must be made.
- Negotiate the outcome according to agreed guidelines.
- Make follow-up arrangements sharing thoughts on possible developments.
- Prepare for the next call and be professionally safe, keeping good records.
Other Considerations
Knowing the patient
One thing that distinguishes GP phone consultations from the service provided by NHS Direct is the medical professional’s familiarity with patients and access to their records. This reduces uncertainties in communication and diagnosis. When the doctor doesn’t know the patient, for example, if a locum makes the call, it is less likely to be successful.
Structure and teamwork
So that patients are given consistent advice and treatment when they call, policies and boundaries need to be established within the primary care team. Practices should decide what proportion of clinical time should be set aside for telephone consultations, what conditions will be managed this way and what advice will be given for each condition.
Risks and warnings
A lack of training and confidence can limit the effectiveness of telephone consultations.Doctors tend to feel more confident when conducting telephone consultations with familiar patients during practice hours, than when making calls out of hours. According to 38 doctors interviewed for a study in Cambridge in 1997, the factors most frequently associated with difficult calls are:
- a difference of opinion on the need for a visit;
- parental anxiety about children;
- chronic conditions; and
- mental health problems.
Telephone consultations are prone to errors in:
- information gathering, from inadequate knowledge of drug usage and allergy history;
- relationship building, usually through anger on one or other side;
- decision-making, for example premature decisions; and
- explanation and planning, due to poor communication.
The relative anonymity patients have when talking on the phone promotes clear communication, but it’s just as likely to inhibit it. Doctors should keep this uncertainty in mind when conducting telephone consultations. Be prepared for any eventuality.
Credit and references
Some of the information here is adapted from Telephone Consultations in Primary Care by Tony Males (Royal College of General Practitioners, London, 2007, available to purchase from the RCGP bookshop.)
Suppliers
There are no suppliers mentioned in this section.