About this event Key findings from the Healthwatch Southwark report Appointment systems at GP practices are they working? What the NHS Southwark CCG is doing to support general practice services and how they are going to use the HWS report Reflections from the expert panel Q&A discussion Final reflections and next steps
Appointment systems at Southwark GP practices are they working? Aarti (Healthwatch Manager)
Why did we look into this? Top issue identified when we asked Southwark residents what should be our priority areas in 2017/18. Frustrations with appointment systems. Every practice has a different system. Time to wait for an appointment. GP Patient Survey shows Southwark performs lower than the national average when it comes to the experience of making or ability to get an appointment.
What we did Enter and View visits to every Southwark GP practice. We spoke to 550 patients registered with Southwark GP practices. We spoke to 50 receptionists (at least one from each practice) 39 Practice Managers completed an online survey. What is Enter and View? When trained authorised representatives visit publicly funded health and social care services to talk to service users, their relatives and carers, as well as staff.
Information we gathered Contacting the GP practice Understanding of appointment systems Booking appointments in advance Booking same-day appointments Clinical triage Extended Primary Care Service Receptionists asking about a The role of receptionists redirecting patients Support and training for receptionists Walk-in systems Alternatives to face-to-face appointments Use of Advanced Nurse Practitioners (ANPs) Pressures and challenges patient s condition
Today s focus Contacting the practice Understanding of appointment systems Booking appointments in advance Booking same-day appointments Clinical triage Extended Primary Care Service Receptionists asking about a The role of receptionists redirecting patients Support and training for receptionists Walk-in systems Alternatives to face-to-face appointments Use of Advanced Nurse Practitioners (ANPs) Pressures and challenges patient s condition
Our findings Information is purely based on what we heard from Practice Managers, receptionists, and patients. Not our intention to recommend the ideal appointment system, or to rank practices. Not reflective of all the views and experiences of all Southwark s GP registered population and practice staff. However, we did speak to a large sample of people, and had conversations with them.
Booking appointments in advance ( routine )
Time patients wait for advanced appointment 28% of people said they waited less that 1 week for their last GP appointment....the waiting time was about 5 weeks to see my Doctor and about 4 weeks to see ANY Doctor. By that time, any ailment will probably have cleared up or killed me! (Patient) 71% waited less than 2 weeks and 5% waiting longer than 4 weeks. Some people spoke to us about not being able to book appointments far enough ahead, for convenience....their booking system is the biggest problem, e.g. if you call on a Monday, they ll only offer you an appointment for the next Monday or they say there s no appointment and tell you to call back the next day at 8am, maybe then there ll be one for the Tuesday a week later. (Patient)
When practices release their advance appointments Significant variation in how far ahead practices release their appointments. 13 practices told us that they stagger the release of their appointments e.g. every few days of every few weeks. When I was told that there was a minimum 4 week wait, I was told to ring at 8am and then somehow there might be appointments available? I'm really not sure how that can be the case... (Patient) the practice release appointments at least 3 times a week which they call embargo appointments but are for when patients want to book an appointment sooner than 4 weeks (Receptionist)
Recommendations Practices should consider: If they are operating ideal ratio of same-day vs. booked-ahead appointment system. If their system for booked-ahead appointments is fit-forpurpose and that there is a rationale for the system.
Booking same-day appointments ( urgent )
Ease of getting a same-day appointment 42% of patients said they could always or usually get a same-day appointment Those who can get a same-day appointment mentioned need to call at certain times and difficulty getting through on the phone. You have to call immediately after 8am and redial repeatedly but all the slots tend to go within 20 minutes or so, before the surgery opens for face-to-face bookings. (Patient) There will not be any appointments in the day if they miss the morning call in times. (Receptionist) You have to programme yourself to get up and get an appointment. (Patient)
Recommendations Practices should consider when same-day appointments should be made available e.g. if two release times (morning and afternoon) might work for patients.
Clinical triage
When do practices use triage? One practice triages all patients requesting any type of appointments. Most often used when patients want a same-day appointment. There are two main ways triage can be used: In 16 practices, all patients requesting a same-day appointment are triaged. In 27 practices, receptionists book in patients requesting a same-day appointment up to a certain point, and then triage is used once all/certain number of appointments have run out.
Advantages GP decides in what order to talk to each patient based on description provided to reception. It can save GP time, as some patients can be dealt with quickly over the phone as it may not require them to come in to be seen. In-surgery slots are available for those that need them. The duty doctor calls urgent cases first and leaves sick notes and blood results to the end of the day. (Receptionist) They get an advisor to call you back to decide if you need to be seen that day. (Patient)
Disadvantages They usually do call back. It s ok what I want gets dealt with. [But] if it s a real emergency I don t want to have to have to wait for the GP to call me back to find out I ll get an appointment I ll just go to A&E. (Patient) Patients have to wait about for the GP to call them. Some practices specify a call time and others don t (e.g. if they call in order of priority). If triage requires a referral to the Extended Primary Care Service, this could involve another phone call. It just creates more work for everyone. Often I have to call the patient back a few times to get through and book them in [at EPCS], or the patient keeps calling back. One of the GPs just booked them in himself which is much easier, its just time-wasting otherwise (Receptionist)
Recommendations Practices should ensure they are carefully reviewing their triage system on an ongoing basis, from both a staff and patient perspective. NHS Southwark CCG and GP federations should explore the different triage systems in operation to determine: How practices can share learning about their triage systems. What systems work well and why. Whether practices should adopt any good practice identified. Practices and GP federations should consider how triage call-back systems could be improved from both a staff and patient perspective.
Extended Primary Care Service (EPCS)
Practice feedback - referring patients to EPCS Extent of use of EPCS varied significantly. For some practices, it is the only option for same-day appointments, for others it is a final option (when their own slots have run out). During our visits we notices that practice staff refer to the EPCS in quite different ways. The hub QHS A central hub location in North Southwark What is the Extended Primary Care Service (EPCS)? We have an EPCS in the north and south of the borough at Bermondsey Spa and at Lister Primary Care Centre. Patients who can t get an appointment at their own practice can be offered an appointment the EPCS. EPCS hub IHL Peckham overflow The Lister It is open 7 days a week, 8am 8pm.
Patient feedback - do they know about EPCS? 38% of people said they had heard of the EPCS, and 12% of people said they had used the EPCS. Comments were made about people s experience of the EPCS and about the promotion of the service. Some said they had never been offered the service when it would have been helpful. A practice would have to get past the receptionist first...i saw a poster about EPCS in the chemist. When I asked about it at my GP the receptionist said they knew nothing about it! (Patient) Please do check with all the GP practices, their websites, their literature and what receptionists are told to tell patients. I think you will find inconsistency. (Patient) Went to the Waldron Centre when I couldn t get an appointment. It was for my baby who was 5 days old. Would have been good to have been offered an appointment at EPCS. (Patient) Surgery NEVER give me this and tell me to go to Deptford walk-in, but to phone them first for an urgent appointment that day, or I go to King s A&E! (Patient)
Patient feedback - would they use the EPCS? 70% of people said they would use the EPCS. Heard 47 positive comments people saying it sounded like a good idea, or would be helpful. London is a 24-hour city I m pro that. (Patient) I d go because it provides for same-day when needed it doesn t matter who you seen then. (Patient) Heard 58 negative comments people mentioning the distance, travel, continuity. I was told to go to Bermondsey Spa but I was pregnant at the time. It was too far and my child needed to be collected from school. (Patient) I want to see my doctor as I find explaining each time to a different doctor draining. (Patient) The whole point is that the GP is local to me and the Lister isn t near to me at all. (Patient)
Recommendations The CCG and GP federations should monitor and evaluate the impact of the upcoming EPCS communications campaign. The CCG and GP federations should provide an update on their plans to look at flexibility of using either north or south service. The CCG and GP federations should investigate how the referral route to EPCS could be further streamlined. The CCG and GP federations need to review staff training around EPCS and explore further options to avoid: Inconsistent explanations about the service. Patients being referred to out-of-borough services. Patients feeling they have no choice. Not giving patients important information about EPCS. Inappropriate referrals being made
Receptionists asking about a patient s condition and why
Practice and patient feedback Majority of receptionists (37/44 practices) said that they do ask patients questions about their condition when they want a same-day appointment. 25 practice receptionists said that did not ask the reason when patients book appointments in advance. 40% of patients said receptionists have asked them about their condition, and 63% of patients said they did not mind if receptionists asked. Some patients said they didn t like this, feeling it is personal/private, feeling embarrassed, or findings questions intrusive. On the phone this works fine. But until not long ago patients at the desk had to answer personal questions with other patients hanging on every word. This has now been resolved by having patients queue up a yard or two away. (Patient) I understand why they ask it but things don t stay as hush hush as they should. (Patient)
Practice feedback why do they ask? Receptionists said they do this In many cases, only to give information to the triage clinician. So they can use the information to redirect patients away from same-day appointments, e.g. filtering out admin, seeing a non-gp clinician, suggesting routine appointment or another service. [We ask] because we have a wide range of clinicians pharmacists, CPN, doctors, nurses, HCA. Only the GP is triage though. (Receptionist) Anything meds related, we see if patient is aware we have a pharmacist on offer they can do minor ailments... (Receptionist) Reception triage even though we re not supposed to. (Receptionist) We do a little bit of triage though we re obviously not clinicians. (Receptionist)
Patient feedback why do they ask? Some patients spoke to us about how they thought this information was being used by reception staff: Enable better decision-making Allowed for patients to be prioritised Some implied that how you communicated the problem, would determine whether you get an appointment. I normally request appointments for a reason and know how to persuade the receptionists. I worry about people without the same level of confidence (Patient) Last week...i was able to communicate a symptom which triggered an emergency response and I was seen within two hours by the GP. (Patient) I think everyone who requests an appointment needs it; no need to ask why. (Patient) It is silly to be asked, you can just manipulate the system to be seen. (Patient)
Recommendations The CCG and GP federations should ensure receptionists training includes techniques for how to ask patients about their condition: Explaining to the patient why they are asking. Ensuring patients understand that they do not have to give this information. Practices should explore how privacy should be improved at the reception desk. GP Federations should consider providing guidelines for practices explaining under what circumstances receptionists might (or might not) suggest: Routine rather than urgent appointments Services external to the practice It should also be made clear at which point a clinician s decision is necessary.
Alternatives to face-to-face appointments
Patient feedback 72% of patients said they would accept a telephone appointment, 28% would accept an online video chat, and 21% would accept an online typed chat. Positive comments - convenience. I work full time so anything else would be good! (Patient) Negative comments language issues, preferring interaction in person, getting to know Doctor, poor hearing/eyesight, not having internet. Talking to a computer is not as quick, you can t express yourself and the urgency. (Patient) It might not be clear who is on the other side of the messenger conversation. (Patient)
Recommendations The CCG and GP federations should involve patient representatives as they explore alternatives to face-to-face appointments.
Summary
Summary Findings highlight the complex nature of appointment systems. Practices operate different systems each with own benefits and challenges. Not possible to recommend a one-size-fits-all appointment system. Appointment systems need to be flexible. Practices should offer different ways for people to book and receive appointments. Our recommendations reflect ways we think practices can do this.
What is NHS Southwark CCG doing to support GP practices and how will the Healthwatch report be used to inform this work. Caroline Gilmartin, Director of Integrated Commissioning Dr Emily Gibbs, Governing Body Clinical Lead
National context GP Forward View The General Practice Forward View published in April 2016 set out plans to enable clinical commissioning groups (CCGs) to commission and fund additional capacity across England to ensure that, by 2020 everyone has improved access to GP services including sufficient routine appointments at evenings and weekends to meet locally determined demand, alongside effective access to out of hours and urgent care services. Southwark CCG has commissioned this since November 2014 in response to local needs.
Local context Most people in Southwark report a good experience of their GP surgery (national GP survey), however: in Southwark the % of patients reporting very good or fairly good experience has declined in recent years there is variation in experience across practices, with patient experience falling below the CCG and national average for a number of Southwark practices. There is variation across practices when comparing QoF data (National Quality and Outcomes Framework). There has been an improvement in quality as a result of the CCG commissioning services on a population basis through GP federations (Population Health Management Contract). Patients who attend the Extended Primary Care Service (8am-8pm, 7 day per week) consistently report high levels of patient experience; however, general awareness of the service and how to access it could be improved. All but one practice in Southwark has received a CQC inspection. A summary of the outcomes to date are: 4 practices are rated as inadequate overall. 6 practices are rated as requires improvement overall 27 practices are rated as good overall 1 practice has closed Where improvements are required the CCG is working with practices, the LMC and to support practices with the implementation of their improvement plans.
What is the CCG doing to support practices in the areas outlined in the Healthwatch Southwark report?
Booking appointments (urgent and advanced) Healthwatch recommendations: To review the text reminder system and its impact on appointments where patients did not attend (DNAs), in order to determine whether it should be rolled out to all practices. To review the online booking system, to explore: The interface between patients booking online and the triage system (i.e. do people booking online bypass triage?) Whether the appointments patients see available online are the same as those available via reception. What types of appointments can be cancelled online (e.g. those booked online only, or regardless of where the appointment was made?) The above should then be shared with practice staff and patients.
Booking appointments (urgent and advanced) CCG s response All practices have access to a text reminder service funded by the CCG. Funding the extended primary care services in Bermondsey and Peckham which provide additional GP and nurse appointments 8am 8pm, 7 days per week. Access to the service is through telephone management to ensure patients get to the right place first and reduce number of ways to access services, which patients told us was confusing. To support practices ensure patients access the right appointment - urgent on the day appointments as well as routine appointments e.g. dressings. To enable practices to spend additional time with patients that need continuity of care e.g. those with long term conditions, complex needs. Working with practices, patients and the LMC to develop an access tool for practices to inform how best to offer access to patients for local needs.
Booking appointments Patient Online CCG s response Hosted workshops for practice staff to raise awareness of the benefits to staff and patients. National funding was used to fund IT staff employed by GP federations to support practices put in processes to make appointments available to book online as well as introducing systems for patients to book online. Project with Age UK to train volunteers to become digital champions to work in practices and support patients with online services. Equipment for practices to support patients sign-up and test online services in practice. CCG expects that all appointments are available to book over the phone, on line or via reception directly at the same time i.e. certain appointments are not offered by each different mode.
Limitations to recommendations CCG s response Practices are able review and manage the number of Do Not Attends (DNA) using processes such as text message reminders. In January 2018 EMIS Web (the system practices) will provide automated data to practices on DNAs within the practice. The CCG does not receive this information and would not be able to review this across the borough. A limitation to the work is that the functionality of the system is determined nationally e.g. patient online.
Extended Primary Care Service Healthwatch recommendations: To monitor and evaluate the impact of the upcoming EPCS communications campaign To provide an update on their plans to look at quantifying practice/patient preference for flexible use of north and south EPCS To investigate how the referral route to EPCS could be further streamlined, particularly in light of our recommendations around triage generally To review staff training around EPCS so prevent inconsistent messages to patients and signposting to other services.
Extended Primary Care Service CCG s response Additional GP and nurse appointments 8am 8pm, 7 days per week Available to all registered patients An extension to Southwark general practice The services can see patient notes with permission, improving the care provided to patients. Access to the service is through clinical review by a senior clinician to make sure that patients are seen at the right place, at the right time by the right person. Working with GP federations to review implement evaluation recommendations including the review of pathways to access the service. This includes 111 being able to book patients appointments directly and training of practice staff. Launched a new communications campaign in winter 2017 to raise awareness with patients
Limitations to recommendations CCG s response Data sharing agreements limit ability for patients to attend both extended primary care services sites but the recommendation is being explored.
Clinical review Healthwatch recommendations: To explore the different triage systems in operation to determine: How practices can share learning about their triage systems. What systems work well and why. Whether practices should adopt any good practice identified.
Clinical review CCG s response Both federations have implemented access to different types of appointments in addition to on the day/next day appointments Reviewing the impact of this on core GP practices
Receptionists asking about patients condition Healthwatch recommendations: To review practices use of walk-in centres in other boroughs, including: Comparison with their use of the Southwark EPCS and the reasons for this. The implications of this for costing and future commissioning. The implications should the Lewisham walk-in centre close. To investigate whether the Pharmacy First system is being operated
Receptionists asking about patients condition CCG s response Practice utilisation of the EPCS and reasons for this is discussed at contract monitoring meetings with GP federations. This information informs commissioning decisions. The Walk In Centre in Lewisham is used by Southwark patients and Lewisham is currently engaging on the future of the WIC. Pharmacy First scheme is provided at all but 1 of the 62 pharmacies in Southwark. The CCG is reviewing the use of the Pharmacy First Scheme.
Receptionists asking about patients condition CCG s response Funding is available through the GP Forward View to up skill and train receptionists to become care navigators. A care navigator will have knowledge of local support services for patients that may support improved health and social outcomes. Customer care training is available to receptionists.
Alternatives to face to face appointments Healthwatch recommendations: To involve patient representatives as they explore alternatives to face-to-face appointments (Healthwatch staff have been involved in some workshops).
Alternatives to face to face appointments CCG s response Online Consultations specification is in development. Healthwatch and patients have been involved in the development of the specification and will continue to do so. Working with practices to develop a specification which meets needs of Southwark practices and patients.
How is the Healthwatch report going to be used?
Healthwatch report CCG s response Report to be shared with stakeholders and patients through the CCG s governance process - Locality Patient Participation Groups, Practice Manager s Forum, the CCG s Engagement and Patient Experience Committee (EPEC) and the CCG s Primary Care Commissioning Committee which meets in public Information from the report will be used to ensure that any proposed changes to practice s appointments / extended access includes further patient engagement Review recommendations to ensure focusing work in response to patient feedback Note that a lot of work already being progressed by the CCG, practices and GP federations as access is a priority area Continue programmes that we are working on: Access tool Online consultation services Recruitment and retention of staff including GP, nurses and pharmacists Training of general practice staff Formal feedback to report to Healthwatch
Question and Answer Session Caroline Gilmartin, Director for Integrated Commissioning, NHS Southwark CCG Tilly Wright, Practice Manager and Chair of the Practice Manager s Forum Nigel Smith, Managing Director of the South Southwark GP federation (Improving Health Ltd) Dr Emily Gibbs, Clinical Lead for Community Based Care, NHS Southwark CCG Rebecca Dallmeyer, Executive Director of the North Southwark GP federation (Quay Health Solutions)