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Smarter Access - a GP experiment!
by Dr Umar Tahir Moss Side Family Medical Practice
Smarter Access - a GP experiment!
The demands on general practice are ever increasing. Both the patient body and the government are demanding greater access, but at what cost? Are the proposed changes sustainable? What difference will they actually make? Will increasing the core hours actually result in greater patient satisfaction, or will it simply result in the same access issues, but during more hours of the day.
Moss Side Family Medical Practice is probably not a great deal different from most city centre practices; a diverse population, busy, and challenging in more ways than one. In order to cope with high demand, we ran an open surgery in the mornings, for two years. Not only did this dramatically reduce A+E attendances, it also improved patient experience. However, as the patient list size increased and patient education was proving difficult, numbers and waiting times increased, as did the stress levels of the GPs. On occasions over 50 patients booked in. With the same kind of problems and requests coming to open surgery, it became clear that this service was not benefitting patients, or the GPs. Like at all GP surgeries, time and clinical staff as resources are limited, and cannot cope with continually growing numbers accessing a particular service. The dynamics had to change, but the quandary was how to continue to provide unrivalled access, but with appropriateness and clinical need the priority. After some discussion, we launched a new triage system. The open surgery became the urgent surgery, and the decision regarding when a patient needs to see a doctor was returned to where we feel it should be; with the doctor.
So here is how it works. The patients book in with reception as usual during the allotted time, usually between 9 and 10 am, and are seen by the triaging GP. The encounter occurs in a room adjacent to the waiting area. The patient is called in and addressed by the GP, who also remains standing. Triage notes are entered onto the patient record, either by the GP themselves, or with the help of another member of the team. After the patient briefly explains their problem or problems, the clinician all the while making an assessment, can decide what access is required from a number of options. The patient can be asked to stay and be seen in the urgent surgery the same morning, which is run by a second GP; requested to return later in the day; be booked for a telephone or Skype consultation; offered a routine appointment with a GP or the nurse; redirected to Pharmacy First; the red eye service; or to reception for items like sick notes, prescription requests, forms etc. With patients for whom English is not their first language, a telephone interpreting service can be used as it would during a normal consultation. Of course, as with any form of triage, there are symptoms, or patient groups for which one would employ a lower threshold to see the same day, and other norms of triage still apply. The advantage over telephone triage, is that the patient can be “eyeballed”, and basic triage tools can be used, like a temperature or pulse check, but it should not go beyond that, or it becomes a full consultation. As with any form of clinical encounter, there is the possibility of making a mistake, but compared to telephone triage this is greatly reduced. The safest and most effective triage is done by the most qualified, which is why it works well with a GP on the front line. At the same time as delivering the most appropriate care, we are able to encourage self care, use all available services, and provide valuable patient education.
There are also added benefits, which the non clinical staff will be grateful for. A decision which may not be entirely desirable to a patient will be coming directly from the GP, rather than a receptionist. This, we have found, makes the outcome much more likely to be accepted, and results in less of a negative reaction or response. Patient satisfaction is higher, both because of the speed with which a GP sees them, and that in the end, the correct means for addressing the problem has been used. As we were already running an open surgery, adding the triage element was fairly simple, and overall, patients were very accepting of the change. The immediate benefit apparent to the patient was reduced waiting time. We are in the first few weeks of the change, but already it has transformed both the patient and GP experience, as well as improved the access to the care that is needed. Numbers vary day to day, but comfortably a lot less than half the patients who book in are triaged to be seen immediately. We expect to be able to provide more rigid data to back up our assertions later this year.
As doctors we all welcome any attempts to improve care for patients, but greater access, I argue, will not necessarily achieve this. Any jobbing GP will agree that an unfortunately large amount of time is spent dealing with problems which have been presented through the wrong channel, or at the wrong time. Making good use of the best form of triage will reduce wasted time, and allow GPs to prioritise care better. The story of the evolution of our open surgery is a microcosm of general practice itself. Demand and numbers will always continue to increase, and our resources will be stretched to the limit and beyond. If we continue the analogy, extending the time for open surgery will not achieve significant results with better patient care, or happier patients, and neither will extending core GP hours. What we are proposing is smarter access over greater access, based on clinical need, and guided by the GP. It seems to be working for us!
Dr Umar Tahir
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Moss Side Family Medical Practice
Practice lead for Children’s Health, Mental Health and Urgent Care