An edited version of this article appeared in Health Service Journal 10 Jan 2012.
“I love working here,” explained Sam. “I’m not fighting off the patients.” It was a eureka moment. Sam is a receptionist at Simpson Medical Practice in Manchester, and I have phoned because at 77% they have the highest score in England on the little known PES survey question “very easy to speak to the doctor.”
Sam has just described to me what happens when a patient calls, wanting the doctor. She identifies their medical record in the normal way, confirms their telephone number and asks for a brief description of the problem. She tells the patient that the doctor will call them back as soon as possible, most likely less than an hour, unless they ask for a later call. That’s it. Her job is to put the patients in touch with the doctor, not to negotiate with them on how urgent their call is, or tell them there are no appointments left today, or call back tomorrow, or be fobbed off with someone else. She is not fighting them off, but welcoming them. There is no special “attitude” training to do this – just having a system in place which allows her to offer the service.
The significance of this conversation with Sam is that, while I know of three practices in Leicestershire who operate in this way, unless I can find some more they would remain a promising curiosity. Now I have a key which enables me to find potentially many others. With all the data on the PES question to hand, I start phoning down the list in order. While the average practice scores just 9% on the question, I call the top 250 which are above 27% and discover that about 40 of them offer a service roughly equivalent to Sam’s description. The key step is the telephone call from the doctor, as the first point of contact to all or most patient demand.
“So we are not the only one?”
Talking to more and more of these practices, receptionists, practice managers and GPs, a powerful body of evidence emerges about how the system works and the effects they are finding. From the initial phone call, if either the doctor or the patient sees the need for a face to face appointment, the doctor asks the patient when they would like to come in. Around 80% of patients say today, the doctor says yes and arranges a time on the spot. They can ask for a later date if they wish. But in many cases, between about 50% and 80%, no appointment is needed. The issue is dealt with by advice only, prescription or perhaps to see the nurse. It is this finding which generates the capacity to see the patients the doctor really needs to see as soon as possible, usually the same day.
The patients love the service, because it is so fast and reliable, and they can always see a doctor on the day if they need to. Some report initial complaints from a few patients, unfamiliar at first with the new idea, but most of their concerns are allayed after finding how well it works. The doctors love the system, because it gives them more control over their workload. They are deciding who comes to see them, and they are prepared when the patient arrives, having already spoken earlier. They kept saying to me that they were going home on time now, not seeing extras, and some went even further to describe how this had brought them back from exhaustion and thoughts of leaving the profession.
All the practice staff clearly enjoyed working with the system. Practice managers, who had often been initiators along with the GPs, found that it enabled them to cope with the ups and downs, even the crises, with relative ease. They reported strong local reputations and growing list sizes. Receptionists all loved the work, many complaining to me that they wished their own GP would adopt the system as they were often told to wait a week or two for an appointment, in one case six weeks. Practice nurses benefited too, from a growing level of appropriate referrals from the GPs. The only complaint I heard frequently was that the PCT didn’t understand how it could work without a set number of appointments available per day, and poor marks on PES 7 & 8 because patients simply didn’t need to book 48 hours ahead, though they could if they wished.
Practices are found all over the country, inner city to rural villages
Where were these practices, what were they like and how had they come to this point? The answers astonished me. They were all over the country, from Penzance to Middlesbrough, from Tower Hamlets to leafy Lechlade, from single hander Simpson to Robert Darbishire with 20,000 patients. The same idea had been invented at least 20 times independently, some eleven years ago, some within the last year. The numbers crept up to 40, as a few practices had learnt the system through local contacts, and the NHS Institute had written up the Stour Access System in 2007, an innovation by Dr Simon Coupe in 2001. This spread to a few more around the country. Other names were Intelligent Access and Dr First. They were reporting similar outcomes, yet the pace of adoption had been glacially slow – most of them knew of no other practitioners, or perhaps a few locally, and felt isolated and unloved, the total coming to fewer than one in 200 English practices. I emailed the early findings to the practices, and started getting replies in the middle of the night along the lines of “We are not alone!”
Yet one crucial question remained. My journey to finding the first few practices in Leicestershire had started with the question: “Why is demand for emergency care rising faster than demographic factors would predict, and what can we do about it?”. Annual rises of 6, 7 or 8% suggest that something is wrong with the system, and with this in mind I found that there was high variation between practices, more than could be explained by age of patients, deprivation or proximity to hospital. Access seemed a likely factor which would vary by practice. I started asking those with the lowest A&E attendance rates whether they could explain their results. Dr Steve Clay at The Cottage Surgery gave an interesting answer: he phones all the patients. How quickly? Don’t know. So we measure it – the median time is 26 minutes. Many of the patients don’t need to come in, but those that do are offered a same day appointment. Dr Clay runs another larger surgery at The Banks in Sileby, and though the GPs are all locums they run a similar service model and achieve similar rapid response.
Now we have a plausible explanation for the low numbers: patients have such confidence in access to their GP that they are less likely to attend A&E when they don’t need to. This chimes with reports from hospitals that 30-50% of A&E attendees could have been dealt with in primary care.
Back to the question on cutting A&E demand – the effect holds
It turns out that Dr Clay brought the idea from his former partner Dr Chris Barlow at Quorn who began the system in September 2000, and his A&E numbers are similarly near the bottom of the range. Could this be the simple, transferable innovation which turns around the rise in emergency demand? We took it to the East Midlands Expo, and the SHA then invited us to present at the national Healthcare Innovation Expo in March. By this time I’d found 29 practices in total, and the key question was, what is the A&E effect overall? Armed with NHS Comparators datasets for age/sex standardization, deprivation indices and some long nights crunching numbers, the answer came: the 230,000 patients served by these practices were 27% less likely than the mean to visit A&E.
Sir Muir Gray from the DH invited us to bring the practices together for a London conference held in June. By then there were 40, and the A&E effect had been refined using better standardized data from Simon Swift of East Midlands Quality Observatory to show a reduction of 20% – the same number held for consecutive years 2009-2010 and 2010-2011. Stories from practices all over the country reinforced the benefits seen, the variety of contexts and the similarity, with small differences, of the method. The conference gave the mandate for an organisation to be formed to make the work available to all.
GP Access was born. A steering group of GPs and practice managers was formed, chaired by Dr Amit Bhargava. Even before the website was launched, other practices have heard what is happening and a few have made the change. We knew roughly what to expect when they started the new method – what we didn’t know was how quickly they would see benefits for both the patients and the practices. Case studies are now available on the website, and these charts show the results from one of them, Thurmaston Health Centre with 6,400 patients in suburban Leicester. After a month Dr Kam Singh reflected, “It’s given me a new lease of life.”
Our vision is “To transform access to medical care for the good of patients, doctors and the NHS.”
We are there to provide practical help, on the basis of evidence: patients to improve your access to primary care, doctors to improve your working lives and the local NHS to reduce A&E costs.