Out of Hours GPs – At What Cost!

Newspaper reports this weekend quote potential earnings for out of hours GPs that show the serious problems that face manning the health service.

Has the Government and NHS England been oblivious to the true cost of running out of hours services.? Has it not twigged that come 6.30pm on a Friday night GPs switch off their responsibility for the treatment and care of their NHS patients. It falls to the highly paid  few who have no long term responsibility.

My recent experience of GP and community care was that on a  Friday morning in late October  a GP decided that palliative care should be initiated in the form of a Rapid Response Team for a dying relative. By 5.30pm that evening there was no sign of a team and after enquiry of the surgery a prescription had been issued and left at a pharmacy to collect. So the wife of a dying man had to go by car to collect a prescription which she could not administer as a syringe driver was required. The Rapid Response Team only contactable via a message taking service arrived at 8.00pm. They administered morphine by injection.  But not the main drug prescribed to calm the patient. No syringe driver was fitted.

At this time the question arises as to whether the 111 service knew about a new palliative care patient. There was no promise of a return visit. Over the next two days the Rapid Response Team responded only to calls that the patient was in distress. The syringe driver was not fitted until 3.00am on the Monday morning. Overheard conversations suggested that the nurses were unclear as to what the GPs instructions were. But surely he was not contactable over the weekend. It would have been a case of contacting ‘111’. Again after the 3.00am visit there was no promise of a return visit. The patient died 7 hours later not seen again by a GP or nurse.

Insult was added to injury when the GP would not visit to confirm death. Legally he does not have to. The nurses on the Friday night also flustered about asking that the patient signed a consent form to apply for funding. Apparently this was a reward for keeping a patient out of hospital.

The lack of coordination and management of care once a GP is off duty is astounding and needs addressing by NHS England as a matter of urgency. I wonder how many more incidents there are like this where a dying patient suffers dreadfully in their dying days and final hours. Yet out of hours doctors earn a fortune. Perhaps the money that is being spent on locum GPs could be redirected at Palliative Care.

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Tweaking Appointments to Meet Demand

Tweaking Appointments to Meet Demand

I am sure that every GP Practice and every GP Practice Manager has at some time or other suggested tweaking the appointments system to try to cope with demand. You can argue with the figures but generally GPs work for 46 weeks a year and if full time probably 4 and half days of each of those weeks unless they are part time. However, the four and half days can be adjusted downwards for up to 10 public holidays and then there are monthly half days for training and clinical commissioning group meetings. Again you can argue with the figures but using one calculation I had in mind that the approximate payment for each consultation is about £26 for seeing about 135 patients per week for 10 minutes each.

‘Need to See’ Appointments

You can call appointments what you like. You can call appointments ‘routine’, ‘regular’, ‘acute’, ‘chronic’, a short appointment, a double appointment’, ‘urgent’, urgent access’, and urgent extras, but when it comes down to it there are simply appointments. Patients don’t need to worry about what an appointment is called. Naming appointments is purely for internal use. So bearing in mind holidays, sickness, maternity and paternity leave, training half days, bank holidays and inclement weather how on earth can a doctor see all the patients who ask to be seen today, let alone the rest of the week. There are those who have come up ideas such as Advanced Access, Telephone Consultations, and Nurse Practitioners et al. But when it boils down to it there is an obligation to see patients who require ‘immediately necessary treatment’.  The payment systems encourage 10 minutes appointments and seeing patients within two days. So patients need to be seen!

Attitudes to Appointments

In practices attitudes vary toward providing an appointments system. Some doctors like to see a cross section of patients, chronic patients and acute patients each session. Other doctors like to spend more time with each patient, say 20 minutes or even longer. This often leaves an imbalance in a practice meaning that some doctors see more patients than others. It can also lead to arguments and an atmosphere between doctors and between the doctors and their staff. The solution lies in either accepting the situation with complaint or setting up a system that means each doctor sees the same number of patients each day no matter how long it takes. This places a greater burden on the reception staff to manage the allocation of patients to doctors and again produces unpleasantness for staff who fail to keep the numbers even.

Busy or Not?

It is difficult to judge when the busy times are going to be; Monday mornings after a long weekend, Tuesday mornings after a bank holiday, Friday before a holiday weekend. I always found Christmas Eve afternoon extremely quiet. I suppose one could argue that the number of patients wishing to be seen is always going to be greater than the number of sessional appointments available whatever the day of the week or the time of the year. There is often great play about the number of broken appointments but in my experience there is usually a sigh of relief when a patient does not turn up unless it is the last patient and th4 doctor has just been twiddling his or her thumbs.

Meeting Variable Unpredictable Demand

So how do you tweak the appointments system to meet variable demand? In my experience it is a matter of knowing what the doctors prefer and working with it not against it. Changing the ratio between the number of regular appointments and urgent appointments is one way. Urgent appointments are those that can only be booked today. It might be possible to embargo the release of appointments until 24 hours before. Another way is to add one or two appointments to each session when demand is expected to be higher. In a practice of 8 doctors this might add up to 144 extra appointments. I worked in one practice where on one occasion 120 extra patients turned up to be seen one morning. The practice had a system of two doctors seeing the ‘extra’ patients whilst the others saw regular patients. When the ‘regular’ doctors had completed their sessions they dipped into the ‘extras’ session. Patients were still being seen at midday. In another practice the ‘extra’ patients were shared equally between the doctors on duty. This meant that the slowest doctor was always the last up for coffee if he or she was ever seen at all.

Try Over Egging the Pudding

Probably fairest way to balance the books is for each doctor to see the same number of patients each day and to fill appointments chronologically. Perhaps the key here is to allow say 20 patients per session rather than 15 but to embargo the last 5 until the day of the appointments. This way supply might appear to be greater than demand. What do you think?

Robert Campbell is a retired GP practice manager with 25 years experience.

This post has been prepared in response to a question raised by a member of GP Practice Managers UK on LinkedIn.

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Pirate Ship and Lego Man – Getting Things Done

So when do you think you will get it done?

Working in a GP Surgery where doctors suffer from the 10 minute syndrome (the standard length of a consultation) of getting things done, Practice Managers and their staff often find it difficult to close the door and get a job done to a specific timetable. You will have met those colleagues too who suffer from ‘the time management syndrome’ the one where their time is more precious than yours. Annoying creatures?

I have two stories that may help you involving games or hobbies that you might play or do in your spare time! Spare time I hear you say, what is that?

Pirate Ship

The first ‘hobby’ is Pirate Ship. This is a model made out of plywood. It has over ninety parts that have to be cut out of five plywood boards. The instructions that come with the model are minimal. There is a sideways picture of the model which does not show the whole of the model ship. There is a plan of sorts which shows content of the five boards and marks the position a by number on the board that the pieces are to be joined together. No glue is required. But a level of degree of thinking that is far superior than you would need for a building Lego model.

To build the Pirate Ship a small knife is needed to carefully cut the pieces of plywood away from the board. A small piece of sandpaper is required to clean up the edges of the pieces. A magnifying glass is also needed to find the numbers on the plan. The trick to make progress is to find the number 1 twice on the plan and then find the pieces on the boards before any cutting starts. Having found the matching numbers and having cut the pieces away from the board you can then join the two pieces together and then continue to repeat the exercise until the model is built. The model took around five hours to make and I would say that at the start of the exercise it was almost impossible to predict how long it would take to build.

So this task of building a plywood pirate ship was quite complex, it needed tools and skills. It required thinking time, and observational skills. The plan and picture required magnification and even a search on the internet for a better set of instructions helped solve some of the construction problems. So research was needed too!

Much like at work, getting things done can be quite complex requiring new skills and new knowledge to achieve your goals. Ideally managers get things done through people and it may be necessary to find people who can take on board new skills and new knowledge.

The Pirate Ship is a Woodcraft Construction Kit P217 made by Quay PO Box 1034 Blackpool FY1 4XB (www.quay.info)

Lego Man

Lego Man 3

The second story relates to building a Lego model ‘man’. The difference with this ‘game’ is that it comes without a plan. Normally ‘Lego’ kits come with a picture book guide to making the model so it is possible to meticulously follow the picture instructions brick by brick and normally produce a perfect replica of the model. The time taken to build a model depends on the number of bricks but it probably quite predictable. Lego Man is a ‘management’ game where a model is presented to the participants already made. About one foot high it is made up of 260 different coloured bricks and at best would probably take about 15 minutes to build from scratch from a selection of loose bricks if the sample model was left in front of you to view. However, that would not be a game. Instead participants are allowed to view the model for 5 minutes and then are given a box of bricks sufficient to build a replica model. After five minutes the model is removed from sight and the participants are asked to build a copy of the model from their box of bricks.

You can imagine the scene. There is a rush on to build the model within the 15 minute time limit. Some start to put bricks together. Others sit and think. Pens and paper appear and sketches are drawn. Overall there is chaos. The model re-appears for short spells to help the builders on their way. What they do not realise is that some have the bricks have changed position. This is what happens in real life. Somebody moves the goal posts.

Time is up and the ‘models ‘are ready or not for viewing. You guessed it none of the models bear any resemblance to the original. Why is this?

The Lego bricks came from Box 5932.

The Lessons

The lessons to be learnt from both of these exercises are to allow thinking time before ‘building’.  For instance you could spend 10 minutes thinking and 5 minutes building the model. You might need to research. Look at the model again. You might need to prepare a plan. Write a procedure or protocol. You might need to agree a policy. You might need new skills. You might need to talk to others and get help. You might need to delegate.

Robert Campbell is a retired GP Practice Manager and web site author.

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Phoning Your GP – is it a rip off

Phoning Your GP – the arguments

The arguments about GP practices using 084 telephone numbers continue unabated. The BBC Rip Off Britain programme claimed this week that despite ‘guidance’ issued by NHS England in 2010 over 260 practices still use an 084 number. Even though the Terms of Service for GPs has been amended to effectively ban the use of non-geographical numbers NHS England stills seems powerless to impose the Regulations.

The 084 number systems provided by such firms as Daisy Line formerly Surgery Line offer an income stream from calls made to a surgery in the form of a refund or discount. The income is supposed to be used to fund improvements in the surgery. I am for one never sure what evidence there is of such a reinvestment being made into a practice. Having said that the modem telephone systems can be very expensive to buy and install and even more expensive to lease the latter of which in my opinion is very unwise choice. These new systems provide automated answering systems and can deal with numerous lines.

In defence of GP practices, their telephone lines can be very busy and to use a telephone switchboard term can often be bust. This means that there are more incoming calls than the number of lines can cope with. This is the eternal question for any business but for a GP surgery patients need to be able to speak to the surgery promptly. No one can predict who is going to call and what it is about and there is nothing worse than being in a queue if you have an urgent problem. I called one surgery in West Yorkshire once and found myself 22nd in the queue. No joy there then! I have recently needed urgent attention during the day and found that the NHS service I was calling was a message service only and I had to wait another half hour to speak to a nurse. My family were caring for a dying man on palliative care. At night it is even worse as you need to explain your situation in considerable detail before action is taken. You might get a call back but the wait is just another stressor.

So it is a very difficult balance to get right. How many telephone lines does a surgery actually need. As as broad guide I could say one line per doctor in the surgery. However probably two lines needs to be barred from incoming calls so that doctors and staff can call out. One line needs to be reserved for incoming calls by the doctors when out on visits. The remaining lines would be available for incoming callers. The problem then is whether there are enough staff on duty to answer all incoming calls promptly. This varies according to the time of day, the day of the week and the time of year. The Tuesday following a bank holiday can be a nightmare. Not an easy judgement to make. In a practice of 15,000 patients. I had 6 lines in use with the capacity to use 10. All these lines cost money with line rentals and call charges. One surgery I know switched on extra lines at busy times and allocated an extra receptionist to take the calls.

This is where modern telephone systems with call answering and options for callers to place a call to a particular telephone come into their own. But the equipment costs a considerable amount of money. I could argue that GP practices are not funded for elaborate and modern phone systems and this is why GPs look for systems that have an element of self funding. Nevertheless incoming calls need to be answered promptly. Perhaps this is one of the pitfalls of merging into larger practices. For instance one switchboard system might in use covering three surgeries. There are options to make an appointment, ask for test results or request a visit. Rarely is there an option to order a prescription. Rarely is there an option to fax a request for a prescription. Again text messaging and email systems are in their infancy but these still need staff to review what’s coming in and such systems are not suitable for urgent calls. What is also lacking is an override for emergency calls. Usually the caller has to listen to all the options before finding out that the urgent/emergency option is the last one on the list.

One firm has encouraged a system of speaking to a doctor first but evidence suggests that a proportion of patients still need to be seen or seen later which simply increases the number of contacts. One practice I know has introduced a nurse practitioner supported by an on call doctor who works all day. The lead GP told me that there was a shortage of GPs and this was a viable option – it seems to work well. Another practice in a North Yorkshire seaside town offers an all day service from 8am to 8pm and this seems to fit the bill very well.

So all in all whilst I agree with those who want to ban 084 numbers that are partly paid for by callers, I agree that GP practices need to examine very carefully the type and level of telephone contact they provide in their practices. It needs to be funded adequately and NHS England need to look beyond just banning inappropriate phone systems. Gone are the days when a surgery had just one telephone and one line and no one answered the phone on a half day…….

Robert Campbell is a retired GP practice manager who has worked at five West Yorkshire practices and now runs a web site for practice staff.

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GP Services 24 hours per day 7 days per week

 

COMMENTS – If you have any Comments on this post please email  robert.campbell@kingfisherpm.com.

 

Both the Labour and Conservative Parties at their annual confrences have made bold pre-election promises that more money will be injected into the family doctor services post the election. But more money does not solve the manpower problems, the growing list sizes and the trend to push more and more care into the community.

In my experience GPs will only work the days and hours they want to. The attraction of more funds may encourage some to work at weekends and nights or stay open for longer days. But the make up of the manpower has been changing with more part time doctors and more working a four day week. These changes have been taking place slowly and quietly since 2004 whne the new contract was introduced by Labour and the facts and figues collected by health organisations I suspect do not reflect the true picture.

The political parties will need to be sure of their facts before hey embark on expecting a 24 hours 7 day service.

 

COMMENTS – If you have any Comments on this post please email  robert.campbell@kingfisherpm.com.

 

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