Where is your Appointment?

These days, Patients are getting used to their GP handing them a letter setting out the details of a hospital appointment. In fact, I suspect that many patients are quite impressed by the doctor’s keyboard dexterity and the speed at which an appointment is offered, although it might be a few weeks to wait, but at least there’s an appointment date and time. There will be a telephone number to ring and a password (I’ve noticed that it always the same password) to use if you want to look at the NHS E-Referral web site to change or cancel your appointment. What is probably missing from the paperwork that is handed to you by your doctor is the name of someone at the hospital to talk to and more likely than not there may not be on the letter the full address of the hospital and outpatient department you are intended to attend, not even a postcode!

It Get’s Worse

So your appointment gets nearer. It could a physiotherapy appointment or an outpatient clinic to see a skin specialist. It could be many things. But it is your appointment and you have patiently waited for the date and time to arrive. However, an envelope arrives through your letter box. Inside the envelope there are two letters. One letter disappointingly cancels your appointment. It says it is necessary to cancel the appointment due to a rearrangement of clinics. The letter is Dated but not signed by a named person. There is a simple apology for any inconvenience, but no real reason given. To soften the blow the second letter moves the appointment two weeks on and you have a fresh time and date.

It Gets Worse Again

Now that might be all very fine once but when a few weeks letter another envelope lands on  your doorstep with an almost complete repetition of the earlier cancellation letter. No named contact. But there is a telephone number for a Booking Centre. No address. Investigations reveal that the Booking Centre is located in another town over thirty miles away – I found the address on the internet, but it was not on the appointment (or cancellation) letter. I telephoned the Booking Centre simply to be told that the consultant had cancelled the clinics (three times). No other substantial reason was given.

What is Reasonable?

Personally, I think one cancellation is reasonable as long as there is an open and honest explanation. Two cancellations is really starting to push your look and three cancellations starts to question whether you are being referred to an imaginary service. Added to that why were you referred in the first place and does the passage of time not being seen increase the urgency of the requested appointment. Once a GP has made the first appointment does that GP get to know about the cancellations and the potential risks involved in delays. Is the patient sensible enough to ask their GP whether the passage of time creates a more urgent situation. Answers on a postcard!!!!!!!

What are the Rules for Cancellation?

Well, so far I have been unable to find any specific rules about how frequently outpatient clinics can be cancelled. There are rules once a patient has been seen and booked in for a procedure or operation, known as the 28 day rule.

Robert Campbell – October 2018

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Appointment Cancelled but guess where!

I do wonder how many patients receive letters telling them that their appointment is cancelled. No reason is given but in the same envelope there is another letter giving details of another appointment. The letters by the way are not signed. There is no Authors name on the letter and even more seriously there is no address and post code showing either the origin of the letter or the address to attend the appointment if one is actually given.

Reasons for Cancelled Appointments

So a consulting session or clinic is cancelled. Would it not be reasonable to say why or is the reason too embarrassing.  Has the clinician  been called to a meeting that is more important than seeing patients.  Is the clinician on holiday, playing golf, going to the gym or just ill. I do wonder.

How many times should a Cancelled Appointment be tolerated.

The next point is how many times would it be reasonable to receive such a cancellation letter. Once, twice, three times or more. It has to be said that a patient has been referred for a reason and initially it might not be an urgent referral. However after say three cancellations might the reason for referral have become more urgent? Who decides? Perhaps the patient should ask his or her GP to review the referral and if necessary ramp up it’s urgency.

Contracting  for Quality

CCGs in their contracts with hospital trusts should insist on a certain standard of both waiting times and only one cancellation and no more.

If you have any views on this blog contact me, Robert Campbell at

kingfisherpm@hotmail.com

Revised December 2018

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When the EPS system was first proposed my understanding was that it would speed up the dispensing of prescriptions. However my continuing experience is that this is not so for the following reasons:1. Patients need to check that the nominated pharmacy is correct, particularly if they have been away from home and changed their nominated pharmacy temporarily.

2. GP Practices are taking longer to issue repeat prescriptions – sometimes more than two days, particularly if the request is for an acute not repeat prescription.

3. Small pharmacies often have stock problems meaning patients might have to wait far more than two days for their drugs. One pharmacy I know has prescriptions made up elsewhere.

4. If a pharmacy is out of stock the patient has the right to take the prescription to another pharmacy. However this means giving the patient a complex code and returning the prescription to the NHS spine so that another pharmacy can issue it. A simple print out of the out of stock item would suffice.

5. GP Practice’s too on a separate issue are changing patients medication without checking that supplies are in stock at the nominated pharmacy. I have had problems with Peptac, Ranitidine and Nystatin.

I would be interested to hear your solutions to these problems.

Robert Campbell

December 2018

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Are telephone consultations replacing face to face consultations?

As GP Practices battle to provide adequate numbers of face to face appointments I was wondering if other forms of providing consultations are on the increase. I spotted recently a notice in my local surgery which declared that almost one third of consultations in July had been on the telephone. This amounted to a remarkable 40+ per day, and it struck me that that would have taken some dealing with. What it didn’t say was how many telephone conversations resulted in a need for the patient to be seen face to face. What if the patient actually needed to be examined, not just subjected to a telephone inquisition.

Telephone Consultations are not effective?

A major survey carried out in 2014 the results of which are on the NHS Choices web site,( https://www.nhs.uk/news/medical-practice/phone-consultations-do-not-reduce-gp-workload/) suggested that whilst telephone consultations provided an alternative method of consultation they were not necessarily as effective. The survey also claimed that telephone consultations did not reduce a GPs workload. It found that almost 12% of consultations had been carried out on the telephone, representing a four fold increase over the previous 20 years. I do recall that the process of telephoning patients who had requested an urgent appointment or a home visit starting in my Practice around 15 years ago very reluctantly and only a handful of calls were made in the early days. One GP in particular much preferred a face to face contact and had five minute appointments.

Triaging Calls becomes run of the mill!

Nowadays, a system of triaging appointment requests is not unusual, although the personnel that filter the calls may range from a receptionist to a nurse practitioner or a doctor first. In my mind there are always inherent risks involved where a non-clinician becomes involved. To be on the safe side it requires a well trained and experienced clinician to sift and sort the problems presenting on the telephone. I recently came across an example of a telephone consultation being offered by a receptionist in three days time but when the patient needed a referral. So Practices do need to adopt a safe system of filtering calls and allocating appointments. Practices tend to get a GP to phone the patient back, if no offer of an appointment is accepted or simply to be on the safe side!

Seeing today’s patients Today!

Around the time the Quality Outcomes Framework was introduced the idea of seeing today’s patients today was also marketed, which at the time was a fine aim, but the pressures of demand from patients and the inadequacies of supply from doctors have since created a situation where Practices desperately look for alternatives ways of providing a service to patients. The concept of 10 Minute appointment may no longer be valid or achievable. When we first used a senior Practice Nurse to see patients with minor illnesses I have to say that it broadly failed. The nurse saw less patients than the doctors and there was of course the problem of raising prescriptions. The nurse was not a prescriber. Now the likelihood is that a Practice will have a nurse prescriber, even a pharmacist and better training and qualifications mean that the prescriber will probably see just as many patients as their GP colleagues. I can certainly comment that a good nurse practitioner can become a valuable and effective member of the Practice.

When Demand Outstripped Supply

However, what happens if the level of demand still outstrips the availability of prescribing clinicians. Here are some thoughts:

• Over the Counter Medicines

Encouraged by CCGs and NHS England practices are introducing widely schemes to not prescribe OTC (Over The Counter) preparations that can be purchased from a pharmacy. So once patients realise that their medical practice will no longer prescribe simple remedies will the demand for appointments reduce. Practices or CCGs might employ a pharmacist to help manage more effective prescribing. According to NHS England 40% of Practices have access to a Clinical Pharmacist. (https://www.england.nhs.uk/gp/gpfv/workforce/building-the-general-practice-workforce/cp-gp/)

• Signposting to Pharmacy

Signposting patients to pharmacies is another alternative. But it depends how well staffed and how well stocked a pharmacy is for such a service to be successful. A recent suggestion that Gasviscon Advance be replaced by Peptac resulted in a 24 mile round trip to a local town to find a pharmacy that stocked. It cost over £3 whilst Gaviscon Advance was around £8. The bus journey would have cost me £11. Practices, both GPs and Practice Pharmacists need to work with local pharmacies when changing either their prescribing habits or offering OTC advice to patients.

• Encouraging the use of 111

Suggesting patients, make a first port of call to the NHS (111) telephone line is another option. In June 2015, 111 received an average of 23 calls per minute. That month approaching 1 million calls were received. Now that takes some managing.

Possible Pitfalls

But nothing in my view replaces seeing a patient. Those answering the telephone to filter requests for appointments need to be aware that patients might not describe their problem adequately. Likewise they may want to tell an unknown voice what they would tell a doctor or nurse. The idea of an experienced and trained clinician phoning a patient back is probably much safer. But there will be occasions when actually seeing the patient and examining them cannot be achieved in a telephone conversation. The question is what is the appropriate balance between seeing patients face to face or talking to them on the telephone.

More recent findings

The BMJ published an article in September (2017) (https://www.bmj.com/content/358/bmj.j4345) which looked at the growing Practice of patients speaking to a doctor first. Even the new Health Secretary is promoting the development of online GP services. But the question remains as to whether it is a better way to provide services or just an alternative. The BMA article states that much of the work of general Practice can be managed on the telephone. The reduction in consultations is compensated by the time spent on the telephone, but around half of the patients still need to be seen face to face. The article goes onto explain that the success of a telephone system depends on how well it is organised. There is an issue of prompt call back and Practices need to make allowances for patients who have problems dealing with telephone calls. Perhaps too Practices need to make clear that the telephone consultation is a new feature of the service being provided and not an alternative caused by lack of doctors and high demand!

Robert Campbell – Reviewed January 2020

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Steps are being taken throughout general Practice to reduce the prescribing of medications for minor ailments that can be bought at a pharmacy ‘over the counter’.

NHS England have published a leaflet for patients which explains what GPs are trying to do, encouraged by CCGs and Practice Pharmacists.

https://www.england.nhs.uk/wp-content/uploads/2018/08/1a-over-the-counter-leaflet.pdf

But are those promoting the non-prescribing of OTC products overstepping the mark. Should they be telling patients that they can no longer prescribe OTC products. Are they simply trying to substitute cheaper products. Are they following national NICE guidelines are using a different product which they regard as just as effective whilst still saving money. What is going to happen to small pharmacies who loose dispensing fees

In my view Practices need to be very careful about the way they introduce these changes and the words and style of language they use when doing so. Each patients case needs to be treated on its merits and reference should be made to clinical letters and recommendations made by consultants.

My understanding is that the shift to OTC products not being on prescription is not a blanket decision and GPs need to be aware of that.

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