Relentless increase in demand means we need some quick easy solutions that work while the long-term plan of extra GPs and restructuring evolves.
Appointment systems are continually changing in practices varying from nothing booked ahead at all to tranches of appointments being released at different times. Making patients phone back is irritating for them, but also an inefficient use of receptionist time.
Many practices operate a 'doctor first' approach and these GPs find that maybe only 30% of the patients need face-to-face consultations. Doctor triage is undoubtedly the most effective because as GPs we make assessments quickly – if you can cope with all that time on the phone then having the most senior person doing the triage will yield the best results, but it is a way of working that does not appeal to many GPs.
Likewise electronic systems like AskMyGP make the patient give the history (which is over half the consulation time) and allow the GP to phone or email back with an appropriate consultation solution.
The receptionist role
Practices need to understand the role of the new receptionist, or care navigator.
Receptionists basically determine who can have an appointment and who is told to phone back when more appointments become available. They also decide who has a telephone appointment, an electronic consultation or pass a task to the GP. This offering is often proportional to availability of appointments and not to clinical need.
As GPs we need to appreciate the high pressure on receptionists every morning between 8am and 10am. The pattern of high speed appointment allocation at the outset of the day develops into telephone, electronic consultations and then GP tasks for urgent cases where there is no capacity left.
It is also true that our frequent attenders know how to crack this system to ensure they get the appointments they want but do not necessarily need. The danger is that ‘inexperienced patients' with clinically concerning symptoms are likely to accept a sub-standard service with potentially dangerous outcomes.
How could care navigation work?
If we were running a call centre (which we are!) then we would look at our call volumes and get the staff on deck to deal with the calls at a safe and constant rate.
It would be logical to have two or three times as many receptionists for the first two hours as for the rest of the day. When the phones are going and there are appointments on screen then the temptation to give the patient what they (think they) want is overwhelming. And yet the tenet must be every call has to be dealt with on clinical merit and be independent of appointment supply.
The answer must be to spend more time on the telephone with patients at peak times to get a better understanding of their needs and therefore not miss the opportunity to direct them to a more appropriate resource. We must make the most of the first contact with the patient.
Since most of our GP workload is decided in the first two hours of the day, we need to facilitate every patient getting the same level of questioning and assessment so we do not default to the GP appointment slot. At present the depth of enquiry increases as the appointment availability decreases.
Our own care navigation room is physically small so we cannot accommodate more people without the 'call centre' becoming very cramped. Now we have the telephone technology it should be possible to find one or two people to answer the phones between 8 and 10 remotely. They could be seconded for two hours from admin or even work from home.
If the care navigators have any doubt about whether a GP appointment is needed then a call back should be arranged ideally with a nurse practitioner or community paramedic.
We are also looking at how we can improve our automated messaging to direct people to other services, including physiotherapy, if they are put on hold when they call up.
Skill mix and further training
Of course it is vital that if patients are to be managed appropriately everyone in the practice understands which patients can be dealt with by which healthcare professional.
Further care navigation training is in progress ensuring that complicated patients, that will ultimately need to be seen by a GP, do not get booked in with the nurse practitioner or paramedic first.
But, we believe that care navigation has the potential to help us to deliver the double whammy of improved patient care as well as easing workload pressure on GPs.
- View Saxmundham Health poster on same day/urgent appointments, which explains which health professional patients need to see
- View Saxmundham Health poster outlining local services to which patients can be signposted
|The care navigator’s view|
We are certainly under pressure to find quick solutions to patients demands but do try to avoid resorting to GP appointments. We are not clinicians and we can only negotiate with patients and present alternative offerings, but if the patient declines then we make GP appointments.
Thinking about alternatives is new and demanding as well as being time consuming but we are in early days. We do have a large poster in the care navigation room outlining the options we can offer for varying problems - but we can only offer.
There is some satisfaction in finding a solution that is not a GP appointment but convincing patients that it is better for them is always a struggle.
|The PPG view|
While we acknowledge the pressure general practice is under, patients still view an appointment with their GP as their right. Alternatives to GP appointments are accepted if they come from a GP but much less so if they come from untrained staff.
We are happy for alternatives to a GP appointment being suggested by care navigators, but acceptance must be down to the patient without pressure from the care navigator. We are not so keen on the notion that this is designed to take pressure off GPs, but more that it is about seeing the correct professional – so is good practice.
Dr John Havard is a GP at Saxmundham Health, Suffolk