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GP Pilot evaluation reportA report from The Campaign Company (TCC)

Daniel [email protected]

02086880650

www.thecampaigncompany.co.uk

mailto:[email protected]

Contents

Executive summary...............................................................................................3

1 Introduction.....................................................................................................4

2 Methodology....................................................................................................5

3. Quantitative Findings.........................................................................................7

4. Qualitative findings..........................................................................................42

7. Conclusions......................................................................................................55

8. Recommendations...........................................................................................57

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Executive summaryPatient satisfaction

There were no statistically significant changes in overall satisfaction with the service received for each of the schemes.

Satisfaction with the appointment system has dropped for all schemes. In the case of scheme 2 and 3 this was a statistically significant drop. Scheme 1 had a much higher post-satisfaction than the other two schemes.

Patient experience

Patients in scheme 1 practices were significantly less likely to have their calls answered in 30 seconds or less. Very large variations exist between practices in phone waiting times, ranging from 3 per cent to 45 per cent waiting longer than 5 minutes.

There was a significant difference in the appointments patients received. A significantly higher percentage of patients across schemes received same day appointments.

There were no significant changes in satisfaction with the appointments given across the three schemes.

Awareness and perceptions of pilot

Patients in scheme 1 practices have polarised perceptions of the appointment system; with an increase in both those who feel the service has both increased and declined. Scheme 2 registered a significant decrease in those who felt the system had improved

53 per cent of scheme 1 patients had used over the phone consultation. Of those who had three quarters were satisfied and 7 per cent dissatisfied.

6 per cent of patients in scheme 3 had used an online symptom checker and consultation; lower than for patients from other schemes. Of those who had used such systems, a majority were satisfied with their experience.

Qualitative findings

Patients were divided over the use of phone consultation. Whilst some, often younger patients appreciated the efficiency and the increased access, concerns were mentioned over the quality of over the phone consultations, and some patients were not comfortable using them.

Staff felt scheme 1 to have had a positive impact on GP Access but to have created challenges in terms of workload.

Scheme 1 staff felt that there was not enough support provided at the beginning of the pilot and that this created a number of problems in the very initial phase.

A number of staff in scheme 2 practices felt that the changes made as a result of the pilot were positive, however, there was a common feeling

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that the impact was not significant and there could have been more support in implementation.

Uptake of the consultation element of scheme 3 was low. Staff felt that whilst there may have been some positive impact, it was too small to detect.

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1 IntroductionDemand for general practice is increasing in Greenwich due to a growing population with an increasing prevalence of long term conditions and a constrained financial settlement. The need for practices to manage this increasing demand has implications for the operating of care across the health service, as lack of access can lead to patients using alternative less efficient and appropriate forms of care such as accident and emergency services.

Greenwich CCG identified three approaches to improving access for patients in general practices, with the aim of reducing these pressures and improving GP access. These schemes operated in a number of practices across Greenwich for 5 months.

The three schemes are:

Scheme 1. Improving access by systematic telephone triage of all requests for appointments, telephone consultations or visits, supported by the Patient Access company who would do an initial detailed analysis of the current practice supply and demand and then train GP's and practice staff in the new system and support its introduction and monitoring.

Scheme 2. The Primary Care Foundation use a web based tool to produce a semi-automated report for individual practices based on their own data that offers a clear analysis of the practice and offers suggestions for improvement. The process is improved by a follow up session in the practice and the opportunity to access on-going advice and support. All the data can be submitted on-line.

Scheme 3. Improving access for patients through on-line consultations for conditions or concerns that are not urgent, including access to a self-diagnosis algorithm. This work would be supported by the Hurley Group.

The aim of this evaluation is:

To assess the impact of the pilots on patient experience

To assess the impact of the pilots on workload

To provide accurate baseline and post-pilot information.

The report is structured into three parts: quantitative findings, qualitative findings and conclusions and recommendations.

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2 Methodology Overview

The evaluation was designed to measure quantitative evidence of the impact of the different pilots on patients, and gather qualitative insights into the learning and perceptions of staff. The methods used were:

Baseline pre-pilot survey of practice users Post-pilot survey of practice users Depth interviews with GPs Depth interviews with practice managers/receptionists Depth interviews with patients.

Quantitative methodology

The method used was a convenience sample of patients in GP’s practices. This is an effective measure of those within the GP’s surgery with low levels of response bias and high levels of completion rates. This method provides results that are representative of those within the practices but not of GP Practice patients as a whole, as more frequent service users are more likely to have been included in the sample. In the case of the post-pilot survey, users who are using alternatives to attending practices may have been underrepresented through this method.

A baseline survey was used to assess pre-pilot measures. This had a sample size of 535. This was followed up by a post-pilot survey of 1129, with 427 surveys from practices participating in scheme 1, 454 for scheme 2, and 425 for scheme 3. Throughout the quantitative elements of this report, the findings from the post-pilot survey are shown per scheme compared to both the per scheme pre-pilot results and the overall pre-pilot baseline. Findings that are called statistically significant are significant to a 95 per cent confidence level.

In the pre-pilot survey, there were 14 participating practices. Due to the withdrawal of two practices, the surveys from these practices has been omitted from this analysis. The practices analysed in this research and the schemes they are included in are:

Blackheath PMS (scheme 1) Conway PMS (scheme 1) Eltham Palace (scheme 1) Eltham Park (scheme 3) Fairfield (scheme 2 +3) Ferryview (scheme 3) Gallions Reach (scheme 1) Trinity (scheme 2) Triveni (scheme 2) Vanbrugh (scheme 1) Sherard Road *scheme 2)

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The data produced in the main report includes graphs of the key findings. The full data tables for these graphs are included in Appendix 1 showing the count for each finding.

Qualitative methodology

Depth interviews over the phone and face to face with patients and staff were conducted. 21 patients were interviewed in total: 8 from scheme 1, 7 from scheme 2 and 4 from scheme 3. The interviews were selected based on their experience of using the schemes and recruited through the post-pilot survey.

Sampling for staff interviews was designed to gather a complete picture of each practice through interviewing a GP and practice manager or other member of staff in each surgery. We interviewed 21 members of staff in total. To allow interviewees to speak candidly about their experiences, these interviews are recorded here anonymously, with the scheme denoted in the text but not the individual practices.

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3. Quantitative Findings

3.1 Patient satisfaction

3.1 Overall, how satisfied are you with the service you receive from your GP’s surgery

For the benchmark of overall satisfaction with the service that patients received, there was a significant decrease in satisfaction for scheme 1 practices as a whole when compared to the pre-pilot measures (78 per cent compared to 84 per cent). In particular the number of respondents who responded “very satisfied” dropped from 55 per cent to 41 per cent. The number who were dissatisfied declined, but not significantly, with 9 per cent dissatisfied in the post-pilot survey compared to 5 per cent in the pre-pilot survey. However, this change is not significant when the comparison is the pre-pilot baseline that includes all practices evaluated, which had an 80 per cent satisfaction level.

Scheme 2, which included a practice on both scheme 1 and scheme 3, had an overall increase in satisfaction when compared against the pre-pilot results for scheme 2 practices (78 per cent compared to 84 per cent) , but no significant increase in satisfaction when compared to overall pre-pilot benchmark of 80 per cent.

Scheme 3 had a drop in satisfaction from 84 per cent to 78 per cent. This is not significant when using the pre-pilot benchmark of 80 per cent.

Scheme 1

Scheme 2

Scheme 3

Pre benchmark

78%

84%

79%

84%

78%

84%

80%

Satisfaction with the service received

Pre-satisfactionPost-satisfaction

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3.1.2 Overall how satisfied are you with the appointments system

All the schemes reported a drop in satisfaction with the appointment system. This trend was strongest in the case of scheme 3,

Scheme 1 practices had a reduced satisfaction level of 61 per cent, compared to 70 per cent in the same practices pre-pilot. This however, was not a significant different when compared to the pre-pilot benchmark. The level of very dissatisfied patients increased from 7 per cent to 11 per cent.

Scheme 2 had a significant drop in satisfaction from 62 per cent to 54 per cent. This is also significant against the pre-pilot baseline. There was an 8 per cent point drop in patients who were very satisfied.

In scheme 3, satisfaction dropped from 67 per cent amongst participating practices to 52 per cent. This drop is also statistically significant against the pre-pilot benchmark satisfaction. In particular the percentage of very satisfied patients fell from 36 per cent to 21 per cent.

Scheme 1

Scheme 2

Scheme 3

Pre benchmark

61%

54%

52%

70%

62%

67%

64%

Satistifaction with the appointments system


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4%

4%

11%

-8%

-8%

-15%

Scheme 1

Scheme 2

Scheme 3

The appointments system

SatisfiedDissatisfied

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3.1.3 The way treated by receptionists and administrative staff

There were no significant changes in satisfaction with the way patients felt they are treated by reception and administrative staff. The largest change from the benchmark of 87 per cent was in scheme 3 where 91 per cent of patients felt they were satisfied. One significant change within the satisfaction level for scheme 1 is a decline in those feeling very satisfied from 64 per cent to 50 per cent.

Scheme 1

Scheme 2

Scheme 3

Pre benchmark

87%

89%

91%

87%

88%

88%

87%

The way treated by receptionists and administrative staff


-1%

-1%

-2%

-1%

1%

3%

Scheme 1

Scheme 2

Scheme 3

The way treated by receptionists and administrative staff


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3.1.4 The way you are treated by nurses and doctors

There were no significant changes in perceptions of treatment by nurses and doctors. The largest change was a drop from 92 per cent to 87 per cent in the case of scheme 1, although this was not significant against the pre-campaign benchmark of 90 per cent.

Scheme 1

Scheme 2

Scheme 3

Pre benchmark

87%

90%

90%

92%

88%

93%

90%

The way you are treated by nurses and doctors


Scheme 1

Scheme 2

Scheme 3

1%

-3%

-1%

-5%

2%

-2%

The way you are treated by nurses and doctors


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3.2 Experience of appointments3.2.1Thinking about the last time you tried to contact the practice by phone, how many times did you have to ring before you got through?

We asked respondents about their experience arranging an appointment. There were not significant changes across the different schemes as a whole, although there were very large differences between different individual practices. These ranged from Blackheath PMS and Triveni where 61 per cent got through on first attempt to 28 per cent in Conway PMS.

In scheme 1, 51 per cent of patients got through on their first attempt, and a further 37 per cent on their second. 29 per cent had to try three or more times. In scheme 2, 56 per cent got through on first attempt. This is a six percentage point drop which puts it in line with the pre-pilot 56 per cent baseline. This was also the case in scheme three where 57 per cent got through on the first attempt compared to 64 per cent before.

Only once, I got through on first attempt

Twice, I got through on second attempt

Three of four times

Five to ten times

I have never tried to ring the practice

1%

3%

-3%

-12%

-1%

-6%

2%

6%

1%

-2%

-7%

5%

3%

1%

-1%How many times did you have to ring before you got

through? Change

Scheme 3 Scheme 2 Scheme 1

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Three of four times

Five to ten times


56%

20%

18%

19%

6%

49%

24%

23%

21%

4%

51%

27%

20%

9%

2%

How many times did you have to ring before you got through? Scheme 1

Post-Scheme 1Pre-Scheme 1Pre-baseline



Three of four times

Five to ten times


56%

20%

18%

19%

6%

62%

18%

12%

18%

7%

56%

20%

19%

19%

6%

How many timed did you have to ring through? Scheme 2


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Three of four times

Five to ten times


56%

20%

18%

19%

6%

64%

17%

11%

12%

8%

57%

22%

15%

13%

7%How many times did you have to ring through? Scheme 3


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Blackheath PMSConway PMS

Eltham PalaceEltham Park Surgery

FairfieldFerryview Health Centre

Gallions ReachSherard Road

TreviniTrinity

Vanbrugh

61%28%

44%53%

46%52%

48%43%

61%41%

51%

19%29%31%

23%14%

21%20%

15%18%21%23%

16%21%

16%14%14%

11%19%19%

10%20%20%

1%17%

9%7%

23%4%

11%14%

6%18%

5%

3%6%

1%3%4%

12%2%

10%4%

1%1%

How many times did you have to try to get through? Change

I have never tried to ring the practiceFive to ten timesThree of four timesTwice, I got through on second attemptOnly once, I got through on first attempt

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3.2.6 Once you got through, how long do you think you waited for the call to be answered/how long were you on hold for?

Respondents in scheme 1 practices were significantly less likely to have their call answered in less than 30 seconds (20 per cent compared to 34 per cent). However, the percentage on hold for more than 2.5 minutes did not increase by a statistically significant amount, as more calls were answered in between 30 seconds and one minute.

A lower percentage of patients in scheme 2 had their calls answered in less than 30 seconds, (17 per cent compared to 23 per cent). This is also statistically significant against the pre-baseline of 26 per cent.

Patients in scheme 3 also had a lower percentage of calls answered in less than 30 seconds (17 per cent compared to 28 per cent), however only 1 per cent more had to wait more than 10 minutes. This is influenced by a much higher percentage of respondents responded that they didn’t know in this sample.

There are large differences by practice, ranging from Trinity where 71 per cent recalled waiting for less than one minute and only 3 per cent waited longer than 5 minutes, to Fairfied where 45 per cent waited longer than 5 minutes.

No response/don't know

Less than 30 seconds

Between 30 seconds and 1 minute

1 to 2 minutes

2.5 to 5 minutes

5 to 10 minutes

Over 10 minutes

-1%

-14%

5%

4%

1%

1%

3%

5%

-6%

4%

-5%

-4%

2%

5%

10%

-11%

4%

-4%

-4%

0%

5%

How many times did you have to ring before you got through? Change

Scheme 3 Scheme 2 Scheme 1

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Betweeen 30 seconds and 1 minute

1 to 2 minutes

2.5 to 5 minutes

5 to 10 minutes

Over 10 minutes

9%

26%

14%

18%

16%

11%

6%

9%

34%

15%

14%

13%

10%

5%

8%

20%

21%

18%

14%

12%

8%

Once you got through, how long do you think you waited for the call to be answered/how long were you on hold for?

Scheme 1





1 to 2 minutes

2.5 to 5 minutes

5 to 10 minutes

Over 10 minutes

9%

26%

14%

18%

16%

11%

6%

8%

23%

15%

22%

17%

10%

6%

13%

17%

18%

17%

13%

12%

11%

Once you got through, how long do you think you waited for the call to be answered/how long were you on hold for?

Scheme 2


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1 to 2 minutes

2.5 to 5 minutes

5 to 10 minutes

Over 10 minutes

9%

26%

14%

18%

16%

11%

6%

9%

28%

9%

18%

15%

14%

7%

20%

17%

13%

14%

11%

14%

11%

Once you got through, how long do you think you waited for the call to be answered/how long were you on

hold for? Scheme 3






TreviniTrinity

Vanbrugh

59%35%

50%67%

10%20%

28%43%

38%71%

30%

28%42%

29%7%

24%45%

21%37%

44%20%

39%

5%14%14%

2%45%

20%41%

11%11%

3%28%

Once through, how long do you think you waited for the call to be answered/how long were you on hold for? Scheme

3

More than 5 minutes1 minute to 5 minutesLess than 1 minutes

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3.4.3 Last time you wanted an appointment at the practice with either a GP or nurse, what type of appointment did you get?There were significant differences in the appointments that patients received. A significantly higher percentage of scheme 1 patients had appointments at the surgery on the same day (47 per cent compared to 39 per cent). A similar trend was the case for both scheme 2 and scheme 3. It should be noted that the option of call backs from GP’s who then made an appointment for them to come back was not in the pre survey.

8%

-11%

-1%

3%

1%

-1%

0%

0%

4%

-14%

-2%

12%

0%

0%

0%

1%

2%

-10%

0%

7%

1%

0%

0%

-1%

Appointment to be seen at the surgery on the day

Appointment to be seen at the surgery within the week

A telephone consultation on the day

A call back from the GP who then made an appointment for me to come in to …

A telephone consultation within the week

Appointment for someone to visit at home on the day

Appointment for someone to visit at home within the week

Can't remember

What appointment did you get? % Change

Scheme 3Scheme 2Scheme 1

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Can't remember


A call back from the GP who then made an appointment for me to come

in to the surgery to see a doctor


0.0125628140703518

0.00251256281407035

0.00753768844221106

0.0452261306532663

0.545226130653266

0.386934673366835

0.00740740740740741

0.00740740740740741

0.0159574468085106

0.0691489361702128

0.51063829787234

0.393617021276596

1%

0%

0%

1%

5%

6%

40%

47%

What appointment did you get? Scheme 1

Post-scheme 1Pre-scheme 1Pre-pilot baseline

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Can't remember





0.0125628140703518

0.00251256281407035

0.00753768844221106

0.0452261306532663

0.545226130653266

0.386934673366835

0.0144578313253012

0.00240963855421687

0.11566265060241

0.00481927710843374

0.371084337349398

0.491566265060241

0.0222222222222222

0.511111111111111

0.451851851851852



Can't remember





0.0125628140703518

0.00251256281407035

0.00753768844221106

0.0452261306532663

0.545226130653266

0.386934673366835

0.0172413793103448

0.0172413793103448

0.551724137931035

0.413793103448276

0.0109289617486339

0.00546448087431694

0.0737704918032788

0.0218579234972678

0.453551912568306

0.434426229508197



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Conway PMSFerryview Health Centre

TrinityEltham Park Surgery

Eltham PalaceSherard Road

VanbrughGallions Reach

TreviniBlackheath PMS

Fairfield

10%

25%

26%

31%

32%

37%

40%

49%

52%

66%

68%

69%

67%

74%

69%

68%

51%

54%

37%

48%

29%

29%

14%

3%

0%

0%

0%

6%

3%

15%

0%

3%

3%What appointment did you get by day? by practice

A telephone consultation on the dayAppointment to be seen at the surgery within the weekAppointment to be seen at the surgery on the day

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3.2.7 Satisfaction with appointment given

There was no significant change in satisfaction levels with appointments given across all schemes. Scheme 2 had the largest change, with six per cent less feeling that they are not satisfied (17 per cent compared to 23 per cent). This however, is still within the margin of error for the pre-baseline which was 20 per cent.

Scheme 1

Scheme 2

Scheme 3

2%

1%

0%

-1%

5%

-4%

-2%

-6%

3%

Were you satisfied that you got the appointment you wanted?

NoYesNo answer

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No answer/don't know

No

Yes

1%

20%

79%

2%

14%

85%

4%

12%

84%

Were you satisfied that you got the appointment you wanted? Scheme 1



No

Yes

1%

20%

79%

1%

23%

76%

2%

17%

80%



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No

Yes

1%

20%

79%

2%

18%

80%

2%

21%

77%



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3.3 Awareness and perceptions of pilot

3.4.1Do you feel the appointment system has improved or declined recently? (over the last few months).

We asked respondents in both the pre and post surveys whether they felt that the appointment system had improved or declined.

Respondents in scheme 1 practices have polarised perceptions of the appointment system. Whilst there was an increase in the percentage of those who feel the service has declined (25 per cent compared to 15 per cent), there was also an increase in those who feel it has improved (35 per cent compared to 30 per cent). This is matched by a decrease in the number who felt neither from 50 per cent to 34 per cent. This is statistically significant and shows clear evidence of the changes being felt.

Scheme 2 registered a decrease in the percentage who feel that the system has improved from 41 per cent to 29 per cent; the pre-baseline was 33 per cent. This is a significant change against both.

Amongst respondents in scheme 3, there was a 6 per cent increase in those who feel the service has declined and 5 per cent decrease in those who feel it has improved. These are not significant when compared to the pre-baseline.

Breakdowns by practice show major variation, with only 5 per cent of patients at Triveni and Vanbrugh feeling that the system has declined compared to 39 per cent at Blackheath PMS. 44 per cent of respondents of Gallions Reach and 40 per cent of Conway PMS felt the system had improved, yet these surgeries had 28 per cent and 33 per cent respectively, who felt they had declined.

Younger respondents are significantly more likely to feel that all of the schemes have improved rather than declined. A net score (calculated by the overall% improved minus the overall % declined), shows that there is a net positive that all schemes have improved by between 19 and 40 per cent in the under 35 age group, compared to net minus scores for scheme 1 and 2 in the 45-54 age group.

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Scheme 1

Scheme 2

Scheme 3

11%

4%

6%

6%

-11%

-5%

Do you feel the appointment system has improved or declined recently?

ImprovedDeclined

No answer

Declined significantly

Declined slightly

Neither

Improved slightly

Improved significantly

4%

11%

7%

45%

23%

10%

5%

8%

7%

50%

22%

8%

5%

13%

12%

34%

23%

12%

Do you feel the appointment system has improved or declined recently? Scheme 1


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No answer


Declined slightly

Neither

Improved slightly


4%

11%

7%

45%

23%

10%

4%

15%

4%

38%

28%

12%

5%

10%

12%

43%

22%

7%



No answer


Declined slightly

Neither

Improved slightly


4%

11%

7%

45%

23%

10%

2%

11%

4%

45%

28%

11%

7%

11%

10%

43%

23%

6%



values first of 61





TreviniTrinity

Vanbrugh

39%33%

28%18%18%

28%28%

33%5%

34%5%

30%40%

36%28%

27%34%

44%27%

35%30%31%

Do you feel the appointments system has improved or declined recently? post-pilot by practice

ImprovedDeclined

16 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75+

-20%

-10%

0%

10%

20%

30%

40%

50%

29%

20%

2%3%

-8%

6% 6%

30%19%

4%

-9%-13%

0%5%

40%

29%

20%

2% 3%

-8%

6%

Net % improved by age

Scheme 1Scheme 2Scheme 3

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3.4.4 Are you aware of the following services available at this surgery and have you used them?

Phone consultation

We asked respondents in all schemes whether they were aware or had used over the phone consultation. Amongst scheme 1 practices, 53 per cent had used them, with a further 15 per cent being aware of them but not having used them, and 38 per cent not being aware of them. Of the scheme 1 practices, the levels of both awareness and use varied hugely. More than two thirds of Conway PMS patients had used the over the phone consultation compared to 40 per cent at Eltham Palace. Other practices not on scheme 1 also had high use of phone consultation. In particular, more than half of Sherard Road patients had used phone consultation

Scheme 1

Scheme 2

Scheme 3

38%

42%

35%

15%

20%

18%

53%

38%

47%

Over the phone consultation

UsedAvaliable at surgeryNot aware

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TrinityTrevini


FairfieldVanbrugh

Sherard RoadBlackheath PMS

Ferryview Health CentreGallions Reach

Conway PMS

0%10%

20%30%

40%50%

60%70%

80%90%

100%

3%

25%

8%

17%

19%

18%

33%

10%

20%

22%

18%

18%

34%

40%

43%

43%

49%

52%

55%

56%

56%

68%

Avaliable at surgeryUsed

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3.4.5 On-line symptom checker and consultation

We asked about use and awareness of online symptom checkers and consultation. Whilst use is no higher amongst scheme 3 practices than other practices, this is due to large differences between participating practices. Of the three participating practices, 15 per cent of Ferryview patients and 14 per cent of Fairfield patients used the online symptom checker and consultation. Only 2 per cent of Eltham Park respondents uses them and 8 per cent were aware.

81%

74%

73%

10%

19%

19%

9%

7%

6%

Scheme 1

Scheme 2

Scheme 3

On-line sympton checker and consultation

UsedAvaliable at surgeryNot aware

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Eltham Park SurgeryVanbrugh

Blackheath PMSTrevini

Sherard RoadEltham Palace

TrinityGallions Reach

Conway PMSFairfield

Ferryview Health Centre

0% 5% 10% 15% 20% 25% 30% 35% 40%

8%

2%

2%

8%

19%

2%

2%

14%

4%

22%

18%

2%

6%

7%

7%

7%

8%

10%

11%

13%

14%

15%

Avaliable at surgeryUsed

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3.4.6 If used a) how would you rate the service?

Users of the phone service give it an overwhelmingly positive rating, with three quarters of scheme 1 users being satisfied with the service. The highest satisfaction for phone consultation was with practices that were not on the phone consultation pilot – Trinity and Fairfield. Of the practices on the pilot, Conway PMS had the highest satisfaction (84 per cent compared with 7 per cent dissatisfied). Eltham Palace had the lowest satisfaction (61 per cent with 20 per cent dissatisfied).

Very dissatisfied

Quite dissatisfied

Neither

Quite satisfied

Very satisfied

4%

9%

12%

39%

36%

How would you rate the service (scheme 1 - phone)

values first of 61

Eltham PalaceBlackheath PMS

Gallions ReachScheme 1 overall

Ferryview Health CentreSherard RoadConway PMS

VanbrughEltham Park Surgery

TreviniFairfield

Trinity

61%70%70%

75%75%

83%84%87%87%88%91%

100%

20%17%

15%13%

8%7%7%8%

6%4%3%

0%

If you used phone consultation, how would you rate the service?

DissatisfiedSatisfied

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3.4.7 Patient experience of phone consultation (survey)

We asked patients who had experience of the phone consultation an open question to explain why they rated it. In line with the satisfaction levels, there were far more positive comments than negative ones.

The main reasons given for a positive rating, were that the phone consultation system worked quickly, giving them same day access to a GP; satisfaction that their issues was dealt with over the phone, and support for the flexibility of the call back system. A selection of these comments are in the box below.

Positive comments

“All my questions were answered” Patient, Vanbrugh

“They always give mothers priority which is fair” Eltham Palace

“Because it is a great system and the staff are excellent” Eltham Palace

“Did not have to come in – can get things resolved” Patient, Blackheath“I got good advice and could work around my schedule.” Vanbrugh“Whenever we call them the doctor calls us back the same day”. Conway PMS“Within minutes the doctor called back” Patient, Conway PMS

Negative

Out of the negative comments, the main reasons were the feeling that a phone consultation was inferior to a face to face one, poor experiences of doctors, and dislike of using phones. A selection of comments are in the box below:

“Don’t like using the phone” Patient, Eltham Palace

“Because I think the doctor should see you” Patient, Gallions

“I am concerned that the doctor made diagnosis without seeing me. I do not feel confident the doctor has checked my records thoroughly.” Patient, Eltham Palace

“Dr did not understand me” Patient, Eltham Palace

“The Dr was rude and angry” Patient, Gallions

“You can explain in more detail in person” Patient, Conway

“Nothing like the personal touch. Better to see someone.” Patient, Vanbrough

“Too many foreigners clogging up the system” Patient, Conway PMS

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3.4.8 If used online symptom checker how would you rate the service?

Out of scheme 3 respondents, 43 had experience of using the online symptom checker and consultation. More than half were satisfied 52 per cent, with 6 per cent dissatisfied.

Due to the small sample sizes, it is not possible to do effective analysis by surgery within scheme 3.

Very dissatisfied

Quite disatisfied

Neither

Quite satisfied

Very satisfied

0%

6%

42%

31%

21%

How would you rate the service (online/scheme 3)

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Ferryview Health CentreSherard Road

Scheme 3Gallions ReachEltham Palace

TreviniTrinity


FairfieldEltham Park Surgery

Vanbrugh

37%50%52%52%

63%67%

70%71%

77%77%

80%86%

7%17%

6%22%

19%0%

20%0%0%0%

20%5%

How would you rate the service (online) by surgery

Quite satisfiedSatisfied

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4.5 Patient experience of online consultation (survey)

There were very few direct comments about the online symptom checker and consultation. The information provided was described as informative and the word ‘reassuring’ used by two respondents. A patient at Fairfield described receiving a quick response that required them to attend the surgery for a face to face appointment. These comments are below:

“Asked question – doctor got back fast and said to come in” Patient, Fairfield

“Lots of reassuring info” Patient, Ferryview

“Informative and reassuring “Patient, Eltham Palace

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4. Qualitative findings

5.1 Scheme 1 patient experiencePerceptions of scheme one were divided. Whilst patients described positive experiences of the scheme, where they were able to speak to a doctor to resolve their problem in an efficient manner, a number of problems were raised. These problems fit into three categories: the time it takes to get through, the preference for booking appointments, and unfamiliarity and lack of comfort with phone consultations in general.

GP access

Several patients described an efficient process with effective triage delivering rapid access to a GP.

“If you have got a problem you can give the receptionist a rough idea of what the problem is and then she says well I will get the GP to ring you back and they always do ring back, you know, they usually ring back mid-morning and then they ask you questions and then if they think you need to be seen you normally get seen that day.” Patient, Eltham Palace

“I called was it mid-to-late morning and the receptionist said that she would book a telephone consultation with the doctor for later that day. So I had the telephone consultation with the doctor and then I had an appointment a couple of hours later.” Patient, Conway PMS

Another explained how they feel more comfortable getting in touch with a doctor for a phone consultation than a face to face appointment:

“It’s just I think they’re an excellent way of dealing with things because a lot of us don’t want to trouble the doctor but perhaps we should have a word you see, and it enables you to have a word with a doctor without feeling guilty that you’re taking up the time of the NHS you see …” Eltham Palace

Two patients at Vanbrugh described positive experiences of the system then in operation at Vanbrugh. One described how they were unable to attend the surgery, so got a same day call from a GP. Another patient described how, for simple conditions, the phone consultation was effective for immediate dispensation of medication.

“I rang the doctors and said that I wasn’t feeling well and that I would prefer if the doctor rang me because I was too ill to actually go round to the surgery and that exactly happened. My GP then rang me the same day actually and I don’t think I actually waited long for her to ring me.” Patient, Vanbrugh

“I have used it for myself, yeah, and explained a problem and then they’ve been able to issue me with medication over the phone, rather than me going in” Patient, Vanbrugh

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Waiting times/time pressures

A frequent comment in the patient interviews was the waiting time on the phone – with the perception that the system has created a degree of congestion on the phone lines. Satisfaction with this is largely based on expectation and a number of patients were not dissatisfied with significant waiting times.

“Well it takes a few minute to get through. There’s always like congestion when you call the number you have to wait a little bit.” Patient, Blackheath

“It’s always … well it’s quite often quite a long time to sit and wait for the for a phone to be vacant but that’s ok you know.” Patient, Eltham Palace

“You have to wait a few minutes before they answer the phone. I think they’re pretty busy. “ Patient, Eltham Palace

Convenience of call back

Some patients interviewed felt that the call back system was inconvenient, and that there was a risk that if they are not available at the precise moment when they are called back, they miss the appointment and cannot call back. The requirement to be in a safe place to discuss private health matters was also mentioned.

“The doctor will call us. Sometimes, yeah, we are waiting for a long time for the doctor, you know, the doctor to return the phone call but sometime [0:01.28.1] and sometime we cannot hear, you know, then he has no caller ID so we cannot call back - that’s the main problem you know.” Patient, Blackheath

“It should be my decision based on what I want but if I call to have an appointment and then they say the doctor will call you [pause] it’s not convenient as such because the doctor will call me. What if I’m not in a safe place to talk? Do you get it?“ Patient, Blackheath

“Because on the phone the doctor is rushing and when he calls me maybe I have people round or I’m on the road and there’s noise. If I’m ready to miss my work to stay home and see a GP it means I have a reason that I really need to see a GP, not to be called.” Blackheath

“In theory it was quite a good system but I think in practise it was quite difficult because they didn’t have enough reception staff to answer the increased number of phone calls so it would take a really long time to get through and the receptionists seemed really stressed out by it because they were just constantly on the phone.” Patient, Vanbrough

Quality of over the phone consultations

Although there are divergent views of the quality of phone consultations, there was a strong consensus that they are quicker and less thorough than a face to face consultation. The lack of body language and different degrees of comfort with using telephones was mentioned, along with the feeling that you should not keep a doctor on the phone as long.

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“And you’re talking to someone on the end of the phone. But no … you know, as far as service is concerned, no different really apart from that when you go to the surgery you’re actually talking to somebody face-to-face. That’s the only difference.” Patient, Vanbrugh

“Only because it’s on the phone and I don’t like to keep a doctor on the phone too long, and you … with a phone call you don’t have the body language which is telling you that this is coming to an end, so I’m afraid it … that the doc … I get afraid at this end that the doctor would like to bring it to an end, you know, I think that’s what’s unsatisfactory about a phone conversation. ” Patient, Eltham Palace

“Well you have the opportunity to ask more questions I suppose when it’s face to face rather than on the phone. The phone, you know is fairly brief.”, Eltham Palace

“Shorter than in practice consultation” Patient, Blackheath

“It was quite quick. I think I was on the phone for about five minutes – at most. I explained the symptoms to the doctor and then the doctor just said to come in so he could examine it in more detail.” Patient, Conway PMS

“I think when there are question marks about what it is that you have like, for example, with my daughter yesterday, it was a bit unclear and it was much better to be seen as opposed to have a telephone consultation “ Patient, Vanbrugh

Unfamiliarity

The reason for some patients’ aversion to phone consultation was unfamiliarity: it is a different way of doing things than they are used to and comfortable with.

“I don’t know if it’s my age or whatever but, no, I’m not used to having a phone consultation and I don’t think it serves a purpose for me, personally, somebody who’s there regularly and has outstanding issues – it doesn’t serve a purpose for me. I’m not a worker so I’m not one of those people who don’t have time. I have the time, you know, to be able to access the surgery but, again, they’re not willing to.” Patient, Vanbrugh

5.2 Scheme 2 patient experiencePatients’ experiences of scheme 2 did not have common themes as the participating practices had different processes in place. Nonetheless, some prescient individual experiences emerged regarding specific elements of different practices systems.

Patients described challenges waiting to get appointments in scheme 2 practices, with waits of up to three weeks for appointments and waits on the phone of twenty minutes. In particular, several patients from Fairfield described dissatisfaction with the appointments system. One patient of Sherard Road, however described that although there was a long wait to get an appointment but that this was acceptable as they are confident that they will get appointments when they are needed.

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“Well the lines open at 8 o’clock to book an appointment for the same day but it’s … I normally don’t get through. It normally takes about 20 minutes to get through, and even then there’s no guarantee of an appointment being available. I can give an example of when I … when I saw you that day I made an appointment to see my doctor again and it’s over a month forward of that date, so it’s on the 23rd and I think I saw you on the 19th?” Patient, Fairfield

“It’s very difficult to get an appointment on the day. You have to ring from 8 o’clock in the morning when the telephone lines are open and they’re always very busy. Since they’ve put the waiting, call waiting, so you’re in a line, a queue, that’s made it slightly easier rather than having to ring back if the phone’s constantly engaged. But by the time you get through potentially half an hour later often all the appointments are gone.” Patient, Fairfield

“If you don’t get an appointment in the morning then you … or you have to pre-book sometimes it’s two, three weeks wait before you get an appointment” Patient, Trinity

“You always have to wait quite a long time to get an appointment but, you know, you can always get an appointment in the end”. Patient, Sherard Road

5.3 Scheme 3 patient experienceDue to the low numbers of uptake of patients on scheme 3, we were not able to interview a patient who had direct experience of scheme 3.

Patients described awareness and use of a range of online symptom checkers. WEB MD and NHS Direct were described as sites that are regularly used.

“I do a bit of research. Obviously I research different websites, different opinions, different, you know, results and then if it does all come to a conclusion that it’s quite dangerous to my health then I will contact my GP.” Patient, Fairfield

“I’d usually use the NHS Direct website” Patient, Ferryview

“Actually through one of the pharmacists at Boots. When I collect my medication he told me about the symptom checker but I said to him well I don’t really need it. I’ve got my GP. Patient, Fairfield

The patients interviewed with awareness of the schemes, described how they were informed of the scheme.

“I think the receptionist told me if I remember rightly? When it all first came in I think they had it on a sheet of paper that they handed to you and I think they probably said, “these are new features of our surgery if you’re interested” and what you needed to do. I mean it’s quite nice now they send you an email or a text message with a reminder for your appointment, which is very good.” Patient, Eltham Park

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5.4 Staff interviews: Scheme 1Expectations of scheme

GP’s described the scheme against the context of wider pressures for general practice in terms of capacity and funding. The aims of the scheme were understood to be to improve access and support the system.

“Obviously general practice is underfunded. We do not have enough GP’s in the United Kingdom.” GP Scheme 1

“We all know this general practice is struggling, that’s partly or largely because we’ve got mental under-funding so we welcome any change in the way day to day general practice is managed if it helps us to address that need and is beneficial to patients.” GP, scheme 1

Staff, however, did not enter into the scheme did not do so with a high degree of optimism about its ability to ameliorate these pressures. There was a significant degree of scepticism about the ability of the scheme to be achievable in terms of resources, and for patients to adapt to the change. As one practice manager described: “There was a lot of negativity from the staff. They couldn’t see how it was going to work.” By beginning the scheme with the staff in opposition, the practices had a greater challenge in enacting the scheme.

“To be honest, I thought that it was going to be very labour intensive and cause a lot of work for me. In our area we have quite a few patients who don’t speak English and so I thought that would be a bit of a barrier for the scheme. I was a bit apprehensive going in.” GP, scheme 1

“I was quite sceptical to start with, I couldn’t, I couldn’t see how we would it it in the surgery without a massive uproar from the patients… they are very traditional they like to just coe and see a doctor when they want” Practice Manager/receptionist,, scheme 1

“There’s never going to be supply meeting demand because if you increase the supply demand will always take its place.” GP, Scheme 1

Impact on patients

The impact on patients as distinct from the overall impact on the practice, was overall positive. Crucially, staff described the increase in the number of patients that are getting access.

“We are seeing a lot more people. We are providing more access for the patients.” Practice Manager, scheme 1

“Previously we were seeing maybe 40 patients a day, now we are dealing with 60-65 patients a day each.” GP, scheme 1

“Overall I think because of the increase in the numbers of interactions with dealing with the greater number of patients it was too much for us.. if you asked the

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patient population, purely from their point of view, there would be more positive”. GP, scheme 1

“It has meant more patients are able to see GP’s or speak to the G It means that the wait time to actually have contact with a GP is reduced. GP, scheme 1

“50-60% of them don’t need to be seen and things can be done over the telephone.” GP, scheme 1

Patient perceptions

The patients felt to most embrace the system and benefit most from it were younger patients, where face to face appointments were felt to be more of an inconvenience to plan around work commitments.

“The younger patients do like it. They work in town; they like to be able to speak to the GP, have a diagnosis over the telephone, as such, get a prescription, and not have to come to the surgery.” Practice Manager/receptionist, scheme 1

Older patients were felt to find the system more challenging, both in terms of adapting to the new system and being comfortable with phone consultations themselves.

“[the older generation] are going to be the most difficult people to try and change their outlook on healthcare… the only other issues we had is the odd patient that need sto see the doctor face to face, for example, we had one patient who was agoraphobic.” Practice Manager/receptionist, scheme 1

“A lot of the older patients just don’t like ringing on the day, they like to make an appointment so they know when it is and can plan their lives around that.” GP, scheme 1

“I think the patients are getting used to it and we’re getting used to it as well. And I actually think it’s been quite useful. |The patients now are happy to speak to a phone and are glad they don’t have to come up to the surgery a lot of the time.” GP, scheme 1

Impact on resources

The main challenge encountered was the capacity pressures from an increase in the amount of calls. This provided challenges to both receptionists to handle the calls and doctors conducting the telephone consultations. Some practices adapted to this pressure, by changing the times to receive calls and increasing the number of staff at key times of the day (early morning and lunchtime), to ease the pressures.

“We’ve only got four members of staff answering those calls, and people are still having to wait five, 10 minutes to get through; maybe longer.” Practice Manager/receptionist, scheme 1

“Previously we were seeing maybe 40 patients a day, now we are deadline with 60-65 patients a day each.” GP, scheme 1

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Support when setting up the system

The initial period of introducing the scheme was felt to have been the most fraught, with staff learning how the system operates and patients acclimatising to the changes. The support given to practices at the outset was felt by many to have been inadequate. Lack of flexibility in the model being rolled out was also mentioned as a challenge.

“The volume of calls were so high, because patients were panicking.” Practice Manager/receptionist, scheme 1

“[the scheme was] not adequately supported at the beginning. I think it was just one visit and then “off you go” and then you know the first week was very stressful because this was a massive organisational change. I expected them to explain it in more detail and in depth, actually help you organise it, not sort of leave you to do it by yourself, you know, there are the instructions, read it yourself and play the game”. GP, scheme 1

“The provider, they’re a nice group of people, but as I said, they need to be there on the ground the first week that they trial this with surgeries.” GP, scheme 1

A suggestion made by a number of practices was for there to be training included.

“Some training with staff. We were thrown in at the deep end – we had a few visits from the company who have been doing it, but it would have been easier if the girls were being trained.” GP, scheme

“We didn’t have enough training at the beginning; we went live, and we were really sort of on our own. There were lots of questions we needed answering, and we felt like we’d got left on our won to start with.” Practice Manager/receptionist, scheme 1

General support

A common criticism of the scheme was that it was inflexible and the materials were not tailored for the surgeries needs. Another criticism is that there was not enough peer to peer support from other practices implementing the scheme.

“We were given conflicting advice by patient access, one person in patient access said we must offer unlimited access and then a few months later a person said “no this is too much, you should tell patients ring between this and this time”. GP, scheme 1

“The leaflet could have been altered to suit each surgery, because they will know when their peak times are, of patients calling.” Practice Manager/receptionist, scheme 1

“We did try, at the beginning, to see if we could limit the time to calling between 8:00 and 10:30 and then maybe 2;00 to 4:30, but we were told at the beginning that we had to go with what was written on the leaflet.” Practice Manager/receptionist, scheme 1

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“We had a lot of peer support within the practice, my partners and I were, you know, forever throwing things about with each other, but there was no peer support form other practices other than one or two meetings we attended.” GP, scheme 1

Phone system challenges

A number of practices encountered problems with their phone system. For some this was a shortage of phone lines, others had problems with headsets. Practices that ramped up their phone capacity and increased staffing at key times were able to better manage the increase in demand.

“We tripled the phone lines with the aim that the GP’s would be able to call the patients back... but we couldn’t reserve two thirds of those for call out.. so therefore, patients were queuing for 40 minutes, or more to get answered.” GP, scheme 1

“One of the struggles we’ve had was the number of phone lines. I think patients have to sit and listen to an engaged tone for quite a long time.” GP, scheme 1

“We could probably do with a better phone system to cope with it.. the problem is we have a five year contract.” PM 1.2

Another key piece of technology was a high quality headset to help staff accurately hear patients and ensure their hands are free.

“We had headsets introduced as well so it frees up our other hand so were able to deal with patients quicker.” PM 1.3

“I had to buy a headset with my own money to get it to work” GP, scheme 1

Impact on staff

The impact on reception staff was dependent on staffing and the efficiency of the phone system in operation. Wherever patients are dissatisfied by long waiting times or problems with the system, staff operating the phone are most likely to receive complaints.

“Reception staff started to become quite stressed, as well, because obviously, they had angry patients that were calling back, saying they hadn’t been rung.” Practice Manager/receptionist,, scheme 1

“It has probably hit morale a little bit, because its been a great sort of change of pace; its been more labour intensive for the GPs”. GP, scheme 1

“I think our reception staff, there’s certainly a lot more strain on them in the mornings when the phones go live.” GP, scheme 1

The impact on doctors was through additional hours being required to keep up with the increased flow of patients. Many doctors in particular described the workload as unsustainable, mentioning stress levels, low morale, and in one practice threats of resignation.

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“We found the doctors were burning out, basically. We persevered, and we tried to change the system a little bit, by having a pooled list in the morning and afternoon.” Practice Manager/receptionist, scheme 1

“Within the practice we have staff that are very stressed, almost thinking about resigning, sending lots of emails around saying their workload is not manageable, that they are working many more hours than they are paid for, then asking for overtime”. GP, scheme 1

“The clinical staff are extremely stressed. Our families as well. We were working 12/13 hours a day” GP, scheme 1

“As a result of the increase in the number of telephone consultations that were coming through, the overall work load increased, quite appreciably.” GP, scheme 1

“It kind of works, as with a lot of the NHS, from goodwill. So today I brought in five more patients than my slot allowed; but that was because they needed to be seen.” GP, scheme 1

Financial model

One issue raised by a GP was the impact of the scheme on their financial model, due to the reduced amount of opportunities to achieve specific targets linked to the QOF (Quality Outwork Framework). This was not raised by any other GP interviewed.

“There is a very significant impact which hasn’t been measured yet. When we are dealing with patients on the telephone we are not seeing patients and doing the many things we do opportunistically. For example, the Quality Outwork Framework is worth tens of thousands of pounds of income for the practice. It is an annual target that people need to reach.. we are significantly lower on our flu vaccinations this year at this ppnt compared to last year.. if we don’t achieve those targets we get significant financial penalties and the business is at threat. IF you don’t reach those targets you do not get £80,000 a year and that is three or four people’s salaries.” GP, scheme 1

Communicating change

Motivating staff to communicate the changes in a constructive and encouraging way was a challenge for many schemes. As one practice manager described, the way that the system was introduced to patients was felt to have impeded its effectiveness:

“If you come out with, “unfortunately, we’re trialling a new system.” that negativitity already gone back to the patient. We use the wording: “actually, we’re trialling new system which we hope’s going to be of benefit to the patient.” Practice Manager/receptionist,, scheme 1

A GP whose small practice requires a large degree of dependence on locums, explained that they had a challenge to find locums that were able to do phone triage, with some locums being implacably opposed to their use.

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“Some of the locums say “we don’t believe in triage, it brings too many complaints and I’m not doing it”. GP, scheme 1

Adaptions and modifications

Many practices made modifications to the scheme. These included changing the calling time; the adoption of hybrid systems to allow for pre-bookable appointments; and an option for patients to opt out due to specific circumstances.

“One thing we did was allow some pre-bookabe appointments; but only pre-bookabe by the GP’s or the nurse practitioners. And I think that has helped a bit.” GP, scheme 1

“We are going to keep doing telephone consultations, but like a hybrid version of it; we will try to do, for an hour telephone consultations, and then some face to face on the day.” Practice Manager/receptionist,, scheme 1

“We have adapted the system so we have done like a form which they can fill in to explain their reasons why they need extenuating circumstances for an advanced booking.” Practice Manager/receptionist,, scheme 1

“We weren’t allocating enough time between each telephone call, but we didn’t believe we would get through the volume unless we allocated the reduced amount of time that we had allocated.” GP, scheme 1

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5.5 Scheme 2: staff interviewsWhat was recommended?

Staff were generally positive about the recommendations that were provided by scheme 2. Many felt that they were helpful and subsequently implemented them. For example, one practice modified its appointment times as a result and another practice used a greater degree of telephone consultation. There were criticisms focused on the report not offering new solutions.

“We realised that our appointment system was quite confusing for patients, and difficult for them to understand how to get an appointment, and therefore, we offered more telephone consultations.” GP, Scheme 2

“It helped focus everybody’s mind on access issues.. it’s not actually resolved the issue for us, other than actually made us focus on the problems of access, and as a consequence, we’ve actually increased the amount of clinical time available.” GP, Scheme 2

“the findings didn’t really tell us anything we didn’t know.. and when we did sit down and talk to them they couldn’t suggest us doing anything different.. that report was very, if you don’t mind me saying, it was very generic. Because I spoke to other managers and chunks of it were exactly the same for each practice.” Practice manager, scheme 2

Support

The main criticism of the scheme was the degree of support provided after the initial presentation. There was a feeling described that the initial data gathering was a significant resource challenge, but they did not receive sufficient support afterwards to utilise the changes.

“I don’t think there was a lot of background about our practice which is why they would come back with things like you know you need more telephonists at this time of day, well actually if you know our practice, there’s still only a certain number of appointments.” Practice manager, scheme 2

“I think it would have been useful if someone had come and spoken to our practice manager, and perhaps doctors, to see if the decisions we’d made were in line with the recommendations of the access pilot; the second access pilot”. Practice manager, scheme 2

“At the beginning of scheme 2 there was a lot of information gathering – how many doctors we’ve got, how many nurses, how many telephone lines, all that sort of information.” Practice manager, scheme 2

“The recommendations and everything was kind of there without any kind of back-up – any resources to allow us to do that.” GP, scheme 2

Impact

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There were divergent views on whether the changes had impacted significantly on patients. Whilst some felt that the scheme had enabled them to provide a better service to patients, the scheme was generally not felt to have made a significant impact on capacity and workload.

“In general speaking there is not much change only there is more readiness for new consultations and new patient problems.” GP, scheme 2

“I think the workload hasn’t changed but the streamlining is better.” GP, Scheme 2

“I’m not sure we’ve gained a lot.. the underlying issues haven’t changed.”. you know, I still have overflowing clinics.” GP, Scheme 2

“We had a meeting with our patient group and two of those members had really positive experiences.. instead of “can I have an appointment, say on Friday afternoon”? – “No, we haven’t got anything left, ring back on Monday”. The staff were now saying “We can’t give you an appointment, but if you tell me what the problem is, I can possibly go and speak to the doctor and come back to you?”. And they were really happy with that.” Practice manager, scheme 2.

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5.6 Scheme 3: staff interviewsExpectations

Expectations of the scheme before it started were positive but low.

“I think, knowing it was for quite self-limiting conditions which it had to be, it couldn’t be for anything very serious. So we weren’t expecting a deluge of uptake.” Practice manager, scheme 3.

“It’s a good idea and that was hoping to alleviate some of the more mundane requests for appointments to the surgery.” Practice manager, scheme 3

Use

The main challenge with scheme 3 was the small numbers of patients who used the scheme. Whilst the self-care element may have been well used, the use of online consultation had low use participating practices. This makes it hard for staff to discern the impact on capacity and patients as a whole. Use of the scheme declined after the initial publicity surrounding its launch.

“We have a list size of twenty four and a half thousand patients, and in that time from July last year, we’ve only had since last week, 43 patients actually using the online calls.” Practice manager, scheme 3

“The online one it started with quite a lot of people looking at it and its dwindled right down I think May to November we’ve had 41 GP consultation and we’re lucky if we can sort of get one or two a month now.” Practice manager, scheme 3

“Only difficulty is the turnaround of 48 hours for a response. We met nearly all the times, but in a couple of instances, just mabe a little bit longer.” Practice manager, scheme 3.

“it seems to have become less and less popular, which is a bit odd. I would have thought it would become more used as time went on, but it seemed that, actually, our patients weren’t as aware of it as much as they should be.” GP, scheme 3

Impact

The impact was felt to have been small. The online questionnaire was considered to be long and a potential barrier to uptake, and due to the small numbers of users, it was felt not to have influenced capacity.

“It didn’t make any difference to our workload at all.” GP, scheme 3

“They had to read through four pages of information and then lots of things really couldn’t be dealt with by giving a prescription. They often couldn’t be dealt with by a phone call, they needed an appointment.”

“We’d like to continue with the online thing, because I think it does help. Not very significantly, but it does help.” GP, scheme 3

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“We haven’t seen any benefit in regards to reducing demand.” Practice manager, scheme 3

Publicity

Practices publicised the changes through text messages, adverts in leaflets and prescriptions and through large banners in the surgery. This publicity was at the outset of the changes. There was one practice manager who complained that they did not receive the banner they requested from the supplier.

“We text everyone we had a number for. The big banner we had for the reception area, it never materialised and I chased it and chased it but it just didn’t come. There was a link on our website and the right hand side of the prescription as well as leaflets. And some doctors were promoting it as sort of like word of mouth’, not any but some.” Practice manager, scheme 3

“we’ve got like a great big six foot banner thing in the waiting room that advertises it and its on our practice website. But its quietened down.” Practice manager, scheme 3

“Setting it up was straightforward – putting up the link on the website all went fairly smooth, only problem was the promotional material they promised [a banner].” Practice manager, scheme 3

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7. ConclusionsOverall findings

Capacity pressures are a constant feature of the practices involved in these pilots. Staff are pessimistic about systems changes that are not matched by funding changes. Patients have different levels of expectations in terms of waiting times and access to GP’s; waiting times that are acceptable to some are felt to be unacceptable to others.

The quantitative research recorded declined levels of satisfaction across a number of key measures. These declines were registered in practices that were employing very minimal changes, suggesting significant pressures external to the trail operating between March when the pre-pilot survey was conducted and November when the post-pilot survey was conducted.

The schemes were not implemented uniformly. Within each scheme there was significant discrepancies in the degree to which they were modified and varying levels of publicity raising awareness of changes and encouraging uptake of new methods. In the case of scheme 1, practices modified the scheme significantly. The impact of scheme 2 was influenced by the voluntary nature of the recommendations with practices implementing them to varying extents. Practices participating in scheme 3 pursued different degrees of publicity to encourage uptake, that had significant bearing on the impact.

Scheme 1

Patients and staff perceived that access to GP’s increased through this pilot: patients were more likely to be able to discuss a health issue with a GP on the same day, and a large percentage of appointments do not require follow up face to face appointments, saving time for patients. The higher percentage of patients being seen quickly is evidence of the impact of this.

Three quarters of patients are satisfied with the phone consultations, although there is a significant degree of polarisation with older patients being less likely to embrace the change. Patients with positive experiences, described being able to talk to a GP quickly without them having to visit a surgery. However, some patients have a general antipathy to phone consultations in principle and in practice: they are uncomfortable with the change, feel disrupted by the lack of advance appointments and are concerned that the consultation will be less thorough.

Many of the participating practices struggled severely with implementation and some practices are not convinced that the model is feasible for them to continue operating. The main challenges encountered were:

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- Lack of preparedness for the increase in phone calls at key points in the day, producing long waits for patients and capacity pressures for staff operating the phones.

- An increased workload for GP’s, with demand rising in line with the supply

- Inadequate telephone technology without the capacity for the increase in demand

- Resistance and negativitity from staff implementing the changes

Central to these challenges was a perceived lack of support ahead of the scheme launch.

Scheme 2

Scheme 2 had varied impact on the different practices involved. In some practices the process was significant, allowing them to pursue methods such as telephone triage and better receptionist screening in way that had an impact on patient outcomes. For other practices, the recommendations were thought not to have added any new thinking and were only implemented to a limited extent.

Once the recommendations had been presented, there was little follow up to support the practice through implementing the changes. The practises feel that they are under a lot of pressure and to make changes they need support..

Scheme 3

Awareness and update of scheme 3 was low across participating practices. This makes it hard to assess its impact. The steady drop off in usage is likely to be due to lack of publicity after the initial launch where in some cases text messages were sent out. For those who used online symptom checkers and consultation more than half were positive, although the symptom checkers that patients used included non-specific other online symptom checkers such as NHS Direct.

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8. Recommendations1. Communication

Large changes need staff to be motivated advocates to communicate the changes in a positive way by explain the opportunities and benefits they will provide patients. The challenge for the pilots, especially in the case of scheme 1, was that staff were initially sceptical of its positive impact and concerned about the pressures on the workload.

Alongside this, the changes need to be communicated effectively to patients. The patients most likely to be anxious about change and uncomfortable with new systems need bespoke communications to explain how the changes will not threaten their ability to get access to GP’s.

2. Preparation support

The schemes cannot be implemented as an off the shelf approach. A large degree of support is needed at the initiation to utilise previous knowledge and adapt the staff and patients to the new system and arrive at modifications that are calibrated to technological and staffing capacity. Key elements of this include: technological requirements, staffing at key times of the day, and allowing sufficient time for calls to prevent regular overrunning.

3. Peer support and knowledge share

Many of the challenges faced by practices employing the different pilots were not unique to their practice. There could be benefit in improving the channels of knowledge-share between practices. The schemes that have now implemented the changes, where they have done so effectively, could provide support to any new practices pursuing similar changes. This approach of twinning practices may provide an effective means of achieving this.

4. Training

Training of staff – receptionists’ and GPs – if they are doing new tasks such as phone consultations or triaging, is likely to improve performance. In particular, training of triage staff to better be able to choose for example whether a

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telephone consultation or face to face appointment is required, may have a positive impact on capacity.

5. Follow through

Scheme 2 may have achieved a greater impact if the changes recommended had been followed up with direct implementation support. For scheme 3 to make an impact there will need to be higher uptake of the consultation element. This is likely to require sustained marketing to establish the habit amongst respondents.

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