Reducing demand. Step 3- Navigation, triage, skills mix
We now have supply matching demand – but its not necessarily efficient or a good use of your GP time, the most expensive resource. Often practices have a system which channels everyone to the GP creating unhelpful patient expectations. In this system the GP will see lost of self-limiting conditions, letter requests, sick note stuff etc.
Overall be proactive in managing demand there are lots of ideas here
So what can we do to be more efficient? Telephone consultations have not shown to reduce demand, but may be more efficient; demand for face-to-face consultations was reduced by 39% by GP-led telephone triage (Jiwa at al 2002), and can reduce DNAs (NHS Innovation and Improvement 2007).
Here are some of the steps that are generating a better flow, and managing demand.
1. Phone consultations
Can be more efficient than face to face consults – a face to face is 10 minutes, a phone consult takes as long as it takes, if a patient needs 3 minutes you can get straight onto the next one, if a patient needs to be seen face to face and cant be dealt with on the phone you can call them in. Done well, and it does take time and training, you should end up calling in around 30% of patients or less. Some practices ask all patients to speak to a GP first – the big advantage is that it puts the two people who want to speak to each other in contact as soon as possible. For it to work well the GP call needs to respond in no more than 2 hours after the patient calls the practice. If your supply meets your demand then there is no reason why this isn’t achievable. Not all practices do GP call back for all patients – often it’s an option which patients take up through choice. Either way evidence shows that a GP can deal with around 25 patients in 3 hours rather than 18 – a significant gain. This is different than triage. In this system the caller (patient) decides if they want a telephone appointment. Some GPs will call patients, and then bring too many patients in for face-to-face appointments, so you need to work on phone skills, both in terms of dealing with patients on the phone and closing the conversation quickly. Using locums well here is very important. Get the most senior people to focus mainly on phones and complex presentations which require continuity, and have locums working on acute single presentations. Overall you do need to review how the calls are going. Here is an example:
2. Good Reception Navigation.
Some calls shouldn’t even get as far as a phone consult, a good reception screening should meet the needs of at least 30% of calls without a GP call back. These include people calling for repeat prescriptions, hay fever, sick notes and medication issues.
Example: Tower Hamlets screen in colours: callback from admin, from nurse, from HCA, from pharmacist, from micro team. Good reception requires a good script and agreed protocols for matching the right condition/issue with the right member of staff. Without this reception triage is just adding a block in the flow of appointments. Jubilee Street Practice developed their triage protocols through an audit process
However to put this in place there needs to be training for all staff, and regular review otherwise the process collapses (Murdoch et al 2015).
At the same time as introducing navigation and/or triage, take a look at how to secure better telephone access. Here is an example of impact from Tower Hamlets:
3. Skill Mix.
There is a big overlap here with skill mix. Practices are finding a real benefit in appointments covered by GPs, Nurses and Pharmacists. Pharmacists can deal with medication issues, HCAs and nurses can deal with many people with long term conditions especially if it’s a care plan issue. Everyone should be working to the maximum of their license. There is a useful exercise you can do with the whole team going through a sample of consultations and asking the team who would have “best” dealt with it and using that discussion to identify protocols to share with receptionists and GPs. You can see how one CD did it here
4. Reduce follow ups.
This can be a big area where you can make gains. Often follow-ups have the highest DNA rates. We suggest no follow-up appointments. People should be being supported to manage their own conditions. GPs can have a “just in case” approach (e.g. antibiotics – “come back and see me in 3 weeks” rather than “make another appointment if it doesn’t clear up”). People with complex and long term conditions are often recalled for annual reviews by disease register which means they are called back perhaps 3 or 4 times a year when they could be called in once for a more holistic assessment which would save everyone’s time. None of these work for the GP or the person. Data is key, you need to pull off the number of follow ups each GP does and then work towards no follow-ups. One way of working with people with longer-term conditions is to support them through applications such as e-consult where they can let the practice know how they are managing.