Appendix 2
Response of GP Practices
GP Practices were requested to respond to the following recommendations:
1. all GP Practices in the Borough should consider using a telephone triage (for example ‘Doctor 1st’)appointment system, particularly as a method of reducing non-attendanceat appointments.
2. Practices should clearly publish whether they are currently accepting patients both on their websites and on practice premises;
In addition, a number of Practices also made comments in response to the wider issues and recommendations covered by the report.
Norton Medical Practice
1. Norton Medical Centre adopted the Dr First process in April 2013.
2. There is no issue with registrations at Norton Medical Centre who are currently accepting patients. Standard letters are available at Reception for any patients who have an application refused but this is normally only where they reside outside of our Practice Area. This information is available on the NHS Choices website and in surgery.
[In relation to recommendations 7 and 8] When communicating with patients about the Dr First system the Practice seized an opportunity to include an information leaflet for patients on the “choose well” agenda that identified local services.
NHS111 is the first number on our Out of Hours message for patients requiring assistance when we are closed.
Arrivals and A and BPractices (Stockton)
Arrival is a specialist practice for asylum seekers and has an open list for this group of patients. Publication of this is unnecessary as almost all patients are received via the housing provider who the practice works and communicates with closely. The practice was set up to relieve mainstream practices of the need to accommodate this complex population and despite pressures of greater numbers of asylum seekers to Stockton and quicker claim decisions resulting in larger throughput, we have so far continued to accommodate all asylum seekers who wish to register. Regrettably, historic funding was for 750 patients comprising 500 asylum seekers and 250 refugees but over the years this has increased to almost 700 asylum seekers and 550 refugees with decisions being made within weeks rather than years. Throughput is also greater, therefore, and access is being stretched.
A&B Medical Practice also has an open list and we are quite prepared to communicate this in common with all other practices. Safe management of patients requires control of list size and where practices are overstretched, temporary or unofficial list closure occurs resulting in pressures elsewhere in the system. A consistent approach across all practices is needed and to assist patients in registering we would then be quite prepared to display a sign in the surgery and on our practice website.
As most of the patients registering with Arrival are new to the UK we do seek to signpost to appropriate parts of the service through waiting room advertising of ‘a guide to advertising the right NHS services’. We also display a list of ‘what is a minor illness’ to further promote self-care and use of other health professionals. However as this is not advertised in other languages, patients that are registered with the Arrival practice are dependent on interpreters for reading this information. A&B Patients also benefit from the displays.
Advice and over the counter medication from pharmacies is promoted but with a high proportion of our patients being from deprived populations cost of buying even the cheapest of remedies is a barrier to their accessing alternatives. Free prescription medication is often the driver for requesting GP appointments.
We note the report advocacy of telephone appointments which we do utilize to a degree. However, Dr First is just one variant of this process and as yet is unproven (see attached report findings just published in the Lancet – see Appendix 2b). Undoubtedly some patients do enjoy the increased access but whether this meets “need” or “want” is still under debate and such a system may well fuel higher demand. We offer our own telephone triage within A&B Medical Practice which we believe works well for the patients but currently this is only in use for one GP. We are presently considering its extension to other GPs.
Arrival Practice would not be suitable for telephone triage due to the language barrier and use of interpreters.
Recent national figures reveal that the average waiting time for a routine GP appointment is 18 days although invariably urgent need is met on the same day. In quoting waiting times the nature of appointments should receive consideration as there are three major strands of work in a GP practice, each of which requires a different response. Disease prevention and disease management can mostly be managed through scheduled appointments which tend to be further ahead than the more immediate illness management. At A&B and Arrival, the latter is managed through several tiers of triage to help manage appointment priority, including patient self-triage, reception guided triage and clinical triage when a medical input is needed to inform the process. In all cases of sick children or when adult patients insist referral will be made to a GP to determine whether a same day “slotting in” is required or a next day urgent appointment will suffice.
Queenstree Practice (Billingham)
1. We do not currently use the Doctor 1st approach - we continue to have routine appointments which patients are able to book in advance - also emergency appointments to be used on the same day and telephone appointments for anyone who feels that they need to be assessed urgently - on these occasions the doctor will call the patient back to decide if they need to be seen in the surgery, at home or whether the matter can be dealt with over the phone. We find that this system works well for us and the patients.
2. Our practice list is currently open - this is published on our practice website, however it is not published on the practice premises. This is something we will look into doing. We do not intend to close our list and would encourage new patients to register. Should we close the list in the future we would certainly state this on the practice website, premises and to NHS Choices.
Alma Medical Centre (Stockton)
1. Alma Medical Centre operates an open access system, where patients do not need an appointment each weekday morning. Alma Medical Centre also offers patients telephone consultations each weekday morning and a Saturday morning.
Alma Medical Centre has considered using the Doctor 1st model, however, we do not feel this has any added benefit to our current way of working.
2. Alma Medical Centre has a clear patient acceptance policy and displays this on the website - we review this on a three monthly basis.
Dovecot Surgery (Stockton)
Following the issuing of this report as a practice we welcome this and applaud some of the points is raises. We accept, as we would hope most other providers would that there is always room for improvement and we are always looking at ways to improve the services we provide and the methods in the way we deliver them.
The report shows some interesting statistics around number of GP’s for Stockton which we are having to work within at this time. We also feel we can comment on other services and the wider issue but our biggest knowledge relates to Primary Care and patient feedback.
The conclusion to the report highlights a number of areas and we have provided our thoughts and plans to them below.
1.Doctor First is from our knowledge and this is only third party, a useful tool and can have some benefits. It does require all GP’s to buy into its working but also requires a certain level of practice. It is not suitable for all practices to have and use. Some smaller practices are not big enough and some larger ones do not have the capacity to make it work. To a degree most practices will do some sort of triage to ensure patients can get access at the right time and with the right person. Reducing and dealing with DNA’s is a problem but text messages and reminders is a big tool in helping reduce this also. However patients will still DNA with these too. We have patients who book on the day for 2 hours after they call and still DNA as they didn’t want to wait and went off to the walk in centre. Whilst we accept doctor first may reduce some of this it may not always be feasible. As a practice it is not something we have yet explored as an option.
2.We accept it would be useful to publicise open lists and will take it on board. However we don’t feel this should be necessary as all practices should be classed as open unless they publicise otherwise.
In relation to recommendation 3 -Healthwatch Stockton be requested to encourage patients to make their registration application in writing (to ensure a written reason/response to any refusal is provided), and to encourage patients to report any ongoing issues to Healthwatch.
3.Patients should not have to apply in writing this is an unnecessary burden to place on patients. Patients complete the registration form and become a patient. We do data gather at the time of registration but this just helps with the gathering of information for patients benefit in treating them prior to us receiving their notes from their previous GP. Any practice using this as a screening tool is unacceptable. If a practice is to refuse a patient they are required to do so explaining the reasons in writing. We have spoken to Health watch twice lately about patients having difficulties in joining other surgeries after a removal. Hopefully this will improve soon. To clarify when a patient approaches us we ask their home address. If it is within our boundary we give them the forms to complete and they then become a patient. If they are not we explain they do not come into our boundary area and suggest they ring Healthwatch for a list of surgeries within their boundary if we do not know which to approach ourselves.
Recommendation 4 -the NHS England Area Team should review the current status of GP patient registration in Stockton Borough.
4.This should be done.
Recommendation 5- the Area Team should provide an update on its plans to ensure sufficient coverage of primary care services in Stockton Borough given the population growth.
5.Accept this should happen if required
Recommendation 6- the CCG should consider broadening the role of local pharmacy and
undertaking further publicity of pharmacy’s role in collaboration with NHS England and the Council, and this be further considered as part of the next Pharmaceutical Needs Assessment;
6.Yes
Recommendation 7 - the Council and NHS partners should consider the role of education and communications to ensure that the local population gains a betterunderstanding of what constitutes an emergency versus more minorailments.
7.Yes Yes and Yes! This is the biggest requirement but also the biggest challenge. It is a known fact that the more capacity you create the more demand you create. With the introduction of walk in centres and the increased demand on Primary care and A&E this is clear for all to see. The society we live in today isn’t prepared to wait for anything and unfortunately we have to accept this and strive to improve the way we deliver the services by funding them appropriately or by educating the people of today about what is and isn’t urgent with their health needs. However the last sentence may assist in determining how easy this may or may not be…. It’s a society problem, its wide scale and not only focused on our area. If we are to educate the people it will take a huge multidisciplinary approach from all services in health and social care but is something we should not be put off from doing just because of its size. We need to deliver the message to the people in the right place at the right time using all methods if we are to expect them to know how to access the care for their health needs at the right place and the right time. GP practices can deliver the message. Pharmacies can deliver the message. A&E can deliver the message. 111 can deliver the message. The Out of Hours GP can deliver the message. Social Services can deliver the message. Care and nursing homes can deliver the message. Schools can deliver the message. Opticians can deliver the message. The list is endless. We have multiple tools to do this: Posters, Leaflets, Word of Mouth, TV, The internet, Social Media, Telephones and Text messages, Prescriptions, People, Staff, Clinicians etc.
The task is big and complex but everything needs to start with a small step. Look, listen to the people and start. Learn what works and spread the word, change what doesn’t and spread the word. This could be a whole lot longer but we agree whole heartedly we need to get through to the people what can and should be treat where and when!
Recommendation 8 -the CCG and partners should increase publicity for NHS111 and when to use it.
8. 111 is a good place to start with the above and we should be jumping on the bandwagon for positive stories from it. We don’t, the media manipulate everything and only the errors make the news. We have tools to get messages out and if 111 does work – promote the positive stories. Again take the principals from above. It won’t and doesn’t fit everything but learn from that, change it be it a small or wholesale change and push the good bits more and more!
Conclusion:
In primary care we always feel like we get the blame every time something doesn’t go right with access and as explained earlier, yes there are improvements to be made. The problem is our services are continually changed and altered and we never really get the ability to just deal with the access, demand and needs of patients. In saying that, that is what we do and will continue to do as we are tied to the constraints we have to work within. We will and do look at the way we work and will continue to do so. We are more than happy to receive feedback such as this and also grateful for the opportunity to input into it. This isn’t about laying blame, whinging about our difficulties and problems but all of us are required to be outspoken about and highlighted if we are to really address the issues and problems we have with access to care in Stockton and the surrounding areas. We also welcome the input from the other providers, commissioners and service providers for their thoughts and feelings on this and hope all comments can be fed back to all involved once done.
Yarm Medical Practice
1. Using or adopting 'Dr First' has been considered by the practice. We have already ran a trial using a similar approach however we felt that this approach does not work well for our practice population and generates more work however not saving appointments or decreasing DNAs. Recent reviews of this system would agree with our findings.
2. Our practice list is very much open there I would only advertise the fact that we were restricted or closed list.
In my personal opinion, patient education is paramount to reducing pressures on healthcare services, (that and not seeing them when they attend A&E for non-urgent or appropriate matters) Community pharmacies could be used for minor ailments (as indeed they once were during PCT days in Stockton) but I feel financial constraints will make it impossible for A&E depts to turn patients away when they attract a tariff fee.
Woodlands Practice (Stockton)
1. We considered using this particular appointment system, but concluded it was not suitable for our practice, we will consider adopting a different telephone triage method if it will benefit our patients.
2. If our list were closed we would publish the fact, on the website, NHS Choices and surgery posters etc, as default our list is open.
Thornaby & Barwick Medical Group (Thornaby and Ingleby Barwick)
1. TBMG currently offer our patients access to telephone appointments with our GP's on a structured, timely basis in that patients are given an 'appointment' time that the GP will call them without the need to be available to take a call at an undetermined time over the course of a day. We have found this to be very successful and have increased this capacity to meet the requests of our patients irrespective of their employment status or age.
2. We would note that our practice has never closed or restricted our list to newly registered patients ( given residence within the practice boundaries ). We are proactive in maintaining our NHS Choices web site with all current information. We also have a practice web site ( ) and update this frequently with patient information including how patients may register with our practice. We are aware of the requirements, should we need to undertake to restrict or close our list, and would liaise fully with NHS England should we need to do so.
Eaglescliffe Medical Practice
1. Whilst the practice is not an adopter of Doctor First, nor do we have any future plans to introduce this system into practice, we have, for some time, successfully operated a telephone triage service for our patients which is led by our Nurse Practitioner. This system works well in practice. We have not experience high numbers of wasted appointments and we feel our current system achieves optimum use of our appointment system.