ENTER AND VIEW VISIT RECORDING FORM

VENUE

Enter and View
Date and Time of Visit: / 22.02.12
Establishment Visited: / Sorsby Medical Practice
Visiting Members: / Lin Lahm, Liz Hughes and Soraya Bowen
Assessor Assigned:
Communication and Observations
What were your first impressions of the venue?
  • Our initial impression was of a run-down building with security grills on the windows – it looked unwelcoming
  • When we entered the venue there were no automatic doors which could be an accessibility issue for wheelchair users and mothers with buggies getting into the surgery.
  • The most obvious reception desk was very high - even someone of average heightwould find the desk was way above chest level. This is an instant barrier – and especially if the individual is short or in a wheelchair – though there was a less apparent window for wheelchair users furtherdown the desk. It appeared to us that there was no-one in reception when we arrived, though in fact they were hidden behind the desk. From later comments and observations we conclude the desk is like this for security reasons.
  • The general appearance of the waiting room could be improved and needed decorating. There were not very many leaflets but a lot of posters of the wall – similar types of information were not clustered together, so that patients would not know where to look for info.
  • The baby nappy changer was located in the middle of the waiting area whichappeared an unusual location to us – particularly since it is such a small waiting room.
Response from Sorsby GP Practice:
This was the case when we had the bigger reception area which was partitioned in the recent past. This is the only nappy changer in the waiting area.
  • While we were waiting to introduce ourselves to the Practice Manager, the waiting room filled up, and a young woman patient came in, and sat down on the floor to wait for her appointment. Two members of staff immediately came out and set out another row of chairs.
Response from Sorsby GP Practice:
We make use of the chairs for the practice meeting which is held on every Wednesday, we put them back in reception. Also we have many clinics that particularly day resulting in many customers in the waiting area, unfortunately it was just a coincidence. We try our level best not to get this repeated.
What did you observe:
Good Points:
  1. There are toilets at the entrance of the surgery; however we did not check the accessibility or condition.
  1. Reception staff were welcoming and all staff open in discussing issues during interview
  1. Despite the run down appearance, the waiting room and offices looked clean, though the office space was overcrowded

Issues of Concern:
  1. The appointment system was mentioned as an issue by 5 of the 11 patients spoken to in the waiting room. The GP we interviewed said that there was constant feedback from patients commenting that it was difficult to get appointments. The lead receptionist indicated that some of the issue may be to do with confusion about the new system. The impression we had from patients was that it was a problem both about the availability of appointments and about difficulties of getting through on the phone to book appointments in the small window of time when appointments could be booked.
  2. Waiting times were mentioned as issue by 5 out of the 11 patients we spoke to. Four people said their appointments were overdue – 2 for more than 20 minutes, 1 for 15 – 20 minutes and 1 for 13 minutes and were not informed by anyone in reception with a reason for the wait or how they long they would have to wait to be seen by a doctor. Two patients mentioned that this was a regular occurrence.
  3. We observed the TV screenalone is used to notify patients of their appointment, and wondered how this would work for patients with language and/or literacy issues or those who are partially sighted who could miss their appointment. During our time there this did happen once and the doctor had to come out into the waiting room to call in the patient.
Response from Sorsby GP Practice:
Many of our doctors do come to the reception area to call them in. When they use the calling system and no response from the patients they either the GPs come out of the surgery or ring the reception desk to find out.
  1. The removal of funding for the Turkish interpretation and advocacy service; We only spoke to 2 Turkish speaking patients, but the difficulties they expressed gave the impression the lack of interpretation service had significantly impacted on the quality of service they were receiving, and were likely to result in increased demand, as well as a potential impact on their health.
    One of the Turkish speaking patients had a school age teenage family member interpreting, which raises questions of confidentiality and quality of interpreting by someone who may well not have knowledge of relevant medical terminology.
    While this was 2 people, it raises questions about the quality of service and potential impact on health for all Turkish speaking residents registered at the practice needing interpretation services.
Response from Sorsby GP Practice:
To help customers with language difficulties we book interpreters from advocacy services, use language line. In fact the usage of both of these facilities has gone up which is an indication of helping them.
  1. One of the patients interviewed mentioned the lack of signage which we noticed – it was not clear to us where to go to see the doctor. This patient thought this was an issue for patients with language or literacy issue or those not knowing how the surgery worked.
Response from Sorsby GP Practice:
We will try to improve this
  1. We witnessed an altercation on the steps of the surgery, which started in the surgery and then continued near the entrance. Two young women leaving the surgery were approached by a third woman and an altercation broke out, with one woman hitting one of the others. A patient in the waiting room commented that this was a normal occurrence in the area. This linked to comments from the Practice Manager about concerns about the safety of both staff and patients, particularly during evening surgeries.

What feedback did you get from Staff members?
Interview with GP Nick Brewer, Partner at Lower Clapton Health Centre, part of Temporary Management Team for Sorsby Practice
Q: Why is Sorsby being managed by Lower Clapton Health Centre?
Sorsby was a single-handed practice for many years, working both from here [the Sorsby location]and a branch in Homerton High Street. There were some concerns from the PCT about the clinical and other standards of patient care. The PCT encouraged the practitioner to retire, and took the practice back late in 2009. Then a private company ran it for a while, then the PCT ask local practices to support the Sorsby Practice while they put a tendering package together.
“We (Lower Clapton Health Centre) began work here in April 2010. We put in protocols and dealt with immediate issues – for example there was only 1 phone line, so if a doctor was calling out, nobody could call in. We tried to make these changes as soon as possible – so, for example, there are now 4 phone lines, and we have increased the number of receptionists at busy times of day. There were some problems; some people didn’t like the change. And it takes time to advertise and employ new people – so it was 4 months before we could get permanent members of staff. And it also takes time changing structures and processes – for example, we couldn’t improve the appointment system until we had more phone lines.”
Q: What are the things you have achieved?
  • Our improved QOF data and hugely increased number of appointments, way above what the BMA recommends
  • Our diabetes care – we were the worst in Hackney, and Hackney was the worst in the country – and now we are above the middle in Hackney, and Hackney has moved up the national scale as well.
  • On the day we started, we had a sit-in from the Turkish patients because the advocacy service had been taken away. We got it set up again (through Derman) – however the funding has now been taken away again.
  • We have a new ante-natal clinic and a new baby clinic – both of these were struggles as no-one wants to give you money
  • We have tried to improve the management of all chronic diseases
Response from Sorsby GP Practice:
We have many chronic domains, they are 20 at the moment
  • We have more psychotherapy now
  • Much improved management systems
Q: What are the things you think could be improved?
  • Increase other services on offer – for example an anti-coagulation clinic
  • We had a Turkish advocacy service – it was very well used and valuable, but the funding was cut
  • Improve the building – we have been pressing the PCT about this. In part this is for the staff, as it is not that safe for extended working hours. We need better disabled access, and we have another room we have been trying to bring into use since day one, but we need funds to make it infection control compliant. We could do minor surgery and coils in that room, for example, which we currently do at Lower Clapton Health Centre.
  • The constant is feedback from patients that they feel they can’t get appointments – and we are trying to adapt our systems
Q: How do you collect patient feedback?
  • We have a Patient Participation Group – there have been 3 or 4 meetings. The last one was very successful because we texted people. The first 2 we had a small group of people with a narrow range of issues, the last one was better attended and a broader range of issues were raised. The Turkish speaking health care assistant attended, so she was able to translate for Turkish speaking patients.
  • We also have the patient survey
  • We also have informal feedback from patients
Q: What are the issues that come up in the patient feedback?
The issues that came from this were:
  • Not enough chairs in the waiting room
  • The appointment system
  • The building – there is no electricity, heating or water for the extra roomwhich is meant for the treatment for any purpose, once fully equipped can be used for minor surgery as well.
Interview with SrinivasaraoPutti, Practice Manager, Sorsby Practice
(This was a short interview, as most issues had been covered in the previous interview)
Q: Dr Brewer mentioned that the QOF data is now very good and that you could tell us the rates for the Sorsby?
Our QOF result for 2010 was 65%. For 2011 it was 99%. And so far for 2012 it is 94%.
Q: Dr Brewer also said that your scores against the BMA standard number of appointments was good now?
The BMA standard is 70 to 71 appointments per 1000 patients per week and the Sorsby provides 3 – 5 % more than this.
Other than the things Dr Brewer has mentioned, what do you think has improved at the Sorsby Practice?
Since the Lower Clapton Health Centre pitched in we have 3 part-time nurses and 2 part-time part-time healthcare assistants, one of whom is Turkish speaking.
Other than the things Dr Brewer mentioned, what do you think are the things that most need improving?
  • We are experiencing difficulties in providing services to the Turkish speaking patients. We used to have an interpreter employed directly by the practice, then we had Derman providing the service, but now we have nothing. We use Language Line and advocacy services – and they are very good relatively speaking. But now the demand has gone up, we use more hours than before.
  • We have been trying for the last few years to improve the disability access – the PCT is looking into it.
  • Redecoration of the building – the PCT are considering this too
  • With the high diabetes rate, it would help patients if we could provide chiropody clinic in the surgery
  • We would like to provide a chiropody service and may ask the PCT about this too
  • At present we are short of space, and constrained in what we can do by this
  • We could do with some safe and secure systems – like CCTV. Sometimes it’s very difficult for patients, and for staff – especially in the evenings when we are open until 8pm.
Interview with JanetteFairley, Head Receptionist, Sorsby Practice
I have been here for 4 and a half years, through all the changes – and there have been a lot of change. It’s been for the better. The patient care is better – for example people get called in for their medication reviews and health checks like diabetes checks and smears, and NHS checks aimed at certain age groups. There’s a lot of ringing round.
What do you think is going well?
I think the Customer Service is good – we do try to please, though you can’t please everyone. If you can’t fit someone in, then if we get a cancellation we call them back and say we’ve got this appointment free now. We do things at short notice – for example, older people may not realise their medication is running out, and although they are supposed to give 48 hours notice, we do it straight away to help them. We try to go the extra mile because we try to look at the whole picture.
I think the hours of opening are good too – we open at 7am, and 2 nights are open until 8pm – and it’s often later than that as doctors will run over the appointment times.
We never have any complaints about staff, everyone here is really helpful, and it is working well.
What do you think could be improved?
We’ve got a new appointment system – we have pre-booked appointments, 24 hour slots, 48 hour slots and same day slots. But people are confused about it. You can pre-book appointments up to 4 weeks ahead, but once the slots are filled, people don’t understand and find it frustrating. However if people can’t get an appointment we offer a phone consultation – and we always prioritise children, carers and the elderly.
I know that even at the GP surgery I go to, if I want to see a specific doctor I have to wait 2 weeks or have a telephone consultation.
What feedback did you get from Service Users?
  1. [Patient 1] He was not happy with the service because there was no doctor to speak to directly. He was suffering from multiple conditions but these were not being properly cared for in his opinion. He said that the medication was not helping but he was not taking it as prescribed IE he was taking three times the dose and feeling unwell. The reason for his visit was to sort out his medication.
  1. [Patient 2]. Happy with service. Feels he can speak with his doctor. Has been a patient for a long time. Diagnosed with depression and referred to hospital psychologist which had been very helpful but was unhappy that there was no hospital follow-up once the 16 week treatment period ended. Practice doctor listens to him and he believed he was getting better. Noted that had to be referred to the hospital for blood tests. Stated that he has no complaints.
  1. [Patient 3]. Not happy with service and planning to change GP. She said, via teenage daughter [in school uniform] interpreting, that it’s difficult to get an appointment and that she saw a different doctor every time. No interpreter was available so appointments had to be booked when an English speaking family member was available. Appointments were never kept to time and she always had to wait. The teenage daughter was aware of the touch-in screen and that Turkish instructions were available.
  1. [Patient 4]. Had recently transferred to the practice. Was concerned because he had already waited 20 minutes beyond his appointment time. He had been satisfied with the way he was treated on his first visit, had felt comfortable with the doctor who had listened to him. Said that the receptionist had been helpful, but was troubled that there were different people in reception today.
  1. [Patient 5]. Had been attending the practice for many years. Was no longer happy with the doctors because he considered they were too young and he felt they had insufficient experience and didn’t know enough. He felt that the treatment provided and medication prescribed was not good enough. However, he said that he did not wish to change to another surgery – and had nothing more to add.
  2. [Patient 6]. Waiting 25 minutes past her appointment time. Before she went in to her appointment she said the service at the practice was appalling and she was not happy that her appointment was delayed and that no explanation was given as to why.