Case Study: A realistic rota

How it works

• We limit consultations to 13 per session. 
• Have a number of appointments that are pre-bookable either by the GP or by patients with different timeframes from when they are available. 
• The duty doctor then calculates how many on the day appointments are available that day.  The duty list is then capped at this number.   
• This includes the duty doctor doing 10 consultations as well as the triage, but these are for simple things like med3s rather than complex care 
• Comments are added to the duty list in the morning of when to move to the pm duty list 
• The pm duty list has a comment adding at what point to turn off online consulting and another comment added, typically about 10 slots further down, stating 'emergencies only discuss with duty doctor prior to booking'.  Typically we have 10-15 of these slots. 
• The 111 list sits separate to this with 2 appts in the morning and 2 in afternoon but the duty doctor will move these to the triage list if they are going to need a consultation so that they are included in the capacity count. 
• When we move over to emergencies only, the telephone message changes to make the patient aware that we only have emergency appointments that day so that they are not on hold for 30+ minutes to be told we have nothing left for that day. 
• We don't hold a waiting list, if we are at the points of emergencies only, the patient doesn't need an emergency appointment and there are no pre-bookable appointments available, the patient has the option to put in an econsult the next day, call for an appointment the next day or if they feel it can't wait contact 111, IUC etc. This is the one bit of our system that I don't like as I would like a solution that doesn't require a patient to call back. The reason we don't add them to the list for the next day is that a sig proportion never call back and we can't fill up the following days capacity as the system fails. 
• We do use apex Edenbridge to monitor our appointments, as I think it would be hard to challenge our approach if we are also demonstrating that we are offering more than the average number of appointments per 1000 patients per week than the other practices in our ICB. 

Outcome

This has made a huge difference to our clinicians. We spend longer with patients but it is based on a realistic rota which also enables us to do the clinical administrative work and complete all tasks in the allotted time so I no longer work 2 sessions in a day which actually take 11 hours to complete, this use to be the case. 

Case study: Standard and on-call days

Standard GP day

Morning 

• 12 x 15mins consultations (face-to-face or phone) - split between advance and on-the-day. 
• 2 x 15mins consultations for GPs to book into (eg. Telcon with DN or task necessitating them to initiate call to patient). 

Lunch 

• 1x visit maximum (unless at care home, where may be 2x).

Afternoon 

• 12 x 15mins consultations, as per morning.  

On-call GP day

Morning 

• As per standard day. 

Lunch 

• As per standard day but ONLY visits if all others have a visit already (duty triages requests). 

Afternoon 

• 6x 15mins advance-booked consultations. 
• 3x 15mins 111-bookable slots. 
• Rest of afternoon for admin, answering queries from reception and urgent (EOL/hot kids/DN calls), also reviews and actions any abnormal bloods/urgent scripts coming in after 5pm. 

Case study: Practice example using triage

This practice serves 20,000 patients in a deprived, multi-cultural population using a GP led total clinical triage called CAS (clinical assessment screen) GPs. 

How it works

• Patients access appointments via reception, telcon or accuRx. 
• GP appointments default to telephone: 11 telcons and 3 face-to-face per session. If more face-to-face sessions are needed, telcons are blocked.
• Slot types are either red (same day), amber (1 week), amber (2 weeks), or routine.
• AHPs such as ANPs/paramedics/MHP are used for face-to-face appointments only.
• CAS GPs have no booked appointments - they make clinical decisions on RAG rating of clinical triage and use F12 protocol to communicate this. Routine patients may go on a waiting list if there are not enough appointments.
• CAS screen is capped at either 3:30pm or when each CAS GP has clinically triaged 50 patients per session (which may happen earlier at 2pm). When the cap is reached, all on-line access is closed and patients are told it's urgent only, which are first triaged by care navigators and then CAS GP.  

Evaluation

Pros:

• GPs much happier 
• Continuity much higher 

Cons:

•  Complaints have gone up as patients don't like waiting when it's not urgent.

Case study: Fully online triage

Breakdown by day 

• 12 patient consultations every 4 hours (counted as one session). 
• Face-to-face majority, couple of phonically, and 2 GP Follow ups (mainly MH and continuity of care). 
• 13-minute appointments.  
• One third protected admin time. 
• 15-minute break per session worked.  

Method

System was fully online triage:  

• initially Egerton and then switch to Accurx
• clinical triage by GP in the morning (previously did two sets of triage, am and pm, but this proved difficult to manage workload and demand, as too open ended and labour intensive in terms of GP time and resource)
• window for online triage forms open from 7.30am to 11.00am - clear communication to patients re timings (used to be open over the weekend and all day, but risky in terms of safety if people ignore the red flags, and demand management)
• closed earlier if capacity reached, or if staff sickness etc.

Capacity

Capacity is mapped out, and a RAG (Red/Amber/Green) rating approach taken according to clinical prioritisation, patients with specific needs and vulnerabilities have alerts on system:  

• on the day urgent: red
• less urgent but not routine: amber (48 hours)
• routine - next available: green (safe to wait, no clinical urgency). 

Appointments capacity mapped out in terms of:

• clinicians 
• practice - in house 
• enhanced access - GP Fed - on the day evening and any the weekend (routine) 
• PCN: mole clinic, women's health, minor surgery, social prescriber, physio (this is in addition to the city wide FPOC physio)
• straight to physio (FPOC city wide offer) 
• external services eg Pharmacy first, minor ailments.  

We stopped the PCN MHPs, and reverted to direct practice ones as the MH trust offer didn't really address our needs.

Booking of appointments

• Patients are sent booking links to self-book face to face on the day via Accurx (this helps reduce DNAs as patients can pick the most convenient time). 
• Appointments can be booked in via telephone for nurse and bloods/smears etc (helps prevent inappropriate booking). 
• If patients are unable to use online triage, the forms are completed on their behalf by reception or direct booking into an appointment.  

In tandem with the above, we use an Oncall GP:  

• they have a lighter clinic in place, with empty slots for ad hoc queries  
• their capacity would be used only if the on the day capacity had been reached, and for those patients that could not wait  
• they would also deal with urgent docman (usually mental health or safe guarding. cases), third party queries and review urgent bloods that needed to be actioned for those clinicians that were not in  
• the workload of the on call has greatly reduced since the introduction of total triage ( I used to do the Mondays and art times would have 26 urgent consultations in addition to usual workload, from the morning!)
• if the urgent, moderately urgent and routine appointments are all used up patients are either signposted to other services or, if not appropriate, informed that they will be allocated an appointment once this becomes available
• all text messages including failed contacted have safety netting advice included with NHS111 contact information.  

Case study: A new system for patients

This example is from a practice that services 23.5k patients, semi-rural, deprived population with no UCC locally.

How it works

We are not quite down to 25 contacts a day yet but at 28 on routine days and 15 per session for on call clinicians (mix of GPs and ANPs).  

Some routine appointments are pre-bookable, some embargoed for on the day use (more embargoed on Mondays). 14 appointments per session, about half face to face although many of us convert telephone/online slots to face-to-face if needed. All appointments are fifteen minutes.

Triage hub 

2-3 clinicians per session in a triage hub with receptionists. 2 clinicians ‘on call’ seeing the urgent face to face appointments booked by the hub clinicians - 15-minute appointments.  

Can flex clinicians if needed to/from triage/on call.  

We switch off incoming electronic forms when the hub clinicians judge that we have no more slots to book into. Usually they go off around three pm but can be earlier or later depending on demand and clinical capacity. Patients can then ring in and will be triaged if emergency/directed to 111 if absolutely no capacity left.  

Recently we’ve changed so that if we are on maximum clinicians off for leave we load more on the day appointments.  

Separate appointments

We have separate twenty-minute appointments for coils, implants, first menopause appointments and joint injections. We have a GP with an hour blocked for visits (and visiting matrons) and one with an hour blocked to deal with the blood results of any clinician not in that day.  

Outcome

Clinicians are generally happier than when we had unending duty demand. Patients objected at first but now seem to be mostly okay with the system.