Appointment systems
A comparison of practice appointment systems across three Sheffield PCTs
September 2001
Contents
data for GPs and practice nurses in 3 Sheffield PCTs.8. Appointment systems - other access issues
Appendix 1 - Practices surveyed 32
Appendix 2 - Comparative analysis of appointment & consultation
Introduction
Bar charts
The future NHS will require general practices to provide a high level of immediate patient access.
‘ By 2004, patients will be able to see a primary care professional within 24 hours, and a GP within 48 hours…… all practices will be required to guarantee this level of access for their patients, either by providing the service themselves, or by entering into an arrangement with another practice, or by the introduction of NHS walk-in centres.’
The NHS Plan
To achieve this practices will need to make the most effective and efficient use of the skills of all their staff. With this in mind, three of the Sheffield PCTs - South East, South West and West - asked the Centre for Innovation in Primary Care to work with their practices to compare appointment systems currently in use. This comparison is aimed at stimulating professional interest and commitment to innovation in the field. It provides a framework for practices to learn from each other and tailor the service to meet the needs of Sheffield people.
Thirty of the seventy-four practices in the PCTs participated in the comparison. This report details an analysis of qualitative data, and a one week quantitative snapshot of the number of appointments offered by GPs and practice nurses, and the number of patients seen. The practices, picked from a larger group of volunteers, are broadly representative in terms of geographic spread, socio-economic status of the area served, and practice size.
The report describes innovations practices have developed and adopted to improve patient access, together with more general observations, analysis and conclusions. The appendix presents more detailed analysis of the quantitative information in the form of comparative bar charts. The analysis is presented within a national context of rising demands on general practice.
Every practice is partially unique in its patient base, primary health care team, building, history, and ethos. An innovation that works well in one place may not necessarily work well in another. However it is likely that most innovations have some generalisable lessons. What is presented here is not a set of instructions for a model appointment system, but more akin to a cookbook, with a range of recipes assembled from many chefs. Practices can dip into it as suits their taste.
Main findings
Supply and demand
Appointment systems
Changing roles
Changing the medium
Multi-professional working
Other appointment system issues
A dialogue with patients
Conclusions
Appointment systems
A comparison of practice appointment systems across three Sheffield PCTs
September 2001
The NHS of the future will require general practices to provide a high level of immediate access for patients.
‘ By 2004, patients will be able to see a primary care professional within 24 hours, and a GP within 48 hours…… all practices will be required to guarantee this level of access for their patients, either by providing the service themselves, or by entering into an arrangement with another practice, or by the introduction of NHS walk-in centres.’
The NHS Plan
To achieve this practices will need to make the most effective and efficient use of the skills of all their staff. With this in mind, three of the Sheffield PCTs - South East, South West and West - asked the Centre for Innovation in Primary Care to work with their practices to compare appointment systems currently in use. The purpose of this comparison is to:
Local context
Sheffield has four PCTs. Three of them commissioned the Centre for Innovation in Primary Care to undertake this appointment comparison. The fourth - Sheffield North – is part of the National Primary Care Collaborative and consequently felt that this comparison would be a duplication of effort. In March the North PCT hosted a free conference on Access at the Holiday Inn in order to start the process of sharing their learning. Many of the people interviewed in this survey attended that conference and commented positively that it had given them ideas for their own practice. Four practices in the North made workshop presentations about innovations they had introduced (as well as two practices from other PCTs) and these practices are named in Appendix 1
Methods
A sample of 30 out of the 74 practices were visited, from the three PCTs - 12 in the larger South East PCT and 9 in the other two. These were all practices who had volunteered for the survey after receiving an explanatory letter to the senior partner and practice manager. Since there were more volunteers than could be accommodated in the sample, practices were chosen to ensure:
The thirty chosen practices are listed in Appendix 1 together with the name of the practice manager as a contact. It will undoubtedly be the case that there are other practices in the three PCTs who have adopted innovative approaches to patient access, particularly perhaps in the South East PCT where there were many more volunteers than the twelve required.
At each visit a structured interview was carried out lasting about one hour. This was usually with the practice manager but sometimes was with a GP, sometimes the assistant manager, and sometimes a manager and GP combined. In the course of the interview the practice was given informal feed-back, where appropriate, on what is being tried elsewhere and what seems to work well. The aim was to engage them in the idea of sharing their best work and learning from others.
The interview was followed by simple data collection of consultation activity for a typical week. Whilst visits were carried out between late May and early September, the data collection week was in almost all cases one of the middle weeks in May (avoiding Bank Holidays). The precise choice was made in each practice to use a 'normal' week where all clinical workers were seeing patients and not on holiday - though in very large practices it must be recognised that having a GP or practice nurse on holiday is the norm. Evidence from previous data comparison work undertaken by the Centre for Innovation in Primary Care (CIPC) shows that May is an average month in terms of consultation workload.
An important function of the comparison is to identify innovation and experimentation and enable practices to learn from each others innovations, both successes and failures. Therefore practices who have tried something different are named so that others can contact with them if they wish to ask further questions. Another major purpose of this report is to enable practices to compare aspects of their appointment system with others without feeling that they are being judged or reviewed. For this reason, in the quantitative analysis based on a one week snapshot the practices are identified by a number only, to preserve a degree of anonymity.
Some practices are mentioned frequently in the report, others occasionally. This does not reflect any judgement. Whilst we certainly want to encourage practices to innovate there is no simple formula linking innovation to excellence. There are practices in this sample who are providing a fast, responsive and quality service without departing from what would be considered standard approaches. Necessity is often called the mother of invention. Some of the innovations detailed in this report were explicitly introduced to address areas where a practice was struggling.
Despite the busy life they lead, all thirty practices have been very co-operative and there is an opportunity to use the information sensitively to improve access for patients and job satisfaction for GPs and staff.
The pressure on general practice is rising. This can be attributed to a range of factors including:
Some of these changes may be desirable but GPs feel that their workload is rising inexorably in a context of a much slower rise in GP numbers. Recruitment is a problem in the more deprived areas, GPs are retiring earlier and younger GPs are increasingly opting for shorter working hours and greater family life.
The widespread assumption is that consultation rates are steadily rising yet data to prove or disprove that is difficult to find. The evidence from data that CIPC collected from 30 Sheffield practices via the Practice Data Comparison Project (PDC) is that GP surgery consultation rates were static through the second half of the 1990s. It may well be that GPs are holding back the potential demand by limiting the supply of appointments they provide to that which they can personally sustain or financially afford. In such a situation one would expect ‘waiting lists’ to rise i.e. patients have to wait longer to get an appointment. The wait to see a GP has been a significant complaint raised by patients in the national patient surveys. The Government has taken up the issue in the NHS Plan by setting ambitious targets that by 2004 all patients who so wish will be able to see a healthcare professional within 24 hours and a GP within 48 hours.
General practices and community health professionals have not sat back passively in the face of the rising pressure. A range of strategies have emerged to respond to the situation including:
Underlying all these responses several principles can be discerned:
A new millennium brings new ideas for responding to patient demand. Nurse-led services such as NHS Direct or walk-in centres, telephone consultations or triage, e-mail consultations and the use of the Internet for informing patients, casualty department-style rapid access clinics, and a mooted partial revival of the ‘old fashioned’ open access or drop-in surgery. New, and not so new, ideas may prove valuable, but as yet the evidence for their efficacy is limited.
Whilst all of this national context applies to Sheffield, it should be pointed out that Sheffield Health and Sheffield GPs have made significant investments in staffing and premises prior to the advent of PCTs. There is an above average ratio of GPs to patients, and the city is generally perceived to have good quality primary care. Investment however costs money. In other spheres an organisation that invests money in a better service is likely to get a financial payback through an increase in customers. In health care however patients are reluctant to change GPs and those GPs who do invest their money in improvements may feel themselves penalised rather than rewarded.
This report seeks to assist GPs in providing a better, more accessible, service for their patients. But any suggestions for improvement must be sustainable in the long run and rooted in the real human and financial resources available to practices. Burnt out GPs and practice staff are no good to anybody.
Charts 1-8 in Appendix 2 present data from a week long snapshot of the Sheffield practices. One week’s data can only give a broad brush indication of what is happening, but it is presented in the context of the learning from the data CIPC collected for five years from up to 30 Sheffield practices in the second half of the 1990s. Twelve of the thirty practices reported here participated in that Practice Data Comparison (PDC) project. It is helpful that the snapshot was taken in May because there is evidence from the PDC work that it is a fairly average workload month. Appendix 2 gives a more detailed analysis but below are presented the key findings.
For GPs
For Practice Nurses
There was no relation between the number of GP consults per 1000 patients and the number of practice nurse consults. Whilst using nurse practitioners to see patients with minor illness is a clear substitution of roles, the bulk of what practice nurses do should be seen as an additional provision rather than as a substitute for GPs.
This data set confirms the learning from PDC. The number of patients seen by GPs each week is the outcome of a complex interaction between patient demand and the number and type of appointments a practice offers. National research has been unable to identify a formula that can predict how many appointments a practice should offer. Practice profile (particularly deprivation), GP and practice nurse availability, practice history and practice decisions about the type and quality of service it wants to provide all have an impact.
There are six basic systems or approaches in use, though some practices combine two or more different systems e.g. morning drop-in, afternoon by appointment only. Table 1 shows the typology used in this report.
Table 1 - Types of Appointment System in Use in Sheffield
|
GP Appointment Types |
Description |
|
A |
All slots bookable. None embargoed till the day. Extras fitted in |
|
B |
All slots bookable. Some embargoed till the day for acutes. Extras seen if they occur. |
|
C |
All slots bookable. Some embargoed till the day for acutes. Extras seen if they occur. GP/nurse telephone triages some acutes |
|
D |
Open surgery or drop-in. No bookable slots |
|
E |
Nurse practitioner option for same-day patients, either as drop-in or by same day appointment |
|
F |
"Advanced Access". Majority of slots embargoed till the day with only limited provision for prebooked appointments |
Traditional practice nurse appointments are almost entirely pre-bookable, although a significant minority may be tied to particular clinics or tasks. The main exception is Duke Medical Centre which has a drop-in system for traditional practice nursing work, whilst the University and, to a small degree, Baslow Road and Hackenthorpe, retain some nurse appointment slots for same day only.
Type A - Pre-booking and extras
The simplest appointment system is where practices offer all their appointments as pre-bookable and if/when these fill up on a particular day anybody who needs to be seen that day is fitted in as an extra. Only five practices in the survey operate this system in its pure form (Carrfield, Duke, Sharrow Vale, Upperthorpe, Whitehouse Surgery) and most aim to provide enough appointments that the need for extra appointments is pretty small. Two other practices, Devonshire Green and Deepcar, combine sessions where all the appointments are pre-bookable with a drop-in surgery at some point in the day.
Type B - Same day embargoes
The most common system in operation is Type B where to see a GP you need an appointment but a percentage of appointments are held back till the same day. Mostly these will be morning appointments but usually there will be some in the afternoon as well, which in some practices may not be released till lunchtime or even 3pm of that day. Should all the embargoed appointment slots fill up any overflow are seen as extras.
Same day appointments have the advantage over extras in that, in theory at least, they give patients a specific appointment time rather than being told to come and wait till we can fit you in. On the other hand if too many appointments are held back for the same day it can act to increase the length of wait for patients who want an appointment soon, but not that very day. Tramways have tried to address this issue, successfully they judge, by a more sophisticated use of embargoes. They have appointments that they release 15 days in advance, 3 days in advance (for patients who need to be seen soon but its not 'urgent') and the same day.
A common issue with both extras and same day appointments is what justifies a patient 'jumping the queue' to see a doctor. Some practices are relaxed about this, letting the patient take the decision about whether they need or want to be seen that day. The majority however see these same day slots as for 'urgent needs' only. This raises the issue of who decides what is urgent and often puts receptionists in the position of negotiating with the patient about whether their need is urgent or not. Some receptionists see this as a necessary and legitimate part of their 'gate keeping' role, others feel they are being put into a position of making judgements for which they have not been trained, and for which they get a lot of stick from patients. Some patients resent having the negotiation of whether they can be seen that day with anybody, whilst others see the process as legitimate but feel the discussion should be with a clinically trained person.
Type C - Same day embargoes with telephone triage
A number of practices have responded to the issue of what constitutes an urgent appointment by experimenting in the last year with telephone triage by a clinical worker (Type C). At Crookes, Darnall and Mosborough a duty doctor is available for part of the morning to telephone triage some of the requests for same day appointments. Only Crookes operates telephone triage for afternoon requests, with all afternoon same day requests being put through to the duty doctor. Hackenthorpe is the only practice to use a practice nurse for telephone triage, currently for 1.5 hours only on a Monday morning. All of the above practices feel that the triage has been positive and has reduced the same-day workload. It should be noted that phoning people back adds to the telephone bill, particularly as many daytime return calls may have to be made to mobile phones.
Type D - Open access
Open access or drop-in surgeries (Type D) were once the standard method of meeting the demand. Now most practices operate full appointment systems and the drop-in surgery seemed to be heading for extinction, but in the last year some practices have started to rethink. Four practices in the survey have always retained a drop-in option alongside a system of booked appointments, and strongly feel that it suits their patients. At Deepcar the evening surgeries are drop-in only with appointments in the morning whilst at Dovercourt it’s the reverse. The Sloan Practice are appointments only at their main site but have a morning drop-in on four mornings at their branch surgery which they inherited from a previous single-handed GP a number of years ago. Devonshire Green provide a lunchtime drop-in with appointments morning and afternoon. The timing of their surgery particularly takes into account the lifestyles of the homeless people in hostels and students who form part of their list.
Two practices have recently re-introduced a GP drop-in surgery. Darnall did so about 18 months ago. It runs late morning, with GP appointments earlier in the afternoon, and its timing is partly to take into account the lifestyles of the various ethnic minority communities in the area. The practice feels that the drop-in has been an effective part of a strategy to better meet the needs of their particular patient base which includes over a third ethnic minority patients plus many Travellers. Rustlings Road has experimented with a Tuesday afternoon drop-in since May and are considering expanding it to another day since they feel it has eased the pressure on appointments.
Type E - Nurse practitioner surgeries or drop-ins
As part of the development of the nurse practitioner role, some practices have started to offer nurse practitioner surgeries where patients can be seen same-day for minor conditions. The first to do this in Sheffield was Richmond about 7 years ago. They now have two nurses running same day appointment surgeries 11-12, 1-2 and 4-5 (one nurse) which patients can book into for minor illness. They also see all the children under 12. A GP is always available to provide back-up and sign scripts but only about 5% of patients who see the nurse practitioner need to be passed on to the doctor. The practice is extremely positive about the nurse practitioner role and the strain it has taken off the GPs. They emphasise however that it requires a big training commitment, a stable team and a preparedness on the part of the GPs to trust the nurses enough to be able to delegate to them.
Until recently there had been very little spread of nurse practitioner minor illness surgeries in Sheffield. Birley provided this service but their nurse practitioner left. Norwood Medical Centre in North Sheffield has had a nurse practitioner appointments surgery for same-day minor illness for several years. For some years at Porter Brook on their main site the nurses have had some same-day appointments, whilst at their Hallam University campus site nurses and GPs run parallel pre-bookable surgeries where students can opt to see either a GP or nurse and about 50% opt for the nurse. Unlike at Richmond they have had some turnover of nurses, but have been able to retain the system and feel that if there is good overall GP/nurse team working then new nurses can be integrated into the system.
Now amongst the surveyed practices Darnall and Dovercourt have recently introduced nurse practitioner surgeries, in both cases as drop-in surgeries to complement the GP drop-in surgeries they already provided. Patients can opt to see a nurse or GP in this drop-in, and again about 50% opt for the nurse. Both practices are very positive about the service and confirm the evidence from Richmond that only about 5% of patients need to be passed over to a GP. A number of other practices are thinking about training a nurse to take on nurse practitioner surgeries. The practice nurses at Duke have long run morning and evening drop-ins but this is for traditional practice nursing work rather than a specific focus on the minor illness that has traditionally been seen by GPs.
Type F - Advanced access
The work of the National Primary Care Collaborative has popularised terms such as Advanced or Rapid or Accelerated Access. Advanced Access does not refer to a particular appointment system but rather a philosophy of aiming to do 'today's work today', and can involve whatever changes a practice wishes to make. However elsewhere it often has included the use of nurse practitioners and/or telephone surgeries or triage. Within Sheffield North PCT it is the Bluebell Medical Centre that has probably done the most experimentation on advanced access, but Norwood Medical Centre, Pitsmoor Surgery and Wadsley Bridge Medical Centre have also been working on it.
Within the surveyed practices the first to experiment with advanced access was Woodseats Medical Centre. They used to have one GP seeing same-day patients - an effective drop-in - but felt that this surgery went on too long and was a poor service. Over the Christmas period 2000 they had a week of entirely drop-ins to clear the back-log of patients waiting for an appointment, and at the beginning of January 2001 introduced a new system.
Two thirds of their appointments are now only available on the day, for both morning and evening surgeries; the rest can be booked in advance. If all the same day slots have been taken, the overflow are seen as extras. One GP does a morning telephone advice surgery for 1-2 hours and can call patients in if necessary - but this is provided for patients who opt for advice only rather than acting as a triage system. The system is operated in a flexible way, so that for instance receptionists know they can over-ride an embargo if a patient insists that they need to see a particular doctor next Monday at a time when only same day slots are available.
An even more radical experiment in advanced access is now taking place at Lowedges. In early June they moved from an appointments + extras system to one where 90% of their appointment slots are embargoed till the day. The other 10% are largely reserved for GPs to recall patients. If patients want an advance appointment they are told they can't book one, that they have to ring back on the day they actually want the appointment and they will be given one. Patients who ring late in the afternoon are offered a slot the following morning. If all the same day slots are taken, which so far has been rare, the patient is either seen as an extra or given a slot the next day.
Stonecroft (with a branch surgery at Jordanthorpe) made a similar shift in June but they reserve 50% of their appointment slots till the day at both sites so patients still have the ability to make routine advance appointments. They term this "advanced access" since it represents for them a radical shift from 0% same day appointments to 50%. There are however some Type B practices who have as much as 40% of their appointment slots as same day but have arrived at that point in several small steps over a number of years, though some such as Baslow Road have moved from 0 to 33% of appointments for same-day appointments in one jump this August.
Is advanced access working?
All three practices so far are very positive about their new systems, particularly feeling that it has greatly reduced the stress on receptionists since they now can offer patients choices instead of explaining what is not available. Woodseats though commented that their change felt irrevocable, that it would be hard to return to a less open service without patients feeling that the service had deteriorated.
This ties in to the concern that many GPs will have about such experiments that they could 'open the floodgates' to unlimited demand. So far the practices say that has not occurred but it is still early days, especially at Lowedges and Stonecroft where the system has not yet faced a winter period. Lowedges have increased the number of appointment slots by 10% but there is no evidence yet from any of the practices that they are seeing more patients. Indeed at Stonecroft's surgery at Jordanthorpe an audit of the first 10 weeks of advanced access found a 7.5% fall in patients seen compared to the same period the previous year. Part of this fall is measurably due to the GPs recalling fewer patients since they know they have far fewer pre-bookable appointments to play with. The practice speculates that the other reason for the drop is that some patients who came frequently for minor things are coming less because it isn't so easy to get a routine advance appointment.
All three comment that their DNA rate for GP appointments has slumped - a predictable benefit of advanced access since research evidence shows that the propensity to DNA increases as the gap between making the appointment and actually being seen increases.
Another potential problem with advanced access is that it puts those patients who want a specific advance appointment with a specific GP at a disadvantage, since there are fewer such slots available. Overcoming this may be about getting the balance right between the numbers of pre-bookable and same day slots. Lowedges commented that much of their patient base is not working full time and therefore is able to get in 'that day'. Woodseats in contrast serves a wealthier community and will have a higher demand from working people for advance appointments. Both practices emphasise the need for receptionists to apply the system flexibly and allow exceptions to the rule.
Finally Gleadless are starting in early September a different kind of 'rapid access' experiment. This will involve one GP every morning doing an advertised telephone surgery from 8.30 - 10.30 where receptionists take the initial call and the GP rings back in turn. Triage of home visits requests will form part of this. After 10.30 that GP and 2 healthcare assistants (B grade nurses) will run a 'Three Minute Surgery' bookable only on the day. The healthcare assistants will call the patients in to their room, prepare them and then call the GP in for a 3 minute consultation about one item only. This experiment is a modified and small scale version of the work that has been pioneered in the Ridge Medical Practice in Bradford on Rapid Access surgeries over a number of years.
Comparative data
Charts 9-11 in Appendix 2 present some comparative quantitative data on the appointment systems. They show that:
48 hour access
All the practices surveyed make provision for patients to be seen that day, or at worst the next morning, for those who urgently need it. Most go further and either provide a large number of same day appointments or else aim to provide a routine pre-bookable appointment with a doctor within 48 hours. Spot checks undertaken by the researcher on the site visit invariably confirmed the practices self reported appointment availability.
Several however commented that their patients reported that 'at other practices' there could be a delay of 3 weeks to see a GP. The worst that was found at any practice surveyed was 5-6 working days, though it might be more in mid-winter. The survey was a voluntary undertaking so it may be that practices with poor access opted out. Alternatively such reports may be partly a case of Chinese whispers - tales that grow in the telling.
More importantly there is undoubtedly an issue about the wait to see a particular favourite GP. As the number of part time GPs has grown, practices have had to move to a system where continuity of care resides more in the GP (and wider) team. Some patients at least are reluctant to make this step, and the '3 week wait' may well be for a popular part-time GP who also happened to be on holiday. This is one issue where it seems clear that patient expectations may have to be modified - the service can be personalised, or it can be quick, but it can't necessarily be both at the same time.
A week's wait
In a handful of the surveyed practices the wait to get a routine appointment with any GP was about one week. The obvious question is whether these practices have anything in common. The answer is interesting.
They are all in the South East PCT, which has the most poverty of the 3 PCTs surveyed, yet they mostly are not in the poorest parts of the PCT area. They can generally be found in the middle range of GP consultation rates and they are all above average for nurse consultations. They offer 7.5 or 10 minute GP appointments and all have appointment systems based around a mix of pre-bookable and same day appointments. They all offered 30-45% of their appointments as same day slots and they clearly don’t have a problem about providing access for urgent need.
None of this provides an easy explanation for why they have longer waits than other practices surveyed. An additional curious feature is that in a similar survey conducted by CIPC in Doncaster East PCT, the practices that had long waits for a routine appointment also had the same kind of appointment system and also held back 25-40% of their appointments for the same day.
Is there an inherent problem with this kind of appointment system? Holding back a high percentage of appointments for the same day inevitably reduces the availability of appointments for those patients who want to book in advance, though if the urgent demand is being met this may not matter. Some other surveyed practices operate the same appointment structure without such long waits.
The three experiments in ‘advanced access’ described here are holding back even higher percentages of appointments but they are in their early days. They have also introduced their changes in one 'big bang' step. This may have the advantage over small scale incremental changes that it makes patients aware of a need to change their behaviour. However small scale 'try it and see' change runs less risk of introducing a system that fails or is highly unpopular with patients.
This is all very speculative, which reinforces the need for practices who make changes to their appointment system to audit the effects and spread the learning. Whether a particular appointment system works well depends in part on how the patients respond to it, and we still have a lot to learn about patient behaviour.
Practice nurses
The section on nurse practitioners highlights one example of the way that the skill mix within practice nursing is changing. Other practices are experimenting with the introduction of B Grade healthcare assistants. Gleadless and Sothall have introduced these whilst Birley, Darnall and Woodseats employ a B grade District Nurse support worker for some hours in this role. Typically these healthcare assistants are taking bloods, applying dressings, undertaking new patient checks including blood pressure and urine tests. Gleadless have analysed in detail the kinds of work undertaken by their practice nursing team and based their skill mix decisions on that evidence. They found that 31% of the consultations were for phlebotomy and in all 50% could be dealt with by a healthcare assistant. The data collection forms they used are available for other practices. Other practices have taken different routes to removing phlebotomy from the E/F/G grade practice nurse role. At Dovercourt and the Valley Medical Centre in Stocksbridge they employ a hospital phlebotomist to come in at certain times, whilst Woodhouse and Richmond have trained receptionists to be phlebotomists (see below).
Practice nurse appointments are overwhelmingly bookable in advance but occasional use is made of same-day embargoes e.g. University health service, whilst at Duke the practice nurses have always operated a drop-in service. In some practices the nurses tend to run general surgeries with a standard appointment length, but the receptionists know which kinds of appointment to book for a double or even treble appointment. In others there is more emphasis on special clinics for diabetes, asthma, CHD, well woman etc. and these will have longer appointment slots than a general nurse surgery. The issue of special clinics versus general surgeries has many sides to it - but from the point of view of waiting times one would expect patients to be seen quicker in a system based on general surgeries, because special clinics inherently restrict seeing patients for certain conditions to certain times. Because of this variation in clinics and surgeries it is hard to generalise about appointment length. However two thirds of the practices allotted 10 minutes for the basic nurse appointment length whilst a third allotted 15 minutes
Community nurses
Quite a few practices referred to having an Integrated Nursing Team between practice nurses, district nurses and health visitors, though their scope was variable. Darnall and Woodseats have probably taken the concept furthest. The former has taken advantage of its position in the last 3 years of having been a PMS pilot where the whole practice has been employed by the Community Health Trust. Three of the district nurses (G, E and B grades) each spend a day a week working in a practice nursing role. At Woodseats the employment of the practice nurses was handed over to the Trust and this has led to a high degree of flexible working with practice and district nurses, and health visitors substituting for each other when required and able to.
Many practices reported that integrated nursing meant that their district nurses now had a more flexible role - in some cases offering a weekly drop-in for the patients on their case load who could get to the surgery; in others undertaking, for housebound patients, phlebotomy, diabetes and CHD management, flu vaccinations and over 75 checks. At Birley the district nurses are also running a carers support group for people in the neighbourhood, whilst at Sothall the integrated nursing team was undertaking smoking cessation sessions.
Amongst health visitors the historic trend is for them to take on a greater role within baby clinic and to reduce the input of GPs or practice nurses, to the point where some health visitors will do the injections. At Mosborough the health visitor is running a smoking cessation clinic, whilst at Birley and the Sloan practice they are offering baby massage. Birley have also introduced a booking system into baby clinic where patients can be fast-tracked if they want to see one only of the GP/PN/HV team at the clinic.
Within community midwifery the trend is for midwives to take the lead role at ante-natal clinics, and GPs only see patients when asked by the midwife. This has been taken furthest at Crookes where the midwives see women at home after GP referral and there is no set ante-natal clinic.
Receptionists
As was mentioned above there is a growing interest in training receptionists to undertake phlebotomy and perhaps other low grade clinical activities. Within Sheffield, Richmond pioneered this 7 years ago with two receptionists taking on not just phlebotomy but also the undertaking of patient checks, and ECGs. Woodhouse now also have a receptionist/phlebotomist and Deepcar had one but have reverted back to the practice nurses taking bloods. Quite a few other practices reported an interest in going down this road though one raised concerns about safety. At Gleadless phlebotomy is undertaken by the healthcare assistants but a clerical officer does new patient registration interviews including BP and urine checks on an opportunistic basis. At Woodseats the receptionists are not being trained to take bloods but are undertaking other traditional nursing activities such as stocking rooms with clinical supplies or doing BP checks. It seems that a healthcare assistant role is slowly emerging which people may move into from either a nursing or receptionist background. At Darnall a B grade district nurse was for a while spending one day a week working on reception.
Darnall and Carrfield also have receptionists who are bilingual and can play an informal interpreting role with ethnic minorities, though this should be seen as additional to the role of a specialist interpreter. Pitsmoor surgery in North Sheffield have introduced the idea of administrative staff acting as personal assistants to GPs. The GP has a 15 minute meeting each day with their PA and the PA spends 45-60 minutes per day making phone calls and other urgent paperwork for the GP.
One issue in all these developments is that this usually involves time being taken away from reception duties rather than the creation of extra hours. However it undoubtedly means a more skilled and flexible workforce. Some practices commented that receptionist phlebotomists were preferable to hiring in an outside phlebotomist because it gave scope for the opportunistic taking of bloods. The training in phlebotomy for receptionists was a mixture of in-house and external courses, and several practices commented on the lack of structured training to achieve the necessary expertise.
Telephones
Compared to the USA for instance British general practice has been very slow to embrace the use of the telephone for clinicians talking to patients. The advent of GP out-of-hours co-operatives gave a significant boost to a culture of dealing with problems on the phone rather than in person and NHS Direct has further popularised the idea with patients.
Chapter 4 outlined the still relatively small number of formal experiments in using the telephone for advice and triage. However it is clear that in informal ways GPs in particular are making much more use of the phone. It is now quite common for GPs to ring back patients who have requested a home visit in order to screen whether the visit is really necessary, whilst in some of the larger practices there is a duty doctor system which means that for some of the time at least requests for home visits can be put straight through to a doctor. At Richmond they have gone further and made it a general rule that such requests are put straight through to a doctor and patients know it will happen. They report that consequently patients have largely become self-limiting in their 'unnecessary' home visit requests and 90% of requests are now appropriate. In some practices the need for follow up visits or surgery consultations has been reduced by using the phone for follow-up.
Most practices tell patients that if they want to speak to a doctor they should ring at a certain time, usually after morning surgery. Some advertise this in their practice leaflet, a few specify a precise time period. Some practices reported little take-up of this option, others reported a lot - and it may depend on how much publicity the facility is given. Rustlings Road have begun to formalise this into a slot where a GP takes the calls or rings back patients who have left an earlier message. The University health service provides a 30 minute nurse advice line in the afternoon which is well used and they may extend it to the morning. In contrast Woodseats have long had an hour slot for patients to get advice from a nurse but this is little used - whilst their more recent GP advice surgery is proving popular. Valley, who have a very sophisticated telephone system, are thinking about setting up a pre-recorded telephone advice mailbox - whilst Birley and Richmond are discussing ideas with NHS Direct which would enable patients who ring the practice for advice to be put through to NHS Direct.
The issue of whether to allow patients to order repeat prescriptions over the telephone is a controversial one. Some practices are firmly set against the idea, whilst others allow it and report no significant problems. A few practices have separate lines for prescriptions such as all day at Valley, the University and the Sloan practice, mornings only at Gleadless, late morning at Crookes, middle of the day at Woodseats and Nethergreen, and parts of both morning and afternoon at Stonecroft. Woodhouse used to offer a 1.5 hours/day dedicated line but recently stopped this because patients who couldn't easily get through became abusive. Their new arrangement is that patients can leave scripts in boxes at the local pharmacies who will then take the scripts to the surgery, and later the practice returns them to the pharmacy. Three practices, Birley, Deepcar and Porter Brook have a staffed script phone line for part of the day and answer machine that takes messages for the rest, whilst the Sloan practice will, at busy times, turn over to such an answer machine. They all report that this works very smoothly with very few inadequate messages left.
Prescription lines are part of the wider issue of a practice's availability to patients, particularly for booking appointments. It is one of the commonest complaints by patients that they take forever to get through on the phone. Research has suggested that practices should have one patient access incoming line for every 2500 patients. Only 60% of the practices surveyed met this standard. A number of the practices, such as Valley, Porter Brook and the University, have invested in sophisticated telephone systems that allow multiple callers to queue which is probably preferable to an engaged tone, for most patients.
However telephone access is more than just the physical lines. Often more crucial is the number of receptionists available to answer the phone, and whether they are dedicated to that task or are also attending to patients at the desk. New telephone lines or systems cost less than extra reception hours. Some practices have multiple lines on the same number and take all requests on that line, others have different numbers for appointments, enquiries, prescriptions, test results etc. There are pros and cons to both approaches - all purpose lines are more flexible for patients to get through on, dedicated lines can allow a more efficient allocation of staff time and quicker response to the patient once they have got through.
As the talk grows of telephone triage and telephone consultations one thing is for sure - in many practices the pressure on their telephone system is going to grow and they should consider carefully whether they have sufficient physical and human capacity to deal with that. Advanced access experiments will also add to the pressure. If patients are told that they must ring back on the day that they want to be seen, they may be particularly irate if they then take a long time to get through, only to find that others have already taken all the same day appointment slots.
E-mail and websites
Many practices have recently acquired a website. This is particularly so in the South East PCT which has systematically put its practices on the web in a common format. This PCT-led approach makes sense since many practices will not have anybody with the skills to design a website or keep it up to date. Almost all of these sites contain basic information from the practice leaflet with no facility for patient interaction and no plans to introduce it. It has the feel of a new toy which nobody is quite sure what to do with. There is as yet no popular culture of patients using e-mail and the Internet to 'order healthcare' but it will surely slowly develop.
The University of Sheffield health service has had a website for several years as part of the university website www.shef.ac.uk/health. It has extensive information on patient self-care as well as links to other self-help sites. It also has inter-active facilities for patients to change address, order a repeat script, or fill in a travel questionnaire for vaccinations. It now receives a steady trickle of correspondence and one screen in reception is left permanently on-line for e-mail. Its patient base is of course unique - 15,000 computer literate students all of whom have easy access to e-mail, But what is commonplace for students now may be what other parts of the population are doing in 5 years time, particularly in the more affluent areas.
Woodseats also has had a website for three years – www.woodseatsmedicalcentre.co.uk and is a Beacon site for its use of IT. It similarly has extensive information on self-care and the facilities for patients to send e-mail scripts, messages, comments and complaints as well as ask the practice nurses for advice. So far the main use is for scripts with a steady build up to 10/20 a week though it seems to have reached a plateau for now. One GP is considering the possibility of e-mail consultations. The practice reckons that about 10% of their 8,500 list have made use of the site for information.
Rustlings Road's website has a facility for patients to e-mail the practice, and the practice leaflet advertises individual e-mail addresses for each GP. So far the use is small - requests for repeat scripts and advice required from the GP.
Practices are not islands, they exist in communities. An interesting example of this is the Whitehouse Surgery on the Manor where getting their information on a neighbourhood information website was seen as important as having their own website
Its now largely standard in the practices surveyed to find counsellors and physiotherapists working there. Its an extra therapeutic option available to the practice team, though it also becomes an extra source of complaint about the length of wait to see these professionals. Interestingly the South West PCT has chosen to provide counsellors in a few practices and have the other practices refer patients to the nearest counsellor. Their practices can also refer some patients to others' physiotherapy clinics that may have more specialist equipment or perhaps provide a more convenient time for a particular patient.
Pharmacy advisors now visit most of the practices regularly and there is the beginnings of interest in using them directly in medication reviews of patients on multiple medication. Only Darnall amongst the practices surveyed has tried this for any length of time. A number of practices offer chiropody - sometimes as an NHS service they introduced in fund-holding days and have chosen to maintain, others as a private option. A number of practices provide a facility for the Sheffield Occupational Health Project to interview patients in the waiting room about their occupational history and its impact on their health. Beyond that the provision of other professions is sporadic and largely experimental.
There is some experimentation in the provision of secondary care within general practice. A few of the practices surveyed provided a base for the city wide scheme to provide orthopaedic screening by extended scope physiotherapists. The Valley in Stocksbridge has some outpatient services with visiting consultants in child psychiatry, cardiology, general medicine and audiometry. Some of these services are available to the two other practices in the area..
A few practices provide services that go beyond the medical.
In summary - lots of local initiatives, all services that may, on the margin, reduce the number of consultations a GP has to undertake, but equally all serving to reinforce a change of role, towards a GP who refers on, not just to hospitals but to members of an expanding primary healthcare team.
8. Appointment systems - other issues
It seems clear from both national and local surveys that the big issue for patients is the speed of access, both when they need to see somebody quickly and when they want to see the GP they know for a non-urgent appointment. But there are other lesser issues related to access.
Opening and surgery hours
Almost none of the practices in the survey provide, or even reported thinking about providing, a significant surgery service outside of the traditional hours of 8.30 till 6. The only exceptions are a Thursday morning 8am surgery start at Rustlings Road, one GP at the Sloan practice who provides a few 8.15 appointments, whilst at Sharrow Vale the doors remain open for extras till 6.15pm. Many commented however that often GPs and staff would be there working till nearer 7pm. It is clear that whilst practices were often keen to experiment to better meet patient demand, they did not see providing say an evening service for working people as a priority demand.
At most a few suburban practices took a relatively relaxed attitude to working people taking advantage of the Saturday opening. In general though the Saturday morning service was seen as for emergencies only, or for those who lived in Sheffield but worked in other cities. A few practices had left Saturday opening completely to the out-of-hours service whilst at Darnall the GPs provided Saturday morning telephone cover and only saw patients in surgery if necessary. The Saturday service was provided entirely by doctors except at the University where they also run a one hour nurse clinic.
In contrast a sizeable minority of practices run surgeries that are late morning, lunchtime or early afternoon and they all reported that they saw this as providing a more flexible service for patients. In some cases this was clearly responding to the lifestyles of a particular patient group - students, the homeless, some ethnic minorities, mothers - but in others it was provision for the general population.
Home visiting
Day time home visiting is clearly on the decline, as documented in Sheffield over a number of years by the Practice Data Comparison Project. This decline is seen both in patient demand for acute visits and in practice initiated visiting. Much more use is now made by GPs of telephone advice or triage of acute visit requests, whilst few practices now do much in the way of routine visiting of the very elderly though Baslow Road, Bents Green, Upperthorpe and Woodseats reported that they make weekly routine visits or 'ward rounds' to large residential homes. One practice commented that this policy was controversial because it meant GPs were providing a free service to profit making organisations. Many practices reported some role for either practice or district nurses in the visiting of housebound patients to take bloods, give vaccinations, do over 75 checks, or chronic disease management. Not a single practice reported the demand for home visits as a significant issue, either for them or their patients.
The surgery building
Sheffield GPs and the health authority have invested heavily in the provision of new or expanded surgery facilities and few practices reported that their building was a significant constraining factor in meeting patient demand. For the few that needed larger premises the crucial issues were the seating capacity of the waiting room and the number of consulting rooms, particularly the consulting space on the ground floor of the premises. The approach in the South West PCT of providing counsellors in a few practices who have space, and having others refer in, shows how some space constraints can be resolved by collaborative working. Some practices have split sites and they commented that this made it harder for them to cover holidays because reception staff particularly were used to working on one site only.
Appointment length
Years ago it was the norm for GP appointments to be 5 minutes in length. Now many practices provide 7.5 or 10 minute appointment slots and this has been strongly encouraged by the RCGP. In this sample roughly a quarter of GPs had 5/6 minute appointment slots, another quarter 7.5 minutes and just under half 10 minutes. Research evidence has suggested that longer appointments leave patients feeling more satisfied and provide more scope to undertake health promotion work - though there is no evidence on their effect on clinical outcomes. It should also be emphasised that a GP’s consultation style is a very personal matter and usually set early in their career. There may also of course be a trade-off between consultation quality and quality of access. Certainly the practices in this survey with 5/6 minute appointment slots were all providing relatively rapid access for routine appointments.
The theoretical length of the appointment slot is one thing, the actual appointment length is a number. Quite a few practices reported that GPs over-running was a source of complaint from patients. Few however had responded by lengthening the appointment slot, or by introducing a mid-surgery break to allow catch up time. The exceptions on the latter were the University whilst at Baslow Road and Darnall the morning is structured into two surgeries - early and late morning - with a 30 minute break/catch up time in between. Some other practices reported that their GPs had occasional empty slots to allow them to catch up.
Doctor availability
GPs take holidays, study leave or sick leave. Practices respond by a mixture of partner cover, locums and the dropping of some surgeries. Often locums were seen as a poor option, unable to realistically cover much of the work, and there was a feeling that practices were using them less than once might have been the case. The retainer scheme provides an option for some to supplement their GP supply whilst several practices have appointed associates - Devonshire Green, Duke and Richmond - the latter with an understanding that the associate does extra sessions when the partners are off. The University employs a regular locum, whilst at Darnall they have an annual contract with a locum for a day a week, on the understanding that their work is actually concentrated in weeks when a partner is away. Nethergreen and Woodseats make use of retired GPs as their regular locum of first call.
Becoming a training practice for GP registrars provides another route for supplementing the doctor supply, though with a consequent partial reduction in GP appointments due to the time needed to supervise and support the registrars. It also adds to the tendency for GPs to see a restricted but more complex set of patients.
Did not attends (DNAs)
Many practices have tried to reduce their number of defaulted appointments by putting up posters in the waiting room or sending letters to frequent offenders. In general the feeling was that posters didn’t work and that letters had a limited effect. Most practices either felt that their level of defaults wasn’t a big issue, or else it was something they just had to live with, recognising also the positive relief that a DNA provided for an over-running GP. The general view was that the problem was greater for the practices in the more deprived areas of the city, and greater also for nurse appointments than for GPs - both confirmed in other research that CIPC has undertaken.
Several practices had different standard letters they sent depending on the number of times a patient had defaulted and usually triggered by two or three consecutive defaults. Richmond’s approach, which they feel works, was to make the DNA x 2 letter a very nice one encouraging the patient to come in and be seen for the sake of their own health. The DNA x 3 letter is firmer pointing out the inconvenience caused whilst the DNA x 4 letter asks the patient to come in and discuss their DNA problem with the GP. Patients with mental illness/depression only get sent the first nice letter.
Darnall’s high DNA rate is particularly concentrated in their Bangladeshi population. The practice has tried focusing on educating these patients about the way their appointment system works but they feel with little success. Their conclusion is that they have to enter into more of a dialogue with patients about how they want the system designed.
The proponents of redesigning appointments systems to provide quicker access argue that one effect is to reduce the number of DNAs and there is certainly research evidence to show that the DNA rate increases with length of appointment delay. The experience of Lowedges, Stonecroft and Woodseats is that their new Advanced Access appointment systems have dramatically reduced the number of DNAs with a GP.
Monitoring the demand and fine-tuning the supply
Five years ago practices who had computer appointment systems were a small minority. Now it has become the majority and everybody reported positively on their value for effectively managing appointments. Few however reported using the system as a source of data to monitor the demand and therefore better plan the supply. Tramways has been the pioneer of this and feel that it has been central to fine tuning their appointment supply to provide a responsive and reasonably fast service. They can also show that, in their case, the annual demand/supply of GP consultations has been steadily rising through the 1990s. Walkley have similarly used their computer appointment system but such data can also be collected with a manual system, as have Bents Green who can show that their GP consultation rate has been static!
The propagation of the ideas from the National Primary Care Collaborative has started to make a few other practices try to fine-tune their demand-supply equation. This has involved looking at computer appointment data but also collecting survey data on the daily pattern of demand for first appointments and recalls.
The pattern that has emerged is not surprising - a large bulge of demand on Monday - anything from 25-35% of the weekly demand, with sometimes a secondary bulge on Friday. Responses to this have involved providing more cover on a Monday, or a policy decision not to allow any recall appointments on a Monday (or Friday). Tramways and Valley seek to limit unnecessary GP recalls by embargoing all appointments till 15 days beforehand. A number of practices have also recognised the scale of the demand on the Tuesdays after a bank holiday Monday and responded by providing extra cover or by keeping back many more appointments for same-day only.
Informing
Can the handing out of information to patients, about self-care and how best to use the service, reduce the demand or at least make it more appropriate?
It is normal for practices to provide information to their patients about their services and self-care - via leaflets, posters and practice leaflets. A number go further to produce occasional newsletters for patients e.g. Birley, Deepcar, Devonshire Green, Dovercourt, Mosborough, Nethergreen, Rustlings Road, Sloan, University, Whitehouse and Woodseats. The use of other media to communicate is rare but the University has a Jayex display in its waiting room for passing on information, whilst at Dovercourt they show health promotion videos. Others have tried the showing of such videos in the waiting room and found that it got a negative reaction from patients. The big difference at Dovercourt is that the people on video putting across the health promotion messages are their own patients who produced the videos working with students from Norton College.
Providing information about systems via posters was seen as useful provided they were carefully placed and not too numerous. Nethergreen had put up a poster explaining exactly how long each kind of lab test took to come back and they felt this had led to patients waiting the right amount of time before ringing up for the result.
All practices display leaflets about self-care in their waiting rooms, or hand them out in consultations. At Porter Brook they have leaflets on sensitive issues such as sex and drugs displayed in the toilets. All those practices with the EMIS computer system have access to an on-line database of patient leaflets which can be printed out in the consultation. An alternative, if the practice has a scanner, is to create your own database by scanning in a wide range of leaflets. Crookes have done this and would be happy to make their database available to other practices.
Some practices, such as Richmond, Porter Brook and the University, provide all new patients with a pack of information leaflets. At the University, and Darnall, they hand out a glossy nationally produced booklet - What should I do? Do I go to the doctor? A few practices have produced some leaflets of their own such as Devonshire Green, Hackenthorpe, Richmond, Rustlings Road and Woodhouse, whilst Dovercourt have produced their own booklet for teenagers.
Yet despite all these attempts, many practices expressed some scepticism at whether it made much difference to patient behaviour.
Listening
The perception that patients don’t respond to the messages on self-care and how best to use the NHS may be because the approach is rooted in making patients adapt to the service. This is the conclusion Darnall have reached after putting quite a lot of effort into trying to ‘educate’ patients. They now conclude that the effort has to go into listening to patients about their experience of health, ill-health and health-care, and adapting the service accordingly.
Practices get patient feedback in informal ways and via complaints but it is a minority that have asked patients what they think in any formal way via say a questionnaire. Sometimes such surveys were undertaken 5 or 10 years ago and were focused on what patients thought about an actual or potential major change to the appointment system. The oft expressed reason for not undertaking surveys was the lack of time and resources, but some have found ways round this, for instance by using medical students or registrars to undertake small scale surveys. Others have opportunistically taken advantage of the services of outside organisations to run patient surveys e.g. Sheffield University’s exit survey of its students includes questions about its health service; Darnall, as part of its first wave PMS national evaluation, has had a before and after survey done by Manchester University; whilst Birley have employed the CIPC to run a survey.
Others have done it themselves but made the process very focused e.g. Duke's practice manager interviewed 58 patients in the waiting room over a 2 week period about their experiences of the appointment system, whilst at Carrfield the survey was of patients who came to the Saturday emergency service to see whether it was really necessary. Nethergreen's approach has been to have a rolling programme of short surveys, which patients can pick up at the counter and fill in, that focus on topics where the practice is thinking of making a change and they want to test out patient views of the options. But large scale patient surveys are still feasible for a practice to do within its own resources if it is given a high enough priority, as has been the case in recent times at Dovercourt.
Surveys are not the only method available, running a patient focus group is another. This has been tried and found very useful at Birley, Darnall and Mosborough. Whilst its usually best to start with the support of a skilled external facilitator, the practice manager or another member of staff can learn how to run such groups. Another approach pioneered by Dovercourt, and now being tried by Carrfield, is the development of a Patients Representative Group. Dovercourt now has six people, representative of the age/gender mix of the practice list, who seek out patient feedback and help out with health promotion activities such as the videos mentioned above. They also meet every two months with the practice team to discuss broader issues about the development of the practice. Because of its work Dovercourt has been made a Beacon Site for patient representation.
A related approach is that of Woodseats who have set up a Patients Forum or Participation Group open to anybody and with its own newsletter. They currently have about 20 members, with 7-15 coming to the meetings. It provides the practice with feedback on services, though they aren't sure how representative it is. It has been running for a year but the practice is not sure whether it as yet become viable in the long term.
10. Conclusions
The qualitative and quantitative data within the report can be used by each practice to assess their own situation. Practices are generally aware of where they are struggling but the comparison helps to put this in perspective. Every practice is experimenting with some aspect of the way they respond to patient demand and learning lessons about what does and doesn’t work. Those lessons cannot be mechanically transferred elsewhere, because every practice has its own patient population and its own culture and history, but learning can be re-applied in new contexts.
There is a great potential for the practices in these three Sheffield PCTs to learn from the innovations and experiments of their neighbours. At many points in this report we have mentioned that particular practices are adopting a particular approach. Others may want to talk to them or visit them to see how it works. Appendix 1 gives contact details for each practice.
Innovation is happening everywhere of course. The appendix also gives contact details for practices in North Sheffield PCT who have been working with the National Primary Care Collaborative on improving access. There are also details for the Ridge Medical Practice in Bradford which is an NHS Beacon Site for its casualty style rapid access clinic and more recent use of telephone consultations.
It would be presumptive of us to come up with a checklist of what practices should do to improve access. Nobody has devised the perfect appointment system and even if they had for their own practice, aspects of it would not work in other places. Also many of the currently promising new ideas have yet to be proven over the long term. However we do want to make some general comments.
The above comments are all about how to improve the service - how to ‘work smarter'. But not everything can be extracted from a pint pot.
Appendix 1 - Practices surveyed
South East PCT
Birley Health Centre - Dr Noble & Partners, 120 Birley Lane, S12 3BP
Tel 2392541 - Manager Joanne Briggs
Carrfield Medical Centre - Dr Sivarajan, Carrfield Street, S8 9SG
Tel 2584724 - Manager Sue Willoughby
Darnall Community Health - Dr Czauderna & Partners, 246 Darnall Road, S9 5AN
Tel 2212600 - Manager Jo Sazada
Dovercourt Surgery - Dr Read & Partners, 309 City Road, S3 5HJ
Tel 2700997 - Manager Paul Wike
Duke Medical Centre - Dr Bryson & Partners, 28 Talbot Street, S2 2TD
Tel 2720689 - Manager Pat Barker
Gleadless Medical Centre - Dr Davis & Partners, 636 Gleadless Road, S14 1PQ
Tel 2396475 - Manager Denise Wilson
Hackenthorpe Health Centre - Dr Da Silva & Partners, Main Street, S12 4LA
Tel 2487900 - Manager Richard Wingfield
Mosborough Health Centre - Dr Gelipter & Partners, 34 Queen Street, S20 5BQ
Tel 2487488 - Manager Allison Ward
Richmond Medical Centre - Dr Walton & Partners, 462 Richmond Road, S13 8NA
Tel 2399291 - Manager Denise Brooks
Sothall Medical Centre - Dr Roscoe & Partners, 24 Eckington Road, S20 1HQ
Tel 2480480 - Manager Jackie Ashton
Whitehouse Surgery - Dr Watton & Partners, 189 Prince of Wales Road, S2 1FA
Tel 2397229 - Manager Ken Staniland
Woodhouse Medical Centre - Dr Mitchell & Partners, 7 Skelton Lane, S13 7LY
Tel 2690025 - Manager Kate Chilton
South West PCT
Baslow Road Surgery - Dr Collins & Partners, 148 Baslow Road, S17 4DR
Tel 2369957 - Manager Susan Emberey
Bents Green Surgery - Dr Ansons & Partner, 98 Bents Road, S11 9RL
Tel 2360641 - Manager Kathryn Parkin
Lowedges Surgery - Dr Metcalf & Partners, 127a Lowedges Road, S8 7LE
Tel 2839839 - Manager Pat Ledbury
Nethergreen Surgery - Dr Yates & Partners, 34-36 Nethergreen Road, S11 7EJ
Tel 2302952 - Manager Gerry O'Donnell
Rustlings Road Medical Centre - Dr Sharpe & Partners, 105 Rustlings Road, S11 7AB
Tel 2660726 - Manager Michelle Webster
Sharrow Vale Medical Centre - Dr Saxena & Partners, 129 Sharrow Lane, S11 8AN
Tel 2556600 - Manager Alice Pigott
Sloan Practice - Dr Sloan & Partners, 251 Chesterfield Road, S8 0RT
Tel 2551164 - Manager Lesley Carnall
Stonecroft Medical Centre - Dr Ashton & Partners, 871 Gleadless Road, S12 3LJ
Tel 2398575 - Manager Carol Sayers
Woodseats Medical Centre - Dr Thompson & Partners, 4 Cobnar Road, S8 8QB
Tel 2740202 - Manager Sheila Gilbert
West PCT
Crookes Practice - Dr Mascott & Partners, 203 School Road, S10 1GN
Tel 2660677 - Manager Martin Heeley
Deepcar Medical Centre - Dr Davis & Partners, 241-245 Manchester Road, Deepcar, S36 2QZ
Tel 2882146 - Manager Sue Lambert
Devonshire Green Medical Centre - Dr Harvey & Partners, 126 Devonshire Street, S3 7SF
Tel 2721626 - Manager Anthony Fisher
Porter Brook Medical Centre - Dr Jones & Partners, 9 Sunderland Street, S11 8HN
Tel 2636100 - Manager Susie Uprichard
Tramways Medical Centre - Dr Poyser & Partners, 54A Holme Lane, S6 4JQ
Tel 2339462 - Manager Janet Bark
University Health Service - Dr Osborne & Partners, 2 Claremont Place, S10 2TB
Tel 2222100 - Manager Chris Franklin
Upperthorpe Medical Centre - Dr Russell & Partners, 30 Addy Street, S6 3FT
Tel 2766859 - Manager Gill Hides
Valley Medical Centre - Dr Norton & Partners, Johnson Street, Stocksbridge, S36 1BX
Tel 2883841 - Manager Paul Hancock
Walkley House Medical Centre - Dr Ledingham & Partners, 23 Greenhow Street, S6 3TN
Tel 2343716 - Manager Andrew Sparks
Practices referred to in North PCT
Bluebell Medical Centre - Dr Mathers & Partners, 356 Bluebell Road, S5 6BS
Tel 2421406 - Manager Nigel Ross
Norwood Medical Centre - Dr Hardy & Partners, 360 Herries Road, S5 7HD
Tel 2426208 - Manager Janet Haigh
Pitsmoor Surgery - Dr Edney & Partners, 151 Burngreave Road, S3 9DL
Tel 2722094 - Manager David Emms
Wadsley Bridge Medical Centre - Dr Panniker & Partners, 103 Halifax Road, S6 1LA
Tel 2345025 - Manager Anita Warner
Other practice mentioned
Ridge Medical Practice - 3 Paternoster Lane, Great Horton, Bradford, BD7 3EE
Tel 01274 502905 - Manager Helen Woodhead
Appendix 2
Comparative analysis of appointment and consultation data for GPs and practice nurses in 3 Sheffield PCTs.
Introduction
Data was collected from the computer or manual appointment book of each practice for a week, usually in the middle of May 2001. Weeks containing a bank holiday were avoided and in all cases a week was chosen where the provision of appointments was at a normal level.
Data is presented as a series of bar charts. The 30 practices are identified by number only to preserve some degree of anonymity, though we recognise that in presenting so much information about a relatively small sample, it is hard to maintain complete anonymity. Each practice will be told their own number only. Practices are of course free to share their code with whoever they wish. They may also wish to discuss agreeing to share codes with all the other practices in their PCT or beyond.
The analysis that follows would ideally be based on a whole year's data. Data for only one week is inevitably of lesser reliability and should be treated with some caution, though we know from our previous work in Sheffield that May is an average month as far as workload goes. We feel justified in drawing broad brush conclusions from one week about the overall pattern of supply and demand. Drawing conclusions about individual practices requires greater caution. It seems safe to say that practices who are high or low on particular charts would remain high or low over a longer time span. However practices' precise position on each chart will surely vary from week to week, particularly for those practices with broadly average positions.
In the commentaries that accompany the charts we have drawn broad conclusions. We have also tried to explain any extreme results and take account of any special factors, but it is unlikely that we will be aware of everything. Practices must view their own data critically in that light. In calculating rates per thousand patients we used PCT data on the official practice list size as of April 1st as a measure of what the list size was in mid-May. Three practices - Dovercourt, Duke and Walkley - reported that in April and May they recruited a sizeable number of patients from neighbouring GPs that had just retired and an addition was made for this to their list size.
Practices are identified by PCT according to the following:
South West
South East
West
Commentary
Commentary
Commentary
Commentary
Commentary
Commentary
Commentary
Commentary
Commentary
Commentary
Commentary