In the shadow of the Covid pandemic, Tower Family Healthcare team were exhausted, on the edge of burn out and beginning to realise that something needed to change – the demand for appointments was unsustainable.
An analysis of appointments revealed that a high number of patients were being seen by clinicians unnecessarily, when self-care or community services such as a local community pharmacy, could have provided a more appropriate, quicker route to recovery.
Tower needed a new way to manage patient demand. They needed a solution that resulted in patients being seen based on clinical need, rather than the traditional first come approach of appointment booking that meant all appointments were fully booked within 7 minutes of opening.
Facts
- Tower Family Healthcare cares for 50,000 patients, around a quarter, 25%, of Bury’s total patient population.
- Tower is part of the Horizon Primary Care Network (PCN), that collectively cares for 89,500 patients in Bury.
- Life expectancy for both men and women is lower than the England average
- Bury has more acute income and employment deprivation at borough level
- Some areas of Bury, such as Bury Town Centre and Radcliffe, are in the 10% most deprived in the country
Tower Family Healthcare (Tower) is a GP Practice located in the borough of Bury, Greater Manchester.
The Practice provides services across four sites located within the north, west and town centre.
Strategy
In response, Tower stood up a new communications Hub, which managed appointments across all four of its sites. Supported by their online consultation platform askmyGP (open 8am to 11am Monday to Friday), the solution was to begin using medical professionals to sort and assign each patient request.
Using Winter Access Funding to enable much of the work, Tower focussed on what they needed to do to create ease of access for their patients. And whilst such funding was helpful, the team recognised that they had reached a point where something had to change regardless.
Patients were asked to request appointments online, with reception teams completing the form on behalf of those who rang up, were not digitally enabled or preferred not to use online access. This approach protected patient channel choice whilst encouraging the uptake of digital solutions among the wider patient population.
The approach included a deflection ‘box’ where all self-help or referral conditions, such as MSK conditions were placed, to be dealt with by a dedicated assigner team who were able to direct patients to alternative care pathways.
Understanding patient demand became an integral part of the project, with a Rota Manager being appointed to ensure the right number of shifts were in place to match need. Typically, this included 4 to 5 GPs (6 on a Monday), an Advanced Nurse Practitioner and 3 Assigners – all working together to respond to the workflows generated online or via reception teams.
The base teams were allocated across bases and per clinician there were 30 appointments per day: 10 for use on the day, 9 ‘within a week’ (typically 2 to 3 day lead time per patient), 6 non-urgent ‘within 4 weeks’ and 5 to be used at the discretion of the clinician. The Hub team stepped in once the base teams were at full capacity and also acted as the on-call team for the Practice as a whole.
On top of this, the Hub Manager oversees clinician task workflows – assigning these equally at the end of the day for attention the next Practice day. They also oversaw the distribution of prescriptions by skill level, bloods to the requesting clinician and tasks to the GPs based at each site.
Indeed, the role of the Hub Manager in helping to structure the working day has been recognised by Tower as one of the success stories of this trial, removing the anxiety of workload management from individuals who can otherwise focus on patient care.
Leadership
The leadership team developed their ideas after networking with a similar multi-branch Practice based in Cheshire, who’d developed a similar model and had shared the benefits of their approach with them. Tower colleagues were kindly invited to visit and see their model in operation.
Learning from this, the Tower team were careful to ensure that the partnership was involved in the build, tracking cost, operational learning and clinical impact as they went.
A project team was set up, using the Asana project management tool to help track the progress, and aid the complex project to a successful conclusion and within budget, sourced from a successful bid from a local winter pressures fund.
The project included repurposing a large meeting room at one of the Practice sites, into the Hub. This included 10 workstations and phone lines, as well as a restructure of staffing to manage the Hub and the new, somewhat complex rostering system.
The challenges
One of the biggest challenges of creating a Communications Hub was finding a suitable space to house the centralised team. In the end, and as referenced earlier, Tower took over their large meeting room (The Boardroom) feeling that the need to care for patients outweighed the requirement for operational collaborative space – a decision ratified by the central geographic locality of the room, meaning that all staff had an equal commute to their new place of work.
Tower recognised that they would be bringing staff together into a single room, potentially noisy and a stark contrast to each clinician having their own space. So, they invested in noise-cancelling headsets and sound baffling boards to protect the quality of the patient conversation, whilst providing a safe and comfortable working environment for the team. An additional consideration was the ongoing threat of Covid and the need for PPE along with regular testing for Hub team members to reduce any risk of onward transmission.
As with any pilot project, this will evolve through testing and learning, some of the Advanced Nurse Practitioners identified that the Hub set up was not working for them, something which the data confirmed. The ANPs reported ‘skipping’ too many workflows, which sat outside of their skill set and required a second look by another professional.
Recognising that productivity had turned out to be lower for this role, led to the ANPs returning to their base sites to resume their substantive roles.
Another consideration was ongoing engagement and involvement with reception teams, who are often the first point of contact a patient will have with the Practice, to ensure they were up to date on the evolving Tower model and both equipped and confident to support patients when getting in touch by phone to access services.
What made it a success?
The inclusive approach taken by the leadership team meant that everyone had a stake in the success of the project, and as such outcomes were closely monitored throughout, this meant that operational adjustments could be made quickly if required and benefits could be easily identified.
Key success factors include:
An inclusive project team
Everyone had a stake in the success of the project
A close eye on operational costs
Reduction of appointment requests
Reduction of locum costs
The project team had and continue to have a very close eye on operational costs, weighed up against the benefits which include a reduction of appointment requests and locum costs.
Outcomes
First contact resolution meant that, at that time, the number of appointments had fallen from around 4,500, to between 2,800 and 3,000 a week.
To the same timeline, Locum costs had fallen from £436,000 per annum to less than £296,00, reflecting better use of the wider healthcare team.
[Bringing us to the current day, the clinical team is expanding. The Practice is pleased to have attracted additional skilled Doctors and other health professionals to join the team, this has increased appointment availability for patients and created more resilience within the Practice].
Feedback
Tower were concerned about the impact of bringing professionals into a single space but were delighted to find that staff feedback pointed to this being a positive experience. Staff reported feeling less isolated and identified an opportunity to learn from their peers too. Working in closer proximity also created a sense of positive peer pressure, with confidence breading confidence – especially when it came to the difficult conversations such as encouraging patients to self-serve or declining antibiotics.
When Tower’s demand exceeded capacity and they took the circuit breaker decision, some of the dissatisfaction levels became political, with patients contacting their MP. Inviting those MPs to see the project in action helped to galvanise support for the project, equipping politicians with the insight they needed to explain the operational pressures and the subsequent response to their constituents.
Patients are generally positive about their experience at Tower, with feedback from the HR team suggesting that, despite a national shortage of GPs, this positive operational approach is having a positive impact on recruitment too. As Dr. Ahmad Ali, Project Lead explained “Professionals see the way we do things now and want to be a part of it – they recognise that they want to be a part of it.”
What next?
- Having learnt to respond to demand, Tower is now exploring the extent to which they can influence it by using SMS and social media to create messaging and then monitoring the data to understand the operational impact. Exciting times that enable controlled preventative care.
- SMS is also being used for a range of bookable routine appointments such as health checks and to allow patients to cancel their appointment if this is no longer required – both of these developments are reducing pressure on the phones. In addition, SMS is now used to seek patient feedback via the Friends and Family Test.
- To further tailor the experience of patients when contacting the Practice by phone, the first step towards departmental working has been to create a prescriptions and medicines option. By including specific hold messages promoting the NHS App for example, early data suggest this is encouraging patients to explore online access.
- An inhouse care navigation tool that will be known as ‘GP Nav’ is being developed to equip reception team colleagues with pre-defined outcomes within an algorithm for a range of health concerns and queries. Built by Tower clinicians, the workflows will ensure that patients have a consistent experience of the service and proactive signposting at first contact.
- Whilst the main points of contact for patients are by phone or in person at this time, Tower reception teams now have access to a range of bookable appointments appropriate to a patient’s needs.
- A new call back feature also offers patient the opportunity to reduce their wait time on the phone, by receiving a call back when they would have naturally joined the front of the queue.
- Due to a successful recruitment campaign, Locum costs are currently at zero.
