Managing increasing demand

In November 2018 England LMC leaders voted on whether to introduce a new limit of 1,500 registered patients. The motion was proposed by Shropshire as a potential solution as GPs struggle to cope with increasing patient demands. The motion states that GPs face ‘clinical risks of excessive workload’.

The motion itself was called down – as were calls to reduce core hours to 08:00 – 18:00 – but the question remains; what can GPs and practices do to effectively manage demand?

In early January NHS England published figures that lay bare the crisis affecting primary care. Every year it estimates that 15 million general practice appointments are lost as patients fail to notify the practice that they are not attending. NHS England estimates that this wastes 1.2 million GP hours every year – the equivalent of 600 full-time working GPs. In total this could equate to £216m wasted.

Missed appointments not only waste surgery time, they make it harder for genuine patients to get appointments, with Pulse reporting that the average waiting time is around two weeks.

A GPonline poll has found that three quarters of all GPs believe their practices will struggle this winter and a massive 92% think that the NHS as a whole will be unable to cope. So, just what can practices do to manage demand?

Workload control

The BMA, in its publication Workload Control in General Practice, states that there is no ‘recognised and realistic’ safe limit for GP workload; without limits, the BMA believes that there are no opportunities for practices to raise alarm bells when things are getting out of control. Such a system exists within secondary care, with trusts able to move through the NHS’s Operational Pressures Escalation Levels Framework (OPEL).

At the highest level, hospitals may issue ‘black alerts’ – announcing to commissioners, stakeholders and the public that they are experiencing operational difficulties as a result of increased demand. Designed to be used in periods of extreme pressure, in December the BBC reported how the Royal Cornwall Hospital had been on OPEL level 4 for 134 days.

The BMA proposes a safe limit of consultations per GP – ranging between 25–35 per doctor. Speaking to The Telegraph, Dr Satash Narang, from the Gwent and South Powys division, said GPs would “…go insane, quit and become insolvent” if limits were not introduced.

“For the sake of quality and safety of patient care, and the sanity of its troops, we urge the BMA to take a fresh approach by defining and agreeing what is a safe workload,” he said.

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In a debate on the issue published in the BMJ, GPs couldn’t reach a consensus. Michael Griffiths, a GP partner in South Wales, said that, “[Capping appointments] is the wrong way, because it limits our flexibility and professionalism when dealing with patients.”

He also believes it send out the wrong message. “It does not address the question of bringing additional resources into primary care to manage work that we could undertake if properly funded,” he said.

Practical steps

While the BMA continues to lobby for systemic changes, without them, practices will have to deal with the increasing numbers of patients themselves. Investing in additional capacity is unlikely to be a sustainable solution so, instead, practices should focus on reducing the number of ‘did not attends’ (DNAs).

NHS Improvement has produced a guide on how practices can reduce DNAs, encouraging practice managers to get inside the data and understand why patients may fail to notify practices.

  1. Determine your rate of DNAs

You can assess this by looking at the level of DNAs over the past two years as a percentage of total appointments. Plot the data on a chart so that you can see if there are any trends over time. Consider what level is acceptable and what level you aim to reduce them to. To place your figures in context, look at the levels in similar services from both within your own organisation and nationally.

  1. Determine the causes of DNAs

The two most commonly cited reasons are patients forgetting and clerical errors or communication failures, which mean that the patient was unaware of the appointment.

Other factors that have been shown to affect the DNA rate include:

Socio-demographic factors:

  • Age and gender.
  • Distance patients need to travel.
  • Deprivation of population.

Patient factors:

  • No longer need to attend.
  • Too unwell to attend.
  • Employment – getting time off work.
  • Previous experience of the healthcare setting.
  • Seriousness of illness.
  • Nature of illness.
  • Childcare issues.
  • Cost of travel prohibitive, difficult to organise or public transport difficult to access.

Practice factors:

  • Difficulty in cancelling appointments.
  • Incorrect recording.
  • Poor appointment notification design
  • Lack of notification or short notification.
  • Organisation of clinics.
  • The appointment booking process.
  • Time of day of appointment may be inconvenient.
  • Transport/parking.
Dr Satash Narang, from the Gwent and South Powys division, said GPs would “…go insane, quit and become insolvent” if limits were not introduced.

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