Case study summary
Measham Medical Unit in Derbyshire has a patient population of over 13,000 and 9 GPs of which 6.5 are whole time equivalents. When the practice started to see an increase in the number of minor illnesses presented at its urgent care clinic it needed to find ways to prevent the problem from escalating. One GP took the lead in rolling out active signposting as part of the work the practice was doing on the Learning in Action element of the Time for Care programme. Time for Care is delivered by NHS England’s Sustainable Improvement team and part of the support available through the General Practice Forward View.
Roll out active signposting in the practice and reduce the number of minor illnesses presented at the urgent care clinic.
A service that is being misused
Over the last two years the practice has run an urgent care clinic for acute health issues, which has increasingly seen a rise in the number of minor illness appointments such as sore throats, coughs, diarrhoea and vomiting. Whilst there are pre-bookable appointments and duty doctors available, patients were still turning to the clinic as a first point of call. During the winter the problem peaked with 892 minor illness appointments booked into the clinic in December.
Using data to find the problem
Over two weeks data was collected from the clinic to analyse whether the appointment was appropriate or inappropriate, if the patient was seen by a doctor or nurse, and whether the patient could have been signposted elsewhere or self-cared.
- 28% of appointments received were inappropriate.
- 52% of these inappropriate appointments (14% of all appointments) could have easily self-cared or sought advice from another healthcare professional.
- 10% of appointments were requests for medication not available from usual pharmacy.
Alongside the data collection the practice conducted a survey with four practices in North West Leicestershire who were participating in the programme, to ask reception staff if they felt confident in signposting, whether they felt they had the permission to do so and if they required any training. 96% of staff said they were confident in offering patients more than a GP or nurse appointment, and through the work being done on the programme felt confident they had permission to signpost.
Rolling out active signposting
Having a better understanding of what the issues were, the lead GP set about making a number of changes that would enable active signposting to be implemented effectively across the practice.
- Firstly the active signposting team at the surgery met with the local pharmacist to scope out what should/should not be referred to the pharmacy. Starting small they agreed to focus on three conditions; coughs less than two weeks, sore throats less than seven days, diarrhoea less than three days, thrush in adults and morning after pill requests.
- Receptionists would ask patients for “medication unavailable at their pharmacy” requests, if they had tried another chemist, with contact details for all local pharmacists to be given.
- The GP and pharmacist worked together to redesign the form used to book urgent care clinic appointments. This would include information about advising patients how long they could expect to wait for an appointment, and listed those conditions for which they could go elsewhere to seek help which would be quicker. The form was shared with signposting teams and GPs in the other four practices for their feedback, this was highly beneficial in that it enabled additional ideas and experiences of what was working well elsewhere to be captured and incorporated into the form.
- The First Contact Plus team from the local authority visited the practice to train receptionists on its service, which is an online tool that provides a wide range of local information and resources including health.
- The GP met with the Patient Participation Group to explain the changes being made and why. When the group saw the data and number of minor illness appointments being presented at the clinic they supported the changes.
- Six weeks before active signposting was rolled out the answer phone message was changed, advising patients they would be asked more questions so they were directed to the right person. All five practices would use the same phone message for consistency.
Using the Plan, Do, Study, Act cycle, the team implemented active signposting. Every week they tested the changes being made and altered/made tweaks where necessary. Over the following months the practice added more conditions to the list that could be signposted elsewhere following feedback received from reception e.g. cold sores and mouth ulcers.
- As of September 2018 the practice has reduced inappropriate appointments from its urgent care clinic by 22%, equating to over 160 inappropriate appointments.
- Patients who need urgent appointments are now able to access them easier.
- Team working has improved, the practice has regular and open discussions about problems which has been a positive change.
- Every two weeks the active signposting team meets to discuss challenges and thoughts about expanding the coverage. As a result it is now expanding signposting to cover more clinical areas and across more appointment types.
- Get all staff involved in making change, not only in your own practice but other local practices too. Change is more effective if you work together.
- There is real power in data, use it to help you identify issues and find solutions.
- Practice leadership and a shared purpose is important, consistency of those leading the changes to be visible throughout the process is essential.
Kirk Moore, GP, Measham Medical Unit