Case study summary
Aylsham and Reepham Surgeries are situated in the rural market towns of north Norfolk with four partnered GPs. The two practices serve a practice population of 9,100 patients. Using the Productive General Practice (PGP) Quick Start programme delivered by NHS England’s Sustainable Improvement team, they wanted to establish why certain patients frequently attended the surgeries and whether their care could be managed better. The programme is part of the support available through the General Practice Forward View.
Design a focused, speedy and regular review of patients that frequently attend, and consider different approaches to managing their care more appropriately.
Identifying the issues
The practices formed an improvement working team that initially consisted of a practice manager, an assistant practice manager (who had good analytical skills), and a reception manager. A list was compiled of all of the practices’ patients showing how often they attended over a year. This identified 1,453 patients who had more than 10 appointments during a 12 month period, equating to 26,917 attendances, with one patient having the most frequent attendances with 113 appointments in this period.
The team decided to focus on the 65 patients who had attended between 31 – 40 appointments over the last 12 months, equating to 2,294 appointments combined. They considered this a manageable number of patients to review, yet still substantial enough to establish common reasons for attending.
The team reviewed the patients to identify the following.
- Where the practice had initiated frequent attendance.
- Where the patient had initiated frequent attendance.
The results showed:
- 27 patients were receiving INR (International Normalised Ratio) tests/treatment
- 9 patients for mainly dressings
- 14 patients had other conditions such as mental health/Chronic Obstructive Pulmonary Disease (COPD)/pregnancy/Ear Wash Outs
- 15 had no identifiable single reason.
All the patient records were then reviewed by the GPs, of which 15 patients with no identifiable single reason for attendance were also reviewed by the nurse practitioner to further explore possible reasons.
The results of the review indicated that the majority of the causes of frequent attendance, though appropriate, were within the control of the practice to manage better.After reviewing current processes the following new ways of working were agreed.
- Review of patients to identify those that would benefit from a change of medication to negate INR checking.
- Patients with lower leg wound dressing, where no improvement had taken place within four weeks of practice based care, will be referred to the local lower leg wound clinic.
- Mental health patients will be referred more quickly to the local service where possible and signposted to self-refer if appropriate.
- Any patients who have four or more appointments within a 10 week period will be reviewed as a matter of routine, to prevent them from becoming frequent attenders and/or to establish the cause was appropriate.
- The practice has reduced the number of appointments required by nearly 700 a year for the 65 patients that they reviewed as part of this project. This will release approximately 147 hours of clinical time to focus on more appropriate consultations.
- There are a further 100+ patients the practices are reviewing which they estimate will help release further GP/nursing appointments. All have been peer reviewed in partner meetings and an action plan agreed for each patient.
- Reviews of frequent attenders are carried out every month, with the GPs undertaking peer reviews to see what additional support can be provided to patients with complex care needs who frequently attend. Patients are also monitored monthly and acted on when it is identified that patients are frequently attending to see what additional support can be provided.
- INR care is handled by the appropriate person in a timely manner and care is reviewed to identify patients who could benefit from a change of medication.
- Review a group of patients that is small enough to manage but will also allow you to identify themes and issues that will enable you to review your processes/approaches.
- Ensure you adopt a common approach to reviewing frequent attenders and that all decisions concerning changes in treatment or procedures are peer reviewed.
- A good project team and taking the time out to do this work is essential to success.
Wendy Dicks, Practice Manager, Aylsham and Reepham Surgeries