Sammi Wilson
Hello and welcome to the second series of the Transforming Primary Care podcast. My name’s Sammi Wilson, and I’m going to be your host for today. I’m head of digital primary care in the NHS England, North East and Yorkshire region. And I work and support with our four integrated care boards to deliver the digital primary care agenda.
So today, we’re going to discuss top tips for successful triage.And we know practices are at different stages in their journey to implementing modern general practice, and with implementing modern general practice, we should see a real improvement with patient experience and also the working lives of the general practice staff, and we see that through making sure that patients have a choice of access. So whether that’s digital, using really easy to use accessible practice websites and comprehensive online consultation tools and improved telephone systems or whether it’s more traditional, non-digital access points.
It means we’re gathering structured information at that point of access and then we’re using one care navigation process across all access channels to make sure that patients are assessed and prioritised based on their needs, rather than a first-come, first-serve basis and we make sure that patients get to see the right healthcare professionals in the right amount of time. So this then allows the practice to allocate existing capacity to meet that demand and it helps GPs and practice staff to optimise their time.
And through the digital tools and all of the data and intelligence that we gather, we’re able to build capability within general practice. So we can really implement sustained change. So in this episode we’re going to discuss new triage techniques and the tools that support them and the difference that makes to practices and patients. We’re also going to talk about some of the challenges around implementation.
So joining me today, I’ve got Doctor Minal Bakhai, who’s the national director of primary care and community transformation improvement, and a GP in northwest London. I’ve got Camilla Hawkes, who’s the managing partner at St Martin’s Practice in Leeds. Sarah Rhodes who’s the practice and business manager at Avicenna Medical Practice. Sarah is also the regional representative for Yorkshire and Humber at the Institute of General Practice Management.
We’ve got Lindsay Hughes, who’s director of operations at Primary Care Sheffield, and Mateen Ellahi, who’s the GP partner at Elm Tree Surgery, Stockton upon Tees.
So that is enough from me. We’re going to get right to it, and we’re going to go back to basics and open it up to the panel to say, what do we actually mean by triage? I don’t know if anyone wants to take that one first. Minal, do you want to come in?
Minal Bakhai
Thanks, Sammi and also lovely to join you on this podcast, so thank you for having me. So I think the word triage can be ambiguous, and I’ve definitely found that people interpret it in different ways. So what I think is slightly clearer, is to talk about access assessment and allocation processes. And as you’ve just described, the five key principles of modern general practice that need to be locally adapted.
It’s about having inclusive access, it’s about understanding need at the point of contact, but both the presenting complaint and acuity and as we’re starting to see practices also combining that with population health data, so population segmentation and risk stratification data, so that patients are categorised based on the complexity of their needs, which then helps to enhance the ability for practices to assess need.
To then prioritise care safely and equitably, and allocate the right capacity, their existing capacity to that need, and in particular as you’ve described, navigating people to the right service, the right healthcare professional first time, and that in particular includes continuity of care, but it could also include self-serve options. So we know that we have seen an increase or an improvement in some of the digitally supported self-serve options. Being able to order your repeat prescriptions online, being able to check your test results online, being able to register with a practice online, all of which can then start to help optimise use of capacity, but also what we’ve seen through our national work and particularly our large scale evaluations are that when practices are working in this way, about 30% of the incoming requests could actually be closed with a message -they don’t need further appointments. And this is all part of how we then better match our existing capacity to need to make general practice feel more sustainable.
Sammi Wilson
Fantastic. Thank you. Lynsey – do you want to come in on that?
Lynsey Hughes
Yeah. So I’m Lynsey Hughes, director of operations at Primary Care Sheffield. We run 9 practice sites on 7 different GP contracts, and I would urge anyone that’s thinking of going down this route and going through those processes of getting it live is to really think about how you use the tools. So I think the tools can be used in a different way in every practice to make it fit for your population needs. So for example with our online total triage tool we have decided to have clinicians looking at those requests because we were keen that as part of our model that we had as many patients as possible that were directed or signposted to the right service, which may not be in our general practice. So we’re achieving around 37% of our activity is actually not resulting in an appointment and that’s because we’re using clinicians. However, I’ve seen lots of other models where people are using care navigators or a mixture of both and then running their services in different ways. I think there’s an opportunity for you to model it in the way that you want.
Sammi Wilson
Thank you, Lynsey. That’s really interesting. Camilla, can I bring you in on that point? Is that OK?
Camilla Hawkes
Thank you. Yeah, nice to be here. So that’s the question about what do we mean by triage? I echo Minal’s point that it’s a jargon word. We try not to use it certainly with patients, but in our practice, triage is very much a clinical role carried out by clinicians making decisions about the outcome of the patient’s request. And that therefore is very distinct from care navigation which a non-clinical role, which is about offering an option to a patient based on information they’ve given you and information that the Care Navigator has drawn from the records.
And we stress that a lot when we’re training our care navigators to keep them safe, that they’re not making clinical decisions. They’re not triaging, they are care navigators. They need to go through a training programme, have access to a written policies and procedures to support the outcomes that they’re offering. But it’s different from triage.
Sammi Wilson
Thanks. Camilla Mateen, do you want to come in here?
Mateen Ellahi
Well for me what digital triage is, is using digital tools and technologies, having processes in place and then to assess prioritise, and manage patients before, possibly the patient needing a face to face consultation or in-depth consultation, As a couple of my colleagues have mentioned it can be used as a great tool to manage the demand and given the demands increasing in primary care, I think it needs to be utilised in an effective manner. Simply having, in my opinion a digital triage system is not enough. I think having processes in place and the and the culture behind the team in present adapting to it, I think it’s vital.
I think for me again, this is also involves the use of possibly an online tool alongside it as well using apps, automated systems, which we are using in our practice as well.
And ultimately you can train either clinicians or non-clinicians to do it, but there needs to be protocols in place And I think the other thing which Minal mentioned is it can be used as an automated risk assessment and that’s where I feel it’s going to be used in the biggest manner to stratify risk based on patients’ needs and a background, and then having the making sure that the right patient sees the right clinician the first time. Lastly, I think digital triage also be used. I think this is where I believe primary care will go in the future where there will be remote monitoring of certain patients or high-risk patients from home, being managed at home through a service where a clinician can see in the practice their information i.e. be it their blood results, be it their blood pressure, and to monitor them that way.
Sammi Wilson
That’s brilliant. Thank you. Really interesting discussion. I think what I’m hearing is that we need to be clear on what we mean by triage and avoid jargon – that it’s a process and protocol, but there are different elements that underpin it as well. So we’ve got the digital tools that help support that triage journey we’ve got to ingrain a culture, the right culture within the practice, the right behaviours within the practice and there’s different roles that play a really key point to it. So it was really interesting hearing from Camilla and Lynsey that it’s clinical triage that’s done. We know that sometimes we have different ways of doing this and we might have administrative functions that sit with clinical functions and they sit alongside each other to do the triage. So I think you know it’s coming through that there are just really different ways of being able to do that.
Now we’ve already touched on this, and I think it’s really hard to kind of pull apart process and tools. But I’m wondering is there anything that any of the panellists want to add to the discussion around how these tools help manage the 8 am rush. There’s been lots of talk around the 8 am rush and how can we avoid that and make sure that there isn’t that sort of patient behaviour to phone in at 8 am and how also that supports managing the workload of general practice. So Camilla, am I OK to bring you in there?
Camilla Hawkes
Thank you. Yes. So our 8 am rush is no longer a thing. It’s since we moved to modern general practice, we do not have an 8 am rush. In fact, we have whole chunks of time when the phone does not ring. It’s like we keep picking up the handset to see if it’s still working!
So although we’ve had to find a whole extra person to do our care navigation role, overall, we are managing with fewer staff and that is because – well two reasons. It is quicker to have all that information coming in. It’s quicker to read it than it is to converse about it on the phone. And also it is so much easier to signpost patients when it’s written through text messages going back and forth, because those can be difficult conversations for the frontline staff to have and they can be time consuming. So although they’re skilful, you know that’s a hard conversation to have with the patient who rings for one thing and actually you’re offering them something different. So yes, I’m pleased to say our 8am rush is smoothed away now.
Sammi Wilson
Fantastic. That’s great to hear. Sarah, what’s it like for you in your practice?
Sarah Rhodes
We don’t necessarily have the 8 am rush. However, we do have the early morning contact which is still there and that hasn’t really improved.
But like Camilla says, it’s much easier with the written contacts I do think it’s about setting those expectations of your patients so that they know what to expect and what they’re wanting and it’s managing the need and communicating things better. And I think that’s how we’ll manage to sort of maybe flatten that 8am, that early morning rush is to work with the patients to understand their needs on an even better basis.
Sammi Wilson
Yeah, that’s a great point, isn’t it. I think there’s work to be done around educating and informing the public and patients around expectation management and who they should see within the practice. We’ve got a diverse range of roles now within practice which is brilliant. And I think there’s some work that needs to be done there and it’s fab to hear that you’re doing that engagement. Mateen, what’s it like for you?
Mateen Ellahi
So I think it’s interesting. I think it’s good to give a little bit of background about our practice Elmtree Medical Centre. So in all honesty, we’ve only moved to digital triage very, very recently on the back of my conversation with Minal a couple of months back and I think it was a big decision for us. We were in all honesty, we’re doing actually really, really well anyway. Our rankings for patient satisfaction scores, Google ratings, etc, are quite high, very, very high and I think our waiting times on the phone averaged over a week of 2 and a half thousand calls or 59 seconds. So we were doing actually relatively OK anyway, but because of through our expansion growing from 5000 to now 15,000 patient list size practice, we wanted to further improve and after our discussion I came back, had a chat with our partnership and we said we have to kind of look into this.
So we had a conversation with several providers and then finally we chose one a few weeks back and then we were actually working with the provider to enhance their capabilities, but actually tailor their model towards how it works for us.
And regarding the 8 am rush, so Monday mornings, notoriously difficult. In my opinion most practices were having the 8 am rush, but we were having a two-to-three-minute waiting list during even peak hours which was pretty good. We were happy with that. But through this digital triage system we’ve seen a noticeable difference – so waiting lists from two to three minutes on peak hours on a Monday morning has gone down to less than a minute.
More importantly, we feel, not only that patients are happy – they were happy before – our staff, they found it much less stressful. So on our staff surveys that we do regularly, they found it less stressful knowing that the digital requests are being sent directly to clinicians and I think we’ve managed to utilise some of the staff in different ways as well to help the practice.
Sammi Wilson
Brilliant. That’s brilliant to hear, Thank you – Minal?
Minal Bakhai
Firstly, it’s great to hear that I’ve managed to influence Mateen, so that’s a real win.
And you know, similarly in my practice- so I’m a GP and I work in a very deprived area so particularly, our practice serves a population that experiences a lot of poverty. We’ve got significantly higher than average prevalence of severe mental illness, cardiovascular disease, diabetes. So high complexity, high multi-morbidity and real impact of the wider social determinants of health.
We’ve been working as a modern general practice now for many years, and we’ve seen a flattening in our demand curve and our average response time now on the telephone is 37 seconds, which I think is amazing, particularly for a practice working in a really deprived area because we know how demanding it is.
But I think what I would also say is this is about significantly more than the 8 am rush, and if we just go back to the why and why are we changing? Well, we know that demand has increased, particularly since the pandemic in national data. We see about a 25% increase in demand. We know that GP capacity has fallen, that there are high levels of stress and burnout in our workforce, particularly related to work-life balance to spending, and too much time on what we would deem as low value tasks and also not being able to spend enough time with our most complex patients. And what we’re seeing is this widening demand and capacity gap and that is most acutely felt in areas like mine of high deprivation where GPs in deprived areas are responsible for over 1000 patients more per GP which goes to further impact on healthcare inequalities.
But compounding that is the ill health is expected to rise by about 37% over the next 15 years and our working population is only growing by about 4%. And so, in a tax-funded public health system, that means that our public purse, the funding, is going to continue to remain constrained. And so we have to innovate and we have to make best of our collective resources and funding.
Hence modern general practice – which has been born from the innovation of general practices, in response to these immediate demand challenges and particularly practices feeling like they were drowning in the reactive demand and firefighting all the time – has three objectives, as you said, SammI.
To improve patient experience as we’ve talked about previously just earlier about better matching existing capacity to need and then improving staff job satisfaction to have a more sustainable general practice because that is absolutely foundational to our NHS. It’s the backbone of our NHS. But this is also a strategic stepping stone to help us move from that reactive model of care to a more proactive model of care, particularly as we recognise that by 2035 68% of people over the age of 65 will have multiple morbidities and that is going to continue to grow. So we have to be able to move to that proactive model that Mateen referenced earlier, where we also start to create the headspace. for us to think about how we tackle or address demand upstream and take that more preventative approach.
And of course, neighbourhood working is going to be critical to it, but I think it may be worth me just sharing a little bit about what we’ve been doing nationally to drive improvements in the digital tools.
So I think the technology can be an incredibly powerful enabler as others have described. But it needs to meet user needs and it needs to address the problems that we on the front line are actually trying to solve. And so we’ve done a huge amount of work to improve the digital journeys and the tools, both for patients and for staff, because the research shows that when you’ve got well designed tools alongside a NEC-effective process as a model, that’s when you realise the biggest benefits. And so we’ve worked hard to improve the usability and the accessibility of online tools for patients and the functionality and integration for staff. And we carried out extensive user research particularly with the digitally least confident in in our society and it’s surfaced seven key requirements to improving online journeys, so particularly with regards to online consultation systems or digital triage systems as others have referenced, it’s about them being straightforward to access. They’ve got to be straightforward to find and start, so clearly labelled. Ideally, you know we could argue log in could sometimes provide create a barrier for some individuals. They need to be straightforward to understand, so people know what’s required of them, and particularly as we move to a written and reading medium to keep the volume of information as minimal as possible and then to use written content that meets the NHS guidance standards They need to be straightforward to complete so that people can express their needs easily and clearly, they need to clearly provide the expectations so people understand what’s going to happen with their information, when and how they’re going to receive a response.
They need to be highly accessible so you know PDFs and images don’t work with accessibility software, so the whole end to end journey needs to be accessible and then they need to be highly usable. So consistent with NHS design standards.
We know that when we apply these changes what we see and we looked at 10 and a half million contacts across practices who have implemented modern general practice using highly accessible and usable tools, there’s not only improved access, there’s improved continuity of care, there’s safer prioritisation based on need. They provide a more responsive service that almost all requests responded to on the same day. Actually, the median response time was 4 hours, which I think is absolutely incredible.
And really importantly, both digital and non-digital users benefited. So actually the people that disproportionately benefit the most, are those that have traditionally had the worst experience of general practice. So we see a reduction in inequalities in healthcare access, which I think is incredibly powerful, but also from a staff perspective you start to see releasing in staff time. So admin and clinical time- people feel more in control of their day. I certainly finish at a reasonable time now when I didn’t previously.
But we also see a reduction in avoidable GP appointments, which means I have more time to focus on those that really need me. So I don’t feel so stressed trying to deal with lots of complex needs within a 10-minute consultation, but it also then provides that headspace to think more strategically about what comes next and to continually improve. And I’m just going to throw two more statistics at you because I think this is so important. What we’ve seen is a shift in the marketplace to more usable and accessible tools, which is something I think we should all be really proud of.
The use of practice websites by patients has gone up from 38% to 65%. So people are feeling more comfortable accessing services online and online consultation system uses on track to hit about 40 million plus contacts this year. But importantly what we’re seeing in the data is a channel shift from telephone to online. So we’re freeing up the telephone for those that really need it.
Sammi Wilson
Brilliant. Lots lots in there. Thank you so much, Minall. I think it’s fantastic. We’ve got kind of that user need and we’re shaping the tools we all know. You know, we’ve all spoken to colleagues, neighbours, friends who’ve said, oh, when I went on it, it was really easy and I’m going to do it again. And you think that’s a massive tick for general practice, isn’t it?
What I want to do now is talk about – I guess we’ve had loads of stats around improved response times, staff satisfaction improvements, improvements from patient experience, which is brilliant – but we know it’s not always a real smooth transition to this and I think it’s really important that with the experts we’ve got on the podcast today, we look at some of the challenges that that we’ve faced and how we might overcome them to share with kind of colleagues who are embarking on or part way through a similar journey.
So Lynsey, can I get your thoughts around some of the challenges?
Lynsey Hughes
Yeah. So I think when we started some of the challenges was trying to understand our demand – because there was a lot of unknown demand. What I would recommend to anyone going down this journey is take the time up front to understand what you’re trying to achieve and plan your model around it. I’ve no doubt you will end up changing along the way, but at least you give yourself a good grounding. I think we are in a unique position because we have seven different GP contracts mainly in deprived areas that we’ve seen different challenges in our different practices. And so now we’re a year into our journey, we’ve been looking back at some of our data and in most of our practices, around 90% of patients have chosen to submit their request through the online tool virtually instantaneously. However, in one of our practices, which is deprived and has around 60% of patients where English is not their first language, we have really struggled to get them to use the online tool and we couldn’t get beyond about 45% of our requests coming through.
Which did cause us problems because it meant we still were having the telephone traffic. So we’ve gone back round that with our patients and asked them and try to understand what the issues are. And I think there’s something about trying to give as much educational material as you can up front, on your website, through leaflets as Minal was talking about, making it as simple as possible. And so we have things translated. So we’ve got the instructions on how to use our system, but in multiple languages available as well. We haven’t got up to the 90% in that particular practice, but we have made a 15% shift in a month by trying to just go back round that and say how can we solve these issues, So it’s not been a smooth journey everywhere, but I think if you can take that time and understand what the issues are, then you can start to resolve them.
Sammi Wilson
Fantastic. That’s really interesting. And you hear time and time again, it’s around taking some time upfront to really understand your patient needs, the demand and then looking at your processes. Mateen, is that sort of a similar experience for you?
Mateen Ellahi
I think challenges is something that people don’t talk about enough and I think we should talk about it, especially for people who listen to this podcast who are wanting to adopt digital triage system. So I want to kind of come on the back of Minal and Lynsey mentioning deprived areas. So our practice is in a relatively deprived area also.
One of our challenges was the patient uptake, as Lynsey alluded to as well, it was slower than expected at the start. As I said, we’ve only been ongoing for the last few weeks to be honest, but we’ve seen an uptake over the last week or so. It is on the climb. I can’t remember the exact figure, but I think it’s above 20% uptake increase over the last week compared to before and I think this is probably because patients in our situation, again a unique situation of patients are very happy, didn’t have to wait too long to get to the phone – but this is extremely unique situation in my eyes throughout the UK. So I think the adoption phase took a little bit longer.
Regarding challenges, I think we should also focus on how to overcome some of the challenges. So I think Lynsey again alluded to having a vision or a potentially a mission in the practice and I think that is extremely important for us. So one thing I remember vividly from my MBA is about the culture aspect and, I remember the line ‘culture eats strategy for breakfast.’ So I think having that right culture in place to adopt the change in the first place and we use the Kotter’s model of change, where he goes through the eight steps of change, and I’ll briefly just explain it – first stage is creating a sense of urgency in the first place. So most of our staff said and most of our patients said it’s not broken. why are you fixing it? And I think that’s the first phase you have to overcome. So you have to talk to the staff and say what are the potential opportunities this new research triage will become and how will it help us in the growth of the practice.
And then forming a powerful coalition, so can we get all the key stakeholders in one place, be it a table, have regular conversations with them and hopefully iron out their concerns. Then it’s creating a vision for change which Lynsey articulated really well. Communicating the vision to the whole team so making sure everyone from top to bottom essentially from having the reception team on board to the GPs on board is really vital.
Removing the obstacles, so if you’re engaging with all the key stakeholders, they will have concerns. Can you remove the obstacles then hopefully enable them to gain traction through the change. Creating short wins and actually celebrating these short wins. The short win might be you evaluate the stress levels on a day-to-day basis and that might improve. You evaluate how long how the patients might be feeling by doing a quick survey potentially, building on the change. And lastly anchoring the change in corporate culture and I think that’s the biggest one in my eyes – the change management can happen but sometimes to sustain the change management you have to have the right culture in place and regularly re-evaluate and analyse data which again Lynsey was alluding to.
Sammi Wilson
Brilliant. Thank you. And the change fans will be thrilled to have Kotter’s model referenced and I think Mateen, you’re probably, you know, your practice probably is in a fairly unique position in terms of creating that sense of urgency. I think a lot of practices out there are feeling it now and I think practice staff are feeling it – you can sense the frustration for patients. So I think you know the first stage there is real for people and I think actually embarking on that journey and taking that methodical approach is really sensible.
Sammi Wilson
Sarah, can I bring you into this discussion? I’m really interested to understand how things work in your practice.
Sarah Rhodes
Yes, of course. We’re currently using a hybrid model, so we work with the care navigators who are dealing with the incoming electronic messages through our system, and then they’ll also be answering the phone calls for patients who aren’t able to use those online resources.
The care navigators then decide where they’re wanting that information to go, so they’ll either sign post through the tool on the system, or they’ll then pass on to our clinical team, who then do the clinical triage as if they didn’t have all the information needed so they will then contact the patient and they’ll either then signpost or book them in based on the clinical need. Also to just reiterate Mateen and Lindsay’s views about the communication with the team and patients and the planning as those were our main factors to success too – ensuring you had your whole team involved from the very beginning.
And regular contact with the patients, either through newsletters or our coffee mornings so they were aware of the upcoming changes, so it wasn’t a shock to them when we changed how access was delivered and facilitated going on and it helped to alleviate those worries they had as well. So knowing that they had various options that they could use if the online wasn’t going to work for them.
Sammi Wilson
That’s great, thank you so much. It’s really interesting to see different models and we’ve heard from some of the other panellists around, just having a clinical triage model and you’ve got the two working alongside each other. And yet once again, kind of the comms and planning and engagement and bringing everyone on that journey and that change process seems really critical and a key success factor for yourself.
Camilla, can I bring you in around challenges?
Camilla Hawkes
Yeah. The challenge I’d like to highlight is around recruiting and retaining good non-clinical staff to carry out the care navigation roles that general practice needs to deliver this model successfully. The model we have where we have our care navigator sitting alongside the doctor, all the incoming forms coming to the care navigator in the first instance, works brilliantly for us and in many practices or as Lynsey said earlier, you know each practice can develop their own model that suits them. We have a fantastic team but we’ve got lucky and we’ve developed our own structured training programme because there was nothing out there that met our requirements for this at all.
And I’d really like to see a recognised development pathway for this care navigator role in general practices which has got the potential to really streamline working, save lots of time that can be released elsewhere in the practice. You know there’s a great model out there – a few years ago, NHS England did the development pathway for social prescribing link workers, which is a really great model for the sort of thing that we need for frontline GP care navigator so that we can attract the right staff and pay them well. And that will really unlock a lot of change for general practice.
Sammi Wilson
Minal, can I just bring you in on that point around care navigation and the structured training and whether that’s something that’s sort of noted within NHS England and if there’s any thoughts around that?
Minal Bakhai
Yes. So I think it is noted and I think it’s really interesting what Camilla’s saying, because actually I went to Amsterdam recently to see some of their practices and they have a three-year training programme for the equivalent of what we would call a care navigator or receptionist that’s fully trained up in care navigation. So I think to your point, Camilla, it’s professionalisation of the role and then recognition of that through adequate remuneration and as part of the primary care access recovery plan, there was some training around care navigation.
But actually I think the next step of that and I would agree with Camilla, is that how does that become more formalised and continue because it can’t just be a kind of a single shot, if you see what I mean? And certainly in my practice, I’ve set up my own training programme for staff. So I have a rolling programme of training for all of our reception staff because actually I’ve trained them all in care navigation. But it is continual and it’s reinforcing, it’s using data, it’s using feedback to kind of continue to improve – to continually improve, identify where there might be variation between staff to target additional support where that might be needed.
And so I think I fully recognised what Camilla is saying, and I think that absolutely there needs to be more done to support that professionalisation.
Sammi Wilson
Brilliant. Thank you. Minal, did you want to come in on challenges from a different perspective.
Minal Bakhai
Yes, I agree with everything my colleagues have said and I think I probably want to highlight two key challenges that we faced. as a practice when we went live so to speak. So I think the first is that I think data is absolutely key. So building on what Lynsey said and having a strategic vision using data to inform that is going to be really important. Now when I made these changes in my practice. it was many, many years ago and we didn’t have cloud-based telephony. We didn’t have business intelligence tools. So I actually used a tally chart. So pen and paper and to really understand the volume of demand that was coming in both on the phone and in person, the type of need and we carried out an avoidable appointments audit to look at where we as a practice were also creating failure demand within the practice.
And then we used that as a baseline to design our processes to look at our rotas, to look at our appointment books so that when we did go live, actually it was smoother sailing. Now we’re now in a position where we’ve got access to much more data and in a faster, easier way. So I think my first point to make is that absolutely use your data to help inform how you design your modern general practice approach, because it does need to be adapted locally. I think the second bit of using the data was that there was a general anxiety, particularly from our staff, about an opening of the floodgates or supply-induced demand. And so we were able to track this and compare it to our baseline data and actually we found that demand was very predictable.
What we have seen is a channel shift from the phone to online and demand has remained relatively consistent. What it did surface, though for us were fluctuations in our capacity. And so what we’ve done is we’ve shifted tutorials, meetings, some of our planned long term condition clinics around so that they’re now not on days or at times that are particularly pressurised. And interestingly, as we’ve started to smooth some of that, we’ve also seen less sickness in our teams. And that in itself has helped reduce those fluctuations in capacity.
I think the second challenge I’d like to flag and that others have, is how we take our patients along with us, because this is a significant change for our patients. And naturally, as you would expect, there will be some concerns that people raise because it’s new.
Now we’re really lucky that we’ve got a very well engaged PPG and it’s got broad representation from across our communities, so we use that as a forum.
And we use that as a forum to paint a picture of the changes that we were making.
And to explain both the benefits, but also how we were solving the problems that our PPG had flagged to us, so really connecting the ‘why’ back to our patients.
We also use the data that we were capturing to also to demonstrate the benefits more tangibly. So we played back our telephone wait times, our appointment wait times, our continuity of care so people could see the improvements for themselves. We also asked other patients to describe their positive experiences. What we found was that sometimes people were angry, even though they had really good access and very fast access, but they were still angry, and it was partly related to what they’d been reading in the press. And so we used other patients to try and counter that with a much more positive narrative. And then as others have said, teachings. So we asked other patients to support our kind of wider population to build confidence, to show them how to use the digital system, but we’ve also worked with lots of our community assets, particularly the voluntary sector on digital inclusivity, digital health hubs, access to devices, data, and more and broader digital education.
And we’ve been very, very focused on communication. So both on our website, on the telephone. So it’s really clear what to do, what happens when, how to expect a response. And we’ve tried to embed that in the consistency of messaging that our staff give to our patients as well.
But ultimately, as people have experienced a more responsive service from our practice, that has helped build trust that they will get the care that they need when they need it. And so that has helped us start to shift a change in behaviour. But what I would also say is that it does take time and repetition. So we’ve had to go repeat, repeat, repeat and of course we still maintain parity across all our access routes so. you know, those that are less digitally confident or enabled can still access us, but actually many choose to access us now online.
Sammi Wilson
Yeah. And I think that’s such an important point because you do hear sometimes ‘oh we’re being forced down a route’ and it’s absolutely not about that, it’s around patient choice and making sure that you can access your practice by the way that suits you and suits your needs and your lifestyle. And you know your working hours.
Hearing loud and clear from, I think from everyone on the podcast today that data is really key and that’s fantastic.
I think I’m really interested in trying to explore now has this change been something that’s been driven and supported solely within the practice? Have you received any support, either kind of a localised support offer or we know that there’s a national general practice improvement programme and if you’ve engaged with any of that, how how’s your experience been with any external support?
Lynsey, can I ask you to come in?
Lynsey Hughes
So we have some support from our ICB as we went live, they had a pot of funding where people were able to bid against that in order to get some additional locum cover just to get you on a flat curve as you started the triage process. But what we did do is a year after we’d gone live, we actually went on the GPIP programme with the aim of understanding and trying to work through, how do we help these patients as I described before that are not going online and particularly in this one practice. So we worked with GPIP improvement programme. They helped us to look at more data, but I think they also gave us the time and space to be able to think things through and to be able to – so we sat in the waiting room and talked to patients rather than sending surveys out. I think it just gave us that that space and time to really think about how do we help these patients because we made lots of assumptions about why they weren’t going online and we had all sorts of ideas, but only the patients can really tell you why they’re choosing not to do it. So, I found that particularly useful.
Sammi Wilson
Brilliant. Thank you. Mateen, can I quickly bring you in before we wrap up for the podcast?
Mateen Ellahi
Yeah, pretty quick. So our local transformation team. Luckily, I think we’ve kind of taken our time out as far as to liaise with experts like Minal and people who have adopted the Modern General Practice and digital tools so that that has really helped us. I think data is king but needs to be good.
So we have to find out what good data looks like in the first place and then analyse the data accordingly as well. This having data is not enough. One example that I will give is we’ve used the new telephony system as a good data point. So we have been able to gather all the information about when the amount of digital triage enquiries are coming in throughout the week , throughout the day and you can see a pattern as Minal was mentioning earlier as well, so we use that to actually tailor our staffing models ensuring we have right number of reception, clinical staff available.
Sammi Wilson
Thank you so much for that Mateen. Minal, do you want to come in?
Minal Bakhai
If I just perhaps wrap up with some of the national offers that are available just so people are aware of them, and because this is a large scale complex adaptive change. And so what we’re focused on nationally is to try and create the opportunity, particularly when people are feeling very pressurised, working really hard, time and headspace is often the biggest barrier. To make the process of change easier. So how we bring the learning from all of the other practices and colleagues here, but codify that in a way that then other practices can utilise – to provide that hands on support (and colleagues have referenced the general practice improvement programme) so that practices can realise the biggest benefits from the efforts that they’re investing, but also to build their capability for continual improvement. Working really closely with systems and investing in building their capacity and skills as well, because inevitably there will be obstacles and it’s important we strengthen the capacity and capability of systems to support change and then finally supporting that sharing of learning between peers.
And so we have the national general practice improvement programme. We’ve got the national primary care transformation peer Ambassador Academy – every system has sponsored a peer ambassador, or more than one peer ambassador, and they are there spread both learning from their own transformation efforts in practice, but also from the national network so that’s accessible to all practices.
And then of course in the operational planning guidance that’s been released for 25/26, one of the three key priorities for primary care and modern general practice, and so ICBs are going to be expected to continue to support practices in being able to embed this module or this approach.
And there is funding through incentives through the capacity, access and improvement payment which total 204 million for 25/26 to PCNs and practices again to help support that move towards modern general practice and also just thinking about this more broadly than access, but also about continuity of care, also about sustainability of our workforce and working practices in general practice.
Sammi Wilson
Fantastic. Thanks Minal. I think it’s really important that we hear about what’s available nationally. Well, just leaves me to say thank you ever so much for everyone’s time today. Really interesting discussion, really interested to hear about different experiences and some of the slight, slight differences. There’s definitely themes coming through around the investment in the roles, you know, training of the roles, importance around processes and protocols, the tools that underpin it and making sure they’re really easily accessible and usable for patients and that patient engagement and comms. And data is king. love that Mateen, absolutely. Taking the time to understand at the start of your journey, the demand within your practice so that you can then look at the improvements that have been made. So thank you ever so much. It’s been a pleasure to have you on the podcast today.