Access to general practice is often in the national press with patients complaining that they are unable to see a GP in a timely fashion.
Driven by a local CCG dashboard in January 2014 that showed that we had higher A&E attendances (462 per 1,000 patients) compared to the local CCG average (417), we set ourselves the task of trying to improve access to the surgery without having to increase GP availability.
We undertook a demand and capacity audit, which showed we were providing enough appointments in line with the national average and that we were matching patient demand to peak appointment capacity. So we realised we had to investigate ways of improving efficiencies around appointment usage.
Although the surgery allows patients a mix of appointments such as telephone and face-to-face consultations, we wanted to think of ways of preventing a patient from having to rely on a GP contact for advice.
We undertook a literature search and found that a large body of evidence that self care can positively benefit surgeries. We designed a leaflet providing advice on healthy eating, exercise, smoking and alcohol consumption. The leaflet is handed out to every patient when they register and given to patients who require health promotion advice in consultations. However, we realised this would not give us quick results
Following a practice meeting, the partners identified one area of efficiency was around recalling patients for follow-up of blood test results.
We noticed that a number of appointments were being booked for patients to see the GP to check whether their results where abnormal and, if they were, to discuss what would happen next. Post patient review we noted four outcomes, patients would be reassured, advised to have another set of blood tests, given a prescription or referred to hospital.
We felt that there was scope for us to improve efficiencies around requesting another set of blood results and giving a prescription. The partners identified key areas under each of these outcomes that they felt could be dealt with via a pre-emptive SMS text as opposed to a telephone or a face-to-face consultation.
We spent a fortnight analysing the common tests requested and the numbers of abnormal results found. For each abnormal test result we noted that there were common (non-urgent) conditions that could be safely managed without the patient having to see a clinician again – especially if the requesting clinician had discussed the potential outcomes with the patient at their initial consultation.
The clinicians in the practice agreed which conditions these were, then set about creating management pathways and protocols for how to manage them.
Below are a list of conditions we felt could be safely managed via SMS:
We found that young women presenting with heavy periods and low haemoglobin and low ferritin levels, without any red flag signs, would simply require advice around iron replacement and dietary iron intake. Such patients would usually be called back to see the GP and given a prescription.
Low vitamin D
Patients with low Vitamin D levels, who do not have anorexia or are not taking the weight-loss medication orlistat, with normal calcium levels can be safely signposted to taking Vitamin D replacement from the pharmacy or through dietary intake.
A large number of patients who have a serum glucose test do not go for the test after fasting and hence slightly raised results are found. Patients with a serum glu >6.1, where a diagnosis of diabetes may be suspected, could be requested to have an HbA1c test prior to seeing the GP. Such patients would usually be called back to see the GP to check if they were fasting and then a repeat blood test for HbA1c would be ordered.
Patients with slightly abnormal raised or lowered TFTs would normally come back and see a GP and then be given a repeat blood test after reassurance nothing is probably amiss. Such patients could be reassured via text and asked to repeat the blood tests in 4-6 weeks before seeing the GP if still persistent.
Liver function tests
Patients with an abnormal LFT test, who were not on a statin, could be texted and asked to have a repeat blood test, which would include a hepatitis screen (if at risk), GGT, AST and lipids if they had not been done. If on repeat the bloods were normal, the patient could be reassured that there is no underlying disorder.
Patients with no red flags and a positive H Pylori test are now sent a text to advise them to attend collect a prescription for antibiotics for treatment. Their notes are checked for any penicillin allergy and whether they are pregnant or breastfeeding prior to this. They are also directed to a link the patient.co.uk to read more about what the test result means.
Having had identified key areas that may be managed without having to see the patient and written protocols around them, we had to come up with a way to implement the protocols which saved time.
We populated sections on our website with information about reducing cholesterol, increasing iron and vitamin D through dietary methods. When we text patients with their results we can encourage self-help and management by directing them to the website.
We realised that GPs would not use our protocol efficiently unless it was clear what type of patients should be contacted via the pro-active SMS programme. As a result we created a paper protocol to guide doctors what to do.
We also created an EMIS web template that would:
- Record the details of the SMS sent to the patient
- Provide advice for reception on what to do if the patient attends or calls the practice
- Allow clinicians to add the correct medication if required.
We also had to think about a way of having a shared list of messages available to all staff who would be sending out the messages. We began by creating a shared surgery NHS email address that was integrated into Outlook on all computers.
We then discovered that you could use the signatures on the outlook software to add different SMS messages under each signature. Hence all GP/staff who would action the results or send SMSs to the patient would pull down the pre-defined SMS message from a ‘pick-option’ of signatures saved onto the Outlook programme. They would then copy and paste the patient’s mobile number adding ‘@sms.nhs.net’ to it and send the message.
Once the EMIS template is completed and filed, a multiple choice box offers the GP the chance to automatically add the appropriate medication into the patient’s record, ready to be printed once the patient attends at reception. If no medication is required, clicking ‘NO MEDICATION’ will close the template.
We have around 9,800 registered patients, request around 500 blood tests a week and around 140 of these come back with some sort of abnormality. We undertook a follow-up audit which revealed that after implementing the system we have saved around 12 appointments a week, equating to over 600 appointments a year; equivalent to a single GP’s session a week.
We have also noticed that patients are less likely to book appointments with the GP simply for diet and exercise advice and that patients are being informed more quickly about abnormal results than previously.
Implementing the model has improved clinical care for patients, made it easier and quicker for them to access treatment and also improved our communication with our staff via recorded instructions in the patient’s note.
The SMS part of NHS.net comes to an end in September 2015, so we are currently looking at alternative solutions that could work for our practice.
- Dr Muhammed Akunjee is a partner at West Green surgery and a board member and mental health lead for Haringey CCG.
- Dr Nazmul Akunjee is a partner at West Green surgery, the IT lead for Haringey CCG and clinical lead for the Haringey Primary Care Intelligence Group and CCG Access and Productivity Task Force. He is also co-director of Clinical Prep, an organisation that advises on improving primary care efficiencies.