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Friday 30 September 2016
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Open all hours: introducing the 8 till 8 initiative in practice

Patients & Services

Mensah Osei-Asibey
Assistant Director, Primary Care
"8 till 8" Project Lead
Waltham Forest PCT

Mensah has worked in the NHS for 17 years; the first 11 of those in secondary care. He moved to primary care in October 2000, working on a number of innovative programmes across cardiovascular and diabetes services. In October 2004, he took the lead to pilot the "8 till 8" initiative. His current preoccupations include mainstreaming the extended opening times in general practices and implementing the new dental contract and the new home oxygen service. This, combined with raising three lively children with his wife, and playing an active role in his local church, has kept Mensah very busy!

Traditionally, GP surgeries across the country operate a two-shift system: 9am–12.30pm and 4–6.30pm, with one half-day each week. This generates a maximum of nine slots, within which clinical sessions are organised. The longer opening times of Grange Park Practice and Forest Road Medical Centre, in Waltham Forest, of 12 hours each day, made it easier for existing patients to book appointments and for new ones to be registered.

The extended opening hours allows a three-shift system to be operated seven days a week, increasing the number of available slots from nine to 21 for clinical activities. By restructuring staff working hours and engaging additional workforce with an appropriate skill-mix, these 21 slots are effectively utilised. The results are increased capacity and activity, which has benefited patients, staff, the practice and the PCT.

What are the key lessons learnt?
The initiative created primary care services that are accessible, convenient, reliable and more responsive to the needs of patients, practice teams and the entire health economy, by offering general medical services from 8am to 8pm, seven days a week. Our experience of these working hours has demonstrated that:

  • There is a demand for convenient appointment times, before/after work.
  • Practices can offer patients appointments within 24 hours, or on their preferred day and time.
  • Workload is evenly distributed through the day, avoiding bottlenecks.
  • Fewer patients failed to turn up for appointments.
  • Patients choose to contact the practice first for unscheduled care, instead of A&E.
  • Most staff involved in the service are satisfied with the flexible working hours created by extended opening.
  • There is increased job satisfaction as clinicians are able to spend adequate time with patients, and administrative staff are able to offer suitable appointments.

What were the key barriers?
The main challenges the team faced in moving away from the traditional pattern of general practice were:

  • Organisational – the team had to reshape its working patterns, and at the same time maintain strong relationships with patients.
  • Cultural – as a result of this work, the team is stronger, more relaxed and more confident in its ability to set and meet new challenges.
  • Demographic – the practices serve a relatively deprived community, with diverse and challenging needs. There were initial fears that the project would generate additional demand. With careful planning and patient education, this was avoided.
  • Financial – pump-priming funding had been available to the team for the duration of the pilot, but it has taken hard work to develop and test a financial model, and to persuade sceptics (in the team and outside it) to give the model time to demonstrate its validity.
  • Professional – general practice has faced an extended period of major change. Adding the "8 till 8" concept on top of this required a leap of faith for the practice teams, and they have had to face scepticism and some occasional hostility from professional colleagues.

Benefits to patients and service users

  • Increased access to the practice team, from 27 hours per week to 84 hours.
  • Opportunity to see a GP or nurse at more convenient times, including before and after work, as well as at weekends.
  • Reduced waiting times (24–48 hours to see a doctor, 24 hours to see a nurse; appointments can also be made on a day of the patient's choosing), measured with an advanced access methodology.
  • More patients seen daily by clinicians.
  • Longer consultation times; 10–15 minutes for routine appointments.
  • The practices offer a protocol-led service for patients with long-term conditions.
  • Continuity of care offered by the patient's own practice team.
  • Opportunity for new patients to register with the practices; 2,000 registered in the last seven months.

Benefits to the practice

  • Opportunity to stagger clinics/services, spreading the workload across the day.
  • Effective use of facilities and equipment, ensuring value for money.
  • Ability to attract a total of 2,000 new patients (20% of baseline-list size) over a seven-month period, boosting income potential.
  • Improved uptake of services, minimising the number of appointments wasted through patients not turning up.
  • Increased capacity to develop a range of enhanced services.

Conclusion
The "8 till 8" initiative offers a win–win situation for patients and practices. The PCT also benefits from improved patient access and satisfaction, effective premises' utilisation and cost-effective care provision in the right setting. Therefore, practices willing to establish such a service should be actively encouraged and facilitated.

Hilary Powell
Business Manager
Grange Park Practice

Hilary has not always been a business manager; she was a legal secretary for the first few years of her career. Her first professional encounter with general practice was as a part-time medical secretary in East London for five years, and then practice manager for the next 12 years in Redbridge

Hilary Powell's experiences of setting up the "8 till 8" service
Grange Park Practice is a training practice in Leyton, East London, with 3.5 wholetime-equivalent (WTE) GPs. We have one fulltime practice nurse.

In mid-October 2004, our practice, along with others in the Waltham Forest area, was approached by the lead for Service Transformation Redesign Innovation Project (STRIP) to take part in a pilot scheme for extended surgery hours: from 8am to 8pm, Monday to Sunday. The deadline to start the pilot was to be the beginning of November.
 
This short deadline was a complicating factor in the decision to take part in the pilot. Reception staff and the practice administrator were reluctant to take up the opportunity because the reception staffing issue needed to be urgently assessed and addressed. Our existing staff felt that additional, trained staff needed to be in place before we could begin the pilot. They were persuaded that recruiting trained staff could take some time, but that recruiting untrained staff could be a quick fix, if they worked alongside our existing, experienced team members.

Rearrangement of the weekday receptionists' rotas accommodated many of the necessary changes, except at the weekends, which would be in addition to their contracted hours. There was a little resistance, but a democratic decision was finally reached to go ahead with the pilot.

Readjustment of shifts
The plan for any change to "8 till 8" (as it has become known) included a three-shift pattern of 8–12pm, 12–4pm and 4–8pm, with at least one GP clinical session and a nursing session included in each of the shifts. It was going to be possible because we had members of the team willing to be flexible.

One of our salaried doctors was willing to start his sessions at 8am during the weekdays; another was willing to change his sessions so as to finish at 8pm. Locum GPs would be asked to fill the gaps to provide the missing sessions. To ensure nurse availability for 12 hours every day, we also needed to employ another fulltime practice nurse. Nurse sessions were 8am–2pm and 2–8pm on Saturday and Sunday.

The "8 till 8" plan was ready to be put into place. Two receptionists were on duty at all times. In the evenings and at weekends, there would be one experienced and one inexperienced receptionist.

Financial support
The North East London Strategic Health Authority supported the pilot scheme financially and funded the additional six GP sessions, one WTE F-grade practice nurse and 2 WTE receptionists.

Advantages of the initiative
Benefits to the patients are clear. The extended hours allowed an additional 84 GP appointments per week, at times that are more convenient to patients, especially for those who work during the week. Nursing appointments also increased by 144 per week.

Benefits to the practice included satisfied patients, a monthly increase in the list size of approximately 100–120 patients, and flexible working for GPs, nurses and receptionists. Workload was spread throughout the day, instead of being condensed into 2-3 hours at a time. Making appointments was less time-consuming because there was a lot of choice.

Benefits to the PCT included the innovation in their area and a reduction in attendance at out-of-hours services and at A&E.

Once the scheme was up and running in the practice, the pre-existing experienced members could see the benefits and were willing to take on additional hours in place of the inexperienced staff. We were therefore able to mainstream the initiative with all of our regular staff. We continue to employ two fulltime nurses and a healthcare assistant to manage the registration of new patients.