Francesca is a freelance journalist who specialises in writing about health. She contributes to a wide range of healthcare magazines and websites, and is currently News Editor of Practice Nurse and The Practising Midwife journals
Many practice managers are smarting from the impact of this year's GP Patient Survey, which has resulted in millions of pounds being lost to general practice. The British Medical Association (BMA) reckons that around 3,000 practices have lost money – some as much as £15,000.
Problems have arisen because this year the survey was redesigned to assess patient experience both in relation to access and to the wider quality of services. Two of the indicators for 48-hour access and advance booking (PE7 and PE8) are being used to determine Quality and Outcome Framework (QOF) payments to practices.
A significant proportion of practice managers feel aggrieved because they have worked hard to improve access but have still been penalised. They claim the survey was flawed and many are appealing their results.
But the government has made it clear that the survey is just the beginning of a crackdown on improving access to primary care. Health Minister Mike O'Brien has warned practice managers: "It's clear some surgeries now need to look at these results and identify the areas where patients are still dissatisfied."
He says the survey's results show there is work to be done in improving telephone access to surgeries and making it easier for patients to book appointments in advance.
Practices that have not done well in the survey face increased scrutiny from primary care trusts (PCTs) following the publication in July of a set of tough new targets by the Department of Heath (DH).
The new guidance, Improving GP Access and Responsiveness, published as part of the world class commissioning programme, directs PCTs to adopt a "more rigorous approach" to improving access and responsiveness.1 It reminds them that the Care Quality Commission will consider the GP Patient Survey results in its overall assessment of PCTs.
The document points out that while many practices have done well, 18% of survey respondents were unhappy with their practices' opening times, and 55% would still like to see their surgery open at additional times.1 Likewise, 24% of patients who wanted to book an appointment in advance were not able to, and 19% experienced problems contacting their practice on the telephone.(1)
Many practice managers feel this year's survey was unfair. Christine Andrew, Practice Manager of the Hawthorn Surgery in Redhill, Surrey, says they were marked down by the patient survey on the 48-hour access question, despite having offered advance booking up to three months for more than three years. She feels the problem was that a number of their patients do not speak English well, some hadn't visited the surgery within a few years and many more did not bother to return the surveys.
The results have been demoralising for the practice. Mrs Andrew's view is that the government has used the survey simply to claw back money from general practice. "My GPs start at 8am and they are often still here at 10pm at night," she said.
"Everything here is done for the patients. I feel for the doctors because they really do pull out all the stops. They fit people in all the time, offer long appointment slots, pay for a nurse practitioner and do lots of home visits. I don't think we could do much more or we would all have breakdowns."
Christine Earwaker, Executive Manager of a practice in Horley, Surrey, and Chair of the East Surrey Practice Managers' Group, says around two-thirds of the 20 practices in her forum are appealing their survey results. "I have urged them all to appeal because this is going to be a quarterly survey from now on and it needs to be discredited because of the small numbers involved. Also, we noticed that the number of surveys sent to patients did not seem to relate to list size, ie, practices with smaller list sizes may have had more survey forms sent to patients than larger practices."
Mrs Earwaker's practice has lost several thousand pounds but she says 30% of their appointments are pre-bookable up to two weeks in advance, and the remainder can be booked on the day. The advance booking is advertised on a screen, in the practice and in leaflets, and patients are told about it when they phone up.
She says: "I feel the amount of money attributed to this patient survey has been very subjective and can be based on the mood of a patient who might have been hacked off because they could not get an appointment with a particular doctor, forgetting they would have been offered an appointment with somebody else. It's not as if the money is being docked for something clinical, where the practice is having a real input into patient care where it really matters.
"We got 78% on indicator PE8. If the government had a satisfaction factor of 78%, it would be singing it from the rooftops," says Mrs Earwaker.
Dr Laurence Buckman, Chair of the BMA's GPs' Committee (GPC), says they are actively trying to resolve the problems that have been created by the survey in discussion with NHS Employers and the DH.
"I believe they're genuinely surprised by the effect it has had on practices," he says. "Huge numbers of practices have lost something and a large number of practices have lost significant amounts of money. The paradox is that statistically it was quite possible for you to have greatly improved access in your practice and to still have lost money," he says.
The BMA's criticisms of the survey are that the questions could be misinterpreted, the survey was very long, too complicated and was designed to elicit negative responses. Dr Buckman suggests practice managers should prepare themselves for future surveys by collecting their own statistics about access and of how many people do not get appointments when they want one. He also recommends they put up notices up in their surgeries encouraging patients to respond to the survey. He believes more patients would complete the survey if they realised that failing to do so could damage their practice.
David Stout, Director of the Primary Care Trust Network, says the variation in satisfaction between patients is worrying and health inequalities are an issue. "The survey confirms that black and minority ethnic groups report lower satisfaction with the NHS. While it is encouraging that the variation has started to narrow, there is still more to be done. Primary care access must be considered in its widest sense and not just in terms of extending GP opening hours."
He says PCTs will now be working to help local practices that did not achieve high scores in the survey. Solutions could include widening online booking, extending opening hours or providing telephone consultations.
The new DH guidance suggests that PCTs should investigate practices that:
PCTs may suggest that such practices run: local patient surveys or even rerun the national survey in the surgery; qualitative assessment to help gain deeper insights into understanding patients' experiences of interacting with the practice; focus groups and reviews of complaints.
The DH guidance recommends that practice managers should review the experiences of GPs and practice staff, because frequent discussions about access and recent experiences with patients are a valuable source of information. The reception team are often the first to know when patients are not happy with access, says the document.(1)
The PCT may even bring in external consultants, as was done successfully in Tower Hamlets to undertake an extensive programme of work to improve the performance of 23 practices with the lowest survey scores.
The guidance says that practices that have already achieved a step change in access have typically taken a broad range of actions rather than just one or two, usually addressing both technical access and practice responsiveness. They will often have appointed a GP lead for access to work alongside the practice manager, but achieving improvements requires a whole team effort.(1)
To help GPs respond to the feedback their patients give them, the DH has also published a new provider guide on access and responsiveness, giving practices practical advice on how to deliver the services that their patients need.(2)
It includes examples of best practice, such as the Marple Cottage Surgery on the outskirts of Stockport near Manchester, which continues to develop its own website to keep patients better informed of the services it offers.
The website is very popular with patients, enabling the practice's 6,000 patients to perform a number of tasks online – such as emailing doctors with queries, ordering repeat prescriptions, booking appointments, and checking their blood test results. Asthma patients can also conduct secure online consultations to help manage their health more proactively.
Practice Manager Johan Taylor says enabling patients to book appointments online does save time and reduces phone calls to the practice, but this will only improve access if the operational management of appointments is constantly monitored and controlled.
"If you talk to people who have good access, you will find most of them have gone through the process of monitoring demand on a regular basis," he said. "They will be looking at how their appointments are used and looking for trends and changes – it only takes the extra workload, with the current flu epidemic, or for one of the doctors to change their daily work pattern for the demand for appointments to change."
The practice achieved scores of well over 90% in this year's patient survey. "The website must have helped improve patient satisfaction, because not only does it provide patients with an additional way of booking appointments but it also shows them that slots are available for up to four weeks in advance," says Mr Taylor.
Marie Hoyle, Practice Manager of The Kakoty Practice in Barnsley, which also features in the new guide, says one of the keys to their success has been ensuring the whole team buys in to the process and is open to changing their working practices.
Her practice, which has around 6,100 patients based on two urban sites, is classified as high health need, and access to medical services has to be good.
They began work on improving access before last year's survey. The first stage was to introduce capacity and demand monitoring. They also began a process of monitoring the third-available appointment measure. This took an administrator only a few minutes to complete and the monthly findings supported whether the changes were working.
Changes included altering the times and length of surgeries on different days to minimise DNAs (did not attends) and unused appointments. They introduced internet appointment booking and auto-text patient reminders, which also improved the level of DNAs. They published newsletters to inform patients about the changes and how they could get the best from the appointment system. The practice is now aware of when high demand occurs and plans for it.
But Mrs Hoyle says none of these measures are a fix for life because demand constantly changes. Access is now monitored continuously and is on the agenda of every monthly team meeting.
In this year's survey, although the practice was not financially penalised, they were disappointed that patients did not score them as highly as the previous year. "It did feel very personal, particularly when we had put in so much hard work. But then we decided to be grown-up about it because the survey and the way it is carried out can give an artificial picture."
There is no one formula to getting access right, says Mrs Hoyle. "It comes down to having enough people to meet the need, having the tools to measure it and then anticipating the demand. We make it a team effort and it is very much a continuing piece of work," she says.
1. Department of Health. Primary care and community services: improving GP access and responsiveness. London: DH; 2009. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
2. NHS Practice Management Network. Improving access, responding to patients. A "how-to" guide for GP practices. London: DH; 2009. Available from: http://www.networks.nhs.uk/uploads/pmnetwork/090702__improving_access_re...