Dr Mike Warburton
MB BS DRCOG MRCGP MBA
Independent Consultant and Specialist Medical Adviser,
Primary Care Commissioning (PCC)
Mike qualified as a doctor in London in 1982 and spent 15 years as a GP in West Sussex. He completed an MBA at Imperial College specialising in customer-focused services. After spending four years as Director of Commissioning and Deputy Chief Executive of a PCT, he moved to the Department of Health as National Programme Director for GP Access. Mike is now an independent consultant and specialist adviser for PCC
In a world where the internet plays such a central role in everything we do, where social networks such as Facebook and Twitter form such a significant route for communication, it isn't surprising that the way we engage patients is starting to change by embracing new technology.
Virtual patient or customer groups are not new. If you are a home internet user, just think how many emails you get from companies you have bought something from in the past and who keep your details to let you know of new, exclusive deals. You are part of their virtual customer group.
But if we think about what a retail company would do to engage its customers' attention, it is usually more than just an email. It will be a whole host of other activities that might include advertising, focus groups, complaints and feedback.
Virtual patient groups are the same – patient engagement isn't about one simple email, it is about a whole range of communication techniques that help a two-way dialogue. This dialogue helps us understand patients' views and allows us to communicate with them.
Around 41% of practices have a patient participation group (PPG) – the terminology used to describe the traditional group that tends to meet face-to-face in the surgery.(1) In my practice we had a fantastic group. It had well-attended meetings, passionate and vocal members who ran a newsletter, helped us set up health promotion days and sat in on our quarterly business meetings.
For me, it was their participation in our business meetings that had the most impact. It ensured that everything we discussed retained a patient focus, from opening times, telephone systems and even the profitability of the surgery. And members were fantastic advocates for the surgery.
Virtual patient groups are not about replacing existing groups, but about complementing their role. For the 59% of practices in England that do not have a traditional PPG,1 virtual patient groups represent an achievable way of getting to hear patients' views.
With a bit of support, establishing a group can be very easy and save a lot of time. A range of guides and support are available that will be especially helpful for practices starting a group for the first time. The National Association of Patient Participation (NAPP) provides support for setting up, maintaining and providing ongoing support to a group (see Resources).
Other support guides include the British Medical Association (BMA) toolkit or the PCC step-by-step guide for meeting the patient participation directed enhanced service (DES) requirements (see Resources).
But despite this support, despite some primary care trusts (PCTs) providing financial incentives and despite professional bodies like the Royal College of GPs and BMA all saying practices should have a group, only 41% of practices have one.1 Reasons practices give for not having a group are that they feel it is time consuming to set up, it may be unrepresentative, it is an effort to maintain and only a few people actually come to meetings.
So when the Department of Health/NHS Employers considered a new patient participation DES, it was essential to overcome some of these barriers by using new ways to encourage practices to engage with their communities. For the first time, therefore, virtual patient groups were included as an alternative that would allow practices to comply with the DES requirements.
A virtual group starts by developing a list of patients who have given their email address with consent to be contacted about the services of the practice. The sample form that comes with the DES support pack includes demographic information so the practice can ensure the group is representative.
However, the practice must first understand its demographic makeup – the breakdown of its patients by age, sex and ethnicity. Many practices will have this information but, if not, the PCT public health team, the local authority or looking at the census information on the Office of National Statistics website under 'neighbourhoods' can help.
In four practices where we piloted the DES, they found it very easy to collect 100 email addresses in a week (See Box 1).
If a practice follows a simple recruitment plan with a few key documents, such as a leaflet and posters, it can be very easy to recruit patients. It is important to be clear with patients that it will not be time consuming for them. This can be done very simply through all the various contacts made with patients every day. Once the details are collated, it is as easy to survey 1,000 as it is to survey 100 using online tools.
Many people ask what size the group should be to comply with the DES requirements. The DES is designed to be flexible in order to accommodate different ways of engaging patients, but the practice will have to publicise how many patients it asked, the mix of patients, what the patients said and what the practice is doing about it.
If a practice is using online survey tools, why not ask every new patient to sign up and have regular weekly campaigns to boost numbers? The bigger the patient group, the more valuable the information and the less likely practices are to have a problem with a few loud, unrepresentative voices.
Surveys and information
It is worth bearing in mind that not everyone replies to surveys. The GP patient survey is a paper survey and response rates can be as low as 35-40%.
It is important for practices to consider the nature of the questions being asked and the methodology used to ask them. The better the quality and rigour of the questions, the better the survey and therefore the potential output. If a practice does not take into consideration the correct methodologies for the questions then the survey will not achieve its aims. If this is not done correctly there is a risk to the financial rewards of the DES.
In order to be successful, the questions should not be leading or suggestive and should be designed in such a way as to be collated in an easy and meaningful manner. This is important if practices wish to look at trends over time.
This is an area where a practice may not have expertise, but this can be addressed very easily with some external support. Support at the beginning can prevent long and costly learning curves and helps ensure the terms of DES are met and therefore rewarded.
The virtual patient representative group (PRG) is an easy route for sending out information to the practice patients, as well as a route for gaining patients' views. You might email the group a practice newsletter or health updates such as advice on use of out-of-hours services or flu-jab advice.
Time factors and forums
Over time, patient turnover will mean that practice lists becomes out of date, so it's important to offer opportunities for all new patients to enrol. It may be helpful to have a separate contact list for the PRG so you can maintain it and keep it separate to the main practice system. Letting patients know that you are doing this can help allay any fears some patients might have around doctors knowing what they are commenting on.
The DES stipulates that one survey is carried out per year. However, it is important to keep the group engaged and interested. In addition to meeting the terms of the DES, practices can go further in their interaction with patients to improve services.
In order to promote real, interactive virtual discussions, practices can set up an online discussion forum. This can be useful to get input on practice decisions and can generate genuine debate, leading to helpful thoughts and ideas. If practices have taken a decision to use accredited questions to ensure their survey meets the DES requirements this can be a good way of prompting discussion on specific local issues.
Patient participation is obviously central to the new NHS. The DES had two potential benefits over and above simply rewarding participation. By being less prescriptive it allows different methods of participation such as virtual groups or real-time feedback, and it also prepares practices for the important task of engaging patients on the commissioning decisions of their clinical commissioning group (CCG).
Of course, the DES operates at practice level and each practice has to ask questions on the priorities of its patients. But once each practice has an infrastructure of a representative group this can be easily scaled up to form an important part of the engagement process for CCGs. This can easily be achieved by all practices asking some common questions in their surveys or discussion forums. This can be developed into very rich and genuine patient engagement for CCGs, particularly if every practice is supported to have meaningful groups.