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Saturday 22 October 2016
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Just another manic Monday

Just another manic Monday

The phones are usually off the hook in general practice but Mondays are known to be extra busy with patients scrambling to get the earliest appointments possible. There are ways to look at altering this pattern to free up those phone lines

General practice is facing a threefold crisis. A crisis of recruitment, retention and morale. The back story to this crisis is rising patient demand and falling income. The financial pressures on general practice are not going to go away. If we are to survive, we need to become more efficient. We need to review our internal procedures and to see where we can shave margins and improve efficiency. Many that I speak to feel that this is an anathema to the health service. My argument is that if we want to have a health service that is capable of continuing to deliver healthcare that is of high quality and is sustainable, then we need to learn to do more with less. We need to ensure that tasks are being done in the most cost-effective manner. We should not have GPs taking blood pressures or doing pill checks. We should look to make the best use of technology – not to replace the personal touch of general practice, but as a way of reducing the pressure on surgery personnel where appropriate, thereby allowing a higher quality of personal interaction when called for.
We all know that for the majority of our patients an episode of care starts with a telephone call to the surgery but do we really have any idea what the patient experience is like when trying to call the surgery. We know at some level that it can take a long time to get through. For this reason, many of us have instituted emergency access lines for clinicians to call, to avoid the delays on the appointment lines. Previously it has been difficult to get a realistic measure of the scale of the problem of invisible demand or ‘engaged calls’ at the exchange as we never knew how many calls were being lost before they got through to the surgery. I’ve been asking my telephone provider for some time if it was possible to get this information in January 2016. They provided me with the ability to see how many calls to our reception numbers were dropped – that is how many patients called the surgery and received an engaged tone. We compared these engaged calls to our calls answered from our Oak Telephone Logging Software. The results, shown in Figure 1 were quite surprising. We have called this phenomenon The Monday Bow Wave.
Figure 1 shows that the number of calls answered per day is fairly constant at around 500 calls per day. The number of engaged calls patients experience on Tuesdays to Fridays is around 190. On Mondays the number of these engaged calls is around 1,700.
The data for engaged calls at the exchange does not give us the telephone number of the patient trying to ring us. We don’t believe that those 1,700 patients phoned the surgery on Monday only to get an engaged tone. Rather, we think this number is made up of a lower number of patients ringing several times in an attempt to get through. These patients are not receiving a quality service. As the practice manager, I would like to deliver a service where patients contacting the surgery have their call answered quickly, courteously and efficiently, putting the patient onto the relevant stream within the practice system.

Figure 1. Horsefair Surgery – enagaged calls vs calls answered January 2016

Taking the call
We have six incoming telephone lines and two telephone lines going out. The problem with Mondays is the capacity of our incoming lines. Patients are joining the queue at the exchange faster than calls are being dealt with at the surgery. When we look at this problem further, analysing numbers of calls by hours of the day, as shown in Figure 2, we see that the number of engaged calls on Mondays is significantly weighted towards early morning with a secondary peak at around 13:00.

Figure 2. Horesfair Surgery – enagaged calls by hour of the day and day of the week 2016


We could overcome this by increasing the number of incoming lines, but this would come at a cost – and we need to be cutting costs. This cost would also address a problem that exists only between 08:00 and 14:00 on Monday. On Tuesdays to Fridays we would be paying for unneeded excess capacity.
Before we set about trying to solve this problem, we should try to understand what is causing it. There is little doubt in my mind that the surge in demand on Monday mornings is caused by a latent need for a seven-day a week general practice service. I realise this is a highly unpopular deduction, but I think the figures speak for themselves. If there was a Saturday and Sunday general practice, service, I am convinced that telephone demand on Mondays would follow the same pattern as Wednesdays or Thursdays. That particular argument, however, is beyond my pay grade. How can we, as practice managers, address the very real issue of the Monday bow wave?
There are at least three things we can do:

  • Change patient behaviour.
  • Reduce the length of each telephone call.
  • Cease telephone requests for repeat medication.
  • Promote online communication.

The first thing we need to do is to change patient behaviour. The reason why our patients phone at 08:00 and then again at 13:00 is because we have trained them to do this. We have rewarded the first person through to the receptionist on a Monday morning with a book on the day appointment of their choice. We also embargoed some book on the day appointments to be released after 13:00. Until recently in my surgery, access to an on the day appointment with a GP was not determined by clinical need, but rather by having sharp elbows and the knowledge of the rules of our appointment system and how to use them to one’s advantage.
We have recently introduced clinical triage into the practice. Now, when a patient calls for an appointment on the day, the receptionist takes basic details and books a telephone call for a triage clinician to call the patient back within two hours. The triage clinician will then signpost the patient to the relevant individual within the practice – according to clinical need. This should avoid scarce on the day appointments with GPs being taken up with inappropriate presentations such as the young man who ‘urgently’ needed a vasectomy referral. Clinical triage, by itself, will be slow to change patient behaviour. It needs to proceed alongside a patient communication plan. The plan should set out to assure patients that if they need to be seen on a particular day, they will be seen on a particular day, so long as they call between 08:00 and, say, 16:00. This message can be put across using patient information leaflets, via the practice website and display screens within the surgery. It is also worth approaching your local papers, radio and even TV stations to get the message across.

Changing the system
I said earlier that the Monday Bow Wave is caused by a lack of capacity between 08:00 and 14:00. The capacity could be improved by increasing the number of lines but for reasons already explained that is not cost-effective. The other way of increasing capacity is to reduce the length of each telephone interaction.
If each telephone call into our surgery on Monday could be reduced by 15 seconds, it would produce an additional two hours and five minutes of line availability. Fifteen seconds is actually quite a long time but I think it should be achievable.
As with many things, training is the key. Well-trained receptionists with well rehearsed and well thought out scripts underpinned by clear protocols of how to deal with 95% of the common calls would make this 15 seconds relatively easily achievable. We need to invest in our receptionists. We need to give them the opportunity to learn and develop their trade through training in a calm and supportive environment away from the frenetic pace of the reception office. This should be a win-win situation. High-quality training will motivate your receptionists. The shorter telephone transaction times will result in fewer engaged calls at the exchange, which should result in higher patient satisfaction.
If there are any non-dispensing practices reading this article, who still offer repeat prescription requests over the telephone, I have one piece of advice – cease this service now. Having listened to a number of repeat prescription requests I am convinced that it is potentially dangerous. I have heard patients asking for “some more of the little white pills”, spoonerizing drug names such as SanLoprazole instead of Lansoprazole or forgetting the names completely.
 I am sure we are not the only practice to experience this. We stopped taking prescription requests over the phone in April 2015. It was a very unpopular move. My patient participation group took a lot of persuading. We argued that prescription requests over the telephone did the following:

  • Tied up receptionists for a disproportionate amount of time thereby reducing access for patients for other clinical services.
  • Are inherently unsafe.
  • Can be replaced by safer and more patient friendly methods.

We produced patient information leaflets and posters about the change and distributed them in the preceding three months. We published the change on our website and on the surgery video screens and put a message on to the right hand page of prescriptions.
Despite all of this advance publicity we still received a number of complaints shortly after the change but these were easily and successfully dealt with by explaining that patients could order their medication online, by post, by email or by calling their community pharmacy. I say again, if you are a non-dispensing practice offering telephone reordering of prescriptions, stop as soon as you can. This service is costing you money, clogging up your telephone system and there are viable alternatives available.

Using other tools
Finally, we can increase the effective capacity of our telephone system by encouraging patients to use parallel communication pathways. There are online triage tools available that will enable patients to contact the surgery at a time that suits them and provide the surgery with a fairly detailed history that will enable a clinician to triage the clinical needs of the patient.
If we assume that a clinical history for a particular clinical episode can take between five and 15 minutes of face-to-face patient clinician time – depending on the complexity of the presentation – then using an online triage tool produces this history in the patient’s time rather than in the scarce resource of surgery-based patient contact time. This again is a win-win. It reduces telephone traffic access for those unable or unwilling to use online tools. It also increases capacity for face-to-face clinician patient contact.
In summary I would recommend that you find out if you have a Monday Bow Wave. Contact your telephone provider and ask them for access to figures showing inbound calls, termination type, busy. You should then plot this against your answered calls. If you have a Monday Bow Wave you can in this article. If you haven’t, then I would guess you are already offering appointments on more than five days a week.

Andrew McHugh, manager of a GP surgery in Banbury, North Oxfordshire.