Six case studies: how practices have used the avoidable appointment audit and made changes to the way they work
This section provides six case studies. Five of them describe how individual practices implemented the audit, reviewed the results and made changes to the way they work. The last case study looks at how the audit can be used across a larger group of practices to make changes at both practice level as well as across the wider health system. The six case studies are:
- Yardley Wood Health Centre, Birmingham
- The Market Surgery, Aylsham
- St Nicholas Group Practice, Burnley
- Upton Surgery, Worcester
- The Surgery, Haslingden
- 58 practices across 3 CCGs in Worcestershire
Case study 1: Yardley Wood Health Centre, Birmingham
Report received in January 2018
The practice had already been thinking that some of their G.P. clinical work was avoidable and that they were seeing patients that just didn’t need seeing by a G.P. The audit offered a simple way of testing this out and was supported by the whole team. The practice carried out the audit in January 2018, with 4 GPs reviewing 218 appointments. While the whole team was actively involved, it was felt that only four doctors needed to audit any appointments. There was considerable variation in how the team perceived the level of avoidable appointments, with the newest doctor in the team identifying just 5% while the senior partner felt that far more were potentially avoidable at 43%.
Elizabeth Phillips, one of the GPs and the Practice Lead for Quality Improvement said “The interesting thing is that it made us think about differences in how we work and how we might do things in new ways. The audit is, of course, subjective, how could it not be – the idea of what is avoidable will mean different things in different practices – but at a time when we are drowning in work we need to look at how to do things differently and that’s what made it useful. We had already started thinking about making changes, but the data helped confirm what we should do, and it was important to have data to back things up. The audit was also very easy to do - being open on the screen at the end of each consultation – it quickly became second nature.”
The practice discussed the audit results and decided to make a number of changes. They opted to extend their skill mix, expanding the practice team by recruiting an advanced nurse practitioner and a paramedic too. They are also looking at better signposting from receptionists through to the different members of the clinical team.
The practice is preparing to repeat the audit once the new members of the team are inducted and in post and continue to use the audit on a regular basis. Ideally, the practice would like the audit to become part of continuous data measurement over time rather than just a one-off measurement.
Case study 2: The Market Surgery, Aylsham
Report received in August 2017
This initiative was part of the Productive General Practice Programme and the GPs were talking a lot about how many inappropriate appointments they thought there were, but when challenged, there was no way of quantifying how many there really were. They were aware that this didn’t mean that patients would disappear but that there might be other or better ways they could be seen, even if this might need more resources from elsewhere. The practice did meet in advance to discuss the audit and the clinical team was aware of what was involved.
The practice carried out the audit in July 2017, reviewing 482 appointments (248 doctor consultations, 34 nurse practitioner consultations, and 200 nurse consultations). While five members of the team were actively involved, four chose not to audit any appointments. There was substantial variation in results across the clinical team, with one GP identifying 44% avoidable appointments, while the other who reviewed many more appointments, identifying just 6%, while the nurses consistently reported just under 20%. Overall, the practice identified a rather lower proportion of potentially avoidable appointments compared to the national average.
The practice decided make changes to how they work as a result of the audit. They decided to review how emergency appointments are booked and have become more effective at using the receptionist team to signpost patients to the right member of the clinical team. It has led to more dialogue between the reception team and clinicians about how to manage patients, reducing pressure on GPs and nurses. It has also led to discussion with other local practices about different perceptions of what might be avoidable, with other practices taking a stronger line on tasks that do not need to be seen by GPs, while the Market Surgery has benefitted from having an experienced Advanced Nurse Practitioner capable of taking a substantial workload off GPs.
The practice found the summary audit report very helpful. The main surprise was that despite initial concerns about the levels of avoidable appointments, the actual proportion identified was lower than in other practices. “It is important to have real data rather than anecdotal evidence, so that was helpful and a good result. It was also time efficient for me as a practice manager as I didn’t need to chase people up. It is invaluable to have a clinical perspective.”
Case study 3: St Nicholas Group Practice, Burnley
Report received in January 2018
The practice carried out the audit in January 2018, reviewing 258 appointments (134 doctor consultations, 48 advanced nurse practitioner consultations and 76 nurse practitioner consultations). While five members of the team were actively involved, three others chose not to audit any appointments. There was substantial variation in results across the clinical team, with GPs ranging from 54% to 23% avoidable appointments, while the nurse practitioners varied from 54% to 17%. Overall, the practice identified a substantially higher proportion of potentially avoidable appointments compared to the national average.
When reflecting at the end of the audit, the clinical team identified working with the reception team and improving triage as the most important factors in directing patients towards the right practitioner. Improving access to mental health services was highlighted as the single most important referral pathway for reducing the burden on GPs. They were also keen for the CCG to agree protocols enabling the direct referral of patients to specialist services. Finally, they identified further Advanced Nurse Practitioner time as the best way of taking some of the workload off GPs.
The practice found the summary audit report very helpful. They met as a team to discuss the report and identified changes in the way they work.
Julia Moseley, the Business Partner, reported that they are preparing to implement an element of triage in the surgery each day, as they found that even though they carefully monitor the balance between daily urgent available appointments and routine appointments, this allows them to gauge if they need additional appointments, or locums. Currently, those not needing to be seen by a GP are still slipping in to clinics. “The biggest emphasis is on ensuring that the total number of appointments available per week doesn’t fall below an agreed minimum number”.
The practice is also starting to use care navigation. They are clear that many things can be easily dealt with by a HCA or Practice Nurse, while others can be dealt with over the phone by ANPs who can treat most presentations - and the practice encourages immediate access to a GP if the ANP needs any assistance or if the case is quite complex. They are also establishing a triage nurse who can prescribe and has previously seen same day consultations, passing on the more complex cases for an ANP. The practice feels that this will help ensure that patients see the right person in the clinical team “patients often think that they need to see a GP but, actually, it is not always necessary”.
Case study 4: Upton Surgery
Report received October 2016
The practice carried out the audit in October 2016, reviewing 164 appointments (including 65 doctor consultations). Seven out of 17 members of the team were actively involved, with variation ranging from 27% to 7% of avoidable appointments for GPs, while the nurse practitioner identified 33%. Overall, the practice identified a lower proportion of potentially avoidable appointments compared to the national average.
When reflecting at the end of the audit, the clinical team identified working with the reception team as the most important factor in directing patients towards the right practitioner. Improving social prescribing was highlighted as the single most important referral pathway for reducing the burden on GPs. They were also keen for the CCG to reduce the activity from hospitals where the practice could add little value. Finally, they identified further Advanced Nurse Practitioner time as the best way of taking some of the workload off GPs.
Philippa White, the Practice Director, described the audit as a starting point of a journey for improving the way they work “the audit was a catalyst for change”. The results, supported by a discussion within the clinical team, provided a basis for accessing local transformation funds. They are now working with two other local practices, with a combined population of over 30,000, to develop a consistent approach across the neighbourhood team, implementing health care navigation training for all reception staff. It is a journey that led to a national award from the Self-Care Forum for their collaborative work across the three practices with their Patient Reference Group and voluntary sector partners to plan a year of Self Care activities locally. This has also led to establishing a social prescribing project with Age UK supporting older people to build social connections despite the challenges of poor transport in a rural community.
The practice has also taken steps to strengthen their clinical team, recruiting another Advanced Nurse Practitioner, and they hope soon to be able to appoint a practice pharmacist, all designed to divert workload from the overstretched GPs.
Case study 5: The Surgery (Dr Moujaes & Dr Mannan), Haslingden
Audit report received in November 2017
The practice was encouraged to take part in the audit by their local CCG in East Lancashire who highlighted the link to the PCF website in their quality framework. The practice had already been looking at avoidable appointments over the previous 12 months and had implemented a new care navigation system with the aim of keeping as much work away from GPs as possible. So, although they were happy to try out the audit they were expecting the number of avoidable appointments to be low.
They were surprised to find that although they were below the national average they were still overall identifying 1 in 8 of their appointments as potentially avoidable. The practice carried out the audit in October 2017, with 3 GPs a nurse practitioner reviewing 105 and 25 appointments respectively.
When reflecting at the end of the audit, the clinical team identified continuing to work with the reception team as the most important factors in directing patients towards the right practitioner. Social prescribing was highlighted as the single most important referral pathway for reducing the burden on GPs. They are now working with the wider Primary Care Network in their locality to address this issue. They were also keen to avoid follow up for blood results when not necessary and for the CCG to work with local hospitals to reduce the number of patients being referred back to the practice where they could add no value. Finally, they identified an Advanced Nurse Practitioner as the best way of taking some of the pressure off GPs.
Charlotte Brown, the Assistant Manager, felt that following the audit they were better informed to move ahead with care navigation. They decided to offer further training to the reception team designed to increase their confidence in directing work away from GPs. As a result of the audit they accelerated their plans to set up a call queuing system and a welcome message from one of the GPs asking patients to give details of their appointments so that they can be directed to the right member of the team.
The practice found the summary audit report helpful. They are planning to re-audit in a few months as a way of tracking their progress and will continue to focus their efforts of reducing pressure on GPs as much as they can. They have also introduced other initiatives, including workflow optimisation, designed to ensure that most of the doctors’ administrative workload is picked up by the admin team, freeing up GPs to see patients.
Case study 6: 58 practices across 3 CCGs in Worcestershire
Reports March & April 2017
A. Summary results across 58 practices
The three CCGs across Worcestershire, Redditch & Bromsgrove, Wyre Forest and South Worcestershire, decided to work together to encourage and their practices to take part in the appointment audit. They were keen to support their practices in getting a better understanding of their current workload and the potential to shift work away from GPs, both towards other practitioners and services, as well as avoiding work altogether where the practice could offer little value. They also felt there was an opportunity to inform the wider STP, building on the collective views and opinions of over 200 clinical staff across 58 practices.
The practices carried out the audits over the winter months of 2016/17, collectively reviewing 9,506 appointments. In most cases, there was substantial variation in identifying avoidable appointments across each individual practice team, while across all 58 practices the rate varied from 42% to just 2%. Overall, the practices identified a proportion of potentially avoidable appointments that at 20% was close to the national average. The average number of appointments reviewed in each practice that took part was 170, despite 13 practices reviewing less than 50 appointments each.
The local health community was also interested in how the collective priorities of over 200 clinicians across 58 practices could be used as a better basis for informing future funding decisions across Worcestershire. Everyone who took part in the audit was asked to reflect on four questions after completing their review of appointments. Below, we have summarised their collective priorities and it is interesting to note that the results were broadly similar within each of the three CCG areas.
B. The impact on General Practice and the wider healthcare system
The results of the audit were used at individual practice level to identify ways of managing the current workload in better ways. To access the General Practice Forward View CCG transformation funds, practices were asked to refer back to the results of the audit report and take in to consideration any findings. Many practices are now at the point where they are looking to re-audit so that they can review where they have got to one year on.
At a wider level, the summary findings were shared with the local LMC and the Primary Care Commissioning Committee across the 3 CCGs. The results were also used to inform discussions across localities, now developed as Primary Care Home sites, and were regularly referred to in local plans for implementing the GP Forward View. Key local schemes for improving Care Navigation and Social Prescribing identify the audit as one of the measures for improvement.
Practices also worked on wider priorities across CCG areas. In Redditch & Bromsgrove they focussed on care navigation and worked collectively across practices to agree a consistent way of working to improve access and better signposting for patients. This initiative is fully auditable using an interactive EMIS template. In South Worcestershire there was a collective focus on care navigation training for practice staff, with local agencies presenting what they do and how they can offer support, and practices developing their own directory and practice champion.
All three CCG areas are currently participating in a Social Prescribing pilot working in conjunction with the local county council. The making time audit results were used to support the need to introduce this way of working at practice and locality level.
From an STP perspective, the findings from the making time audits have been used to inform some of the content of the STP Primary Care Workforce Plan, including exploring alternative primary care workforce roles.