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Preliminary Report on new GPAQ patient survey for 2011/2012

Introduction

This survey was obligatory between 2004 and 2009 as part of the NHS Quality and Outcomes Framework (QOF). It used a questionnaire based survey, undertaken within the surgery. It was called GPAQ. In 2009 the government decided to abandon this approach and rely on an external survey done by a market research company, by postal survey. This idea has now apparently been abandoned. The results of this survey for last year can be found, in graphical form, on the NHS choices website (Bankhouse Surgery section – option down the left). We believe this shows Bankhouse Surgery performing substantially better than the local and national averages.

Now that this postal survey has been abandoned, Bankhouse Surgery has decided to again survey its patients via a local anonymous survey. Whilst the GPAQ survey is not perfect, the practice felt we should use this again (at least once more), to give us results which would show us a trend from 2004/5. We had, however, substantial resistance from patients who did not want to fill in any questionnaire. We may, in future issue a smaller, simplified questionnaire in order to improve acceptability.

Discussion

As can be seen from the above figures, the Department of Health has always stressed satisfaction with the GP consultation and eight of the sixteen questions are on this area. The “benchmark” figure has never been fully justified other than being the DOH target figure for practices to be judged against. It has been raised over the years of the GPAQ survey to reflect greater expectations. We have grouped the other questions with two questions relating to administrative performance, and another more varied group of six questions relating to access, continuity and waiting time.

Administrative satisfaction

The average satisfaction level for these two questions has risen in a very satisfying way since the survey started in 2004/5 and this has indeed been the focus of much of our attention since the poor initial results. The average satisfaction level has risen from 62% to 77% over these seven years.

Our worst result in 2005, and the result farthest of all from the benchmark, related to ease of getting through on the telephone. Happily, as a result of real effort from the staff involved, together with investment in new telephones and computer systems, this score has improved from 43% in 2005 to 51% in 2009 and to 72% in 2012.

We are also very happy to see patients’ “satisfaction with receptionists” rise from 73% in 2005, to 79% in 2009, and 83% in 2012 (against a benchmark of 77%).

Satisfaction with GP consultation

Each of these eight questions has consistently improved over these years. In 2005, the average exceeded the then benchmark (though the 2005 now only matches the subsequently increased benchmark of 83%). In the following years, the average consultation satisfaction was 85% in 2009 and is 88% now. All questions exceed benchmark by at least 4%. This is our key measure of patient satisfaction.

Satisfaction with access etc.

This group is a mixed bag with very good performance in some areas balancing out some quite poor performance elsewhere. Satisfaction with opening hours is 1% down on 2009 but is still 10% above the NHS benchmark.

Satisfaction with doctor availability, both “particular” doctors and “any” doctor, has deteriorated significantly (by 6% on average) since 2005, though in both of these ratings the practice still exceeds the NHS benchmark. This was the area with the greatest number of difficult to understand responses. There were as significant number of responses where patients said they could always obtain an appointment with a doctor  

Satisfaction with waiting times has been relatively stable, though at about 1% below the NHS benchmark. This is discussed below.

Satisfaction with ease of phoning the GP for advice has improved by 6% since the last survey though it is still 6% below the NHS benchmark. This is discussed below.

Satisfaction with continuity of care is the weakest area in this survey, with current satisfaction levels 9% below the benchmark, and the trend since 2005 has been consistently downward. This is discussed more below.

GPAQ Surveys, NHS postal surveys and local PCT performance information show clearly that this practice performs at a level well above Hartlepool and national averages and that this is recognised by many patients. The practice has normally achieved maximum points (currently 1000) in the Quality and Outcomes Framework and this high level of performance is reflected in and confirmed by various performance audits undertaken by the local health authority and the Northern deanery (which regulated GP training).

Areas for improvement

There are undoubtedly areas which can be improved (as illustrated by this survey), and these are discussed below. Some of the negative aspects of this survey are also a function of the “model of care” chosen by this practice. All practices have to choose their “model of care”, or the way they operate, either consciously or by evolution. Bankhouse Surgery has chosen its model of care for a number of what the practice believes are very good reasons, with both positive and negative results. This does not mean that improvements cannot or should not be made, but it does probably mean that there will always be areas of relative strength and relative weakness. This is discussed further below.

There are now three satisfaction questions (out of sixteen) where the practice rating is less than benchmark level. The worst is continuity of care (at -9%), the second is with regard to phoning the GP for advice (-6% but improved from -12%), and the third, which is satisfaction with waiting times in practice (-1%).

1) Waiting times (in the waiting room rather than waiting for appointments)

Waiting time in the practice has always been a challenging area. One aspect that we have addressed, successfully we believe, is that of GP’s not starting on time. It is now very rare that GP’s start there surgery’s late without good clinical cause.

This remaining problem varies between GP’s and for several reasons. More traditional GP’s tend to believe that they should deal with all the medical problems brought to their attention, even if it makes them run late. This type of doctor may consider this an ethical obligation. Younger doctors are now trained to deal with the most important issues and get patients to arrange another appointment for other less significant problems “on their list”. Younger doctors therefore tend to run on time except when dealing with emergencies. Another reason why older, more experienced, doctors tend to run late is that they gradually accumulate more complex and difficult patients, which cannot easily be dealt with in the normal 10 minute slot. We have noticed that generally there are very few complaints from patients who specifically wanted to see those doctors with more of a tendency to run late, the dissatisfaction tends to come form those who have been put into these doctors’ clinics as same day “urgent” appointments. There are also cases where a patient is seriously ill and needs to be admitted to hospital and this can cause significant delay for subsequent patients.

2) Satisfaction with ease of phoning the GP for advice

We suspect that the substantially reduced dissatisfaction in this area is more down to the much increased ease of phoning through to the practice in general, than to the practice improving ease of access to GPs.

There is substantial disagreement amongst GP’s in general with regard to the use of GP telephone consultations and the use of GP triage. As demand for consultations has increased, many GP’s have resorted to new models of care to meet the demand. In many practices this has resulted in increased use of nurses (to undertake triage or to actually undertake consultations), or the increased use of telephone consultations with doctors and nurses. We have researched such options. We found that the evidence to date suggests (as one might expect) that telephone consultations are much inferior to face to face consultations and that a model of care which makes widespread use of such telephone consultations results in a much less safe service. It is also highly questionable whether or not telephone consultations are, on average, shorter than face to face appointments. This practice is open to new developments but will not change to an inferior or unsafe model of care. We understand that telephone consultations are very convenient for patients, especially those who are working, and all our GP’s have undertaken courses to improve their telephone consulting skills. They are simply not prepared to practice dangerously. Telephone consultations are used on occasions, particularly to clarify specific issues with patients but we are not yet prepared to use them as a primary mode of consultation.

We also do not allow our receptionists to put non-urgent calls through to GP’s whilst in surgery. Even urgent calls are only put through to that day’s on-call doctor, so the vast majority of appointments are uninterrupted. High levels of telephone access can often be at the expense of other patients. Any questions for our doctors can be communicated via receptionists who send electronic messages, via our clinical system, to the GP concerned. The GP will then answer via the receptionist or telephone directly if appropriate. Most of our patients value this system, via the receptionist, and many feel at more liberty to contact a GP indirectly than they would if the contact were direct. This system uses the GP’s time more effectively, e.g. between patients he/she can respond to several receptionist massages in less than the time it would take to make one call.

3) Continuity of care

Continuity of care is an ongoing problem for all group practices. Where a practice has only one or two GPs a patient is pretty well assured of always seeing someone they have seen before. Except in truly exceptional circumstances (e.g. extended holidays), patients can always make appointments with any of our doctors, well within our four week appointment schedule. The time they have to wait will depend on the popularity / time in practice of a particular GP. If patients need an appointment immediately or within a couple of days, some GP’s will be booked up or on holiday and patients will often complain about seeing someone other than their preferred doctor.

There really is no way around this fundamental problem. A good doctor who has been with a large practice for 25 years will have an enormous number of patients who prefer to see him / her and the practice could probably fill their appointments several times over. Additionally, there are a great many other demands on the time of more senior doctors, GP training, speciality clinics and NHS management being but three which further reduce availability to patients. Unfortunately, patients who need to be seen very quickly have to be seen by whatever doctor is available. We do believe that good continuity of care is possible and for most of our patients it is a reality. It does require a little effort and patience when booking appointments, and the willingness, ideally, to see more than just one doctor.

One other issue is that GP work has, in recent years, become much more of a family friendly and increasingly part time occupation. Many doctors have children and spend part of the week looking after them. Others may have activities elsewhere, perhaps in hospitals, "out of hours" services or GP training centres. These doctors simply are not available for as many hours in the GP surgery as was the case twenty years ago. Some of our doctor’s only stay for six month or twelve month placements as part of training schemes (just like hospital doctors do). This can cause frustration where doctors leave just as patients get used to them.

We have been working hard to improve continuity in serious and terminal cases, and we now have systems in place to ensure such continuity. Continuity is less essential in many cases, and clinical evidence suggests that too much continuity can be very counterproductive. A new set of eyes on a case can often spot something previously missed or offer other treatment options.

4) Access to doctors’ appointments

Satisfaction in this area has dropped substantially since 2005. This is despite our increasing the number of appointments offered per patient and more carefully planning capacity and supply of appointments. The drop in satisfaction and increased demand is even more surprising given the additional access to medical care offered by the walk-in-centre. They are soaking up some of the increased demand.

We believe our service to patients with regard to GP access has improved significantly over this period, even if it has not been recognised in the survey. Our service far exceeds the NHS access targets for GP’s. We monitor our performance in this area very carefully, forecasting demand based on historic trends combined with list growth, with flexibility to cope with considerable volatility. We are proud of our access levels, in absolute terms, and relative to other practices, and also of the safety of our service.

What we believe has rapidly changed in recent years, is the expectation of many of our patients for instant service wherever and whenever it is required. There has been a significant increase in demand per patient over this period, and an increasing tendency to require GP appointments for trivial conditions which are self limiting and about which a GP can do nothing. Even worse, these are frequently considered urgent conditions which require immediate treatment.

We are currently in consultation with our patient group on these topics and would welcome any patient views and / or new patient group members.

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