I know it seems a million years ago but alongside the GP forward view were the “10 High Impact Actions”. High Impact Action 1, Active Signposting, spoke to us as a practice. Indeed, it was our practice mission to “partner with our patients”. Helping them to find the right service or clinician at the right time aligned perfectly. We set about restructuring our process (total telephone triage) to incorporate an element of understanding the patient’s need before making an offer of the available services and appointments that matched.
Back in 2016 this was truly reinventing the wheel because we had to develop our own training, policies, protocols and what is now commonly referred to as the Directory of Service. We hit some bumps in the road, particularly around convincing patients that this was a good thing for them. This was quite the culture shock for our patients. Having gone from total triage, where you rang up and got a telephone appointment without disclosing any details. Having to “tell your story” to the “receptionist” cause more than a little upset.
However, by 2017 the process was fully embedded, with support from our PPG. We were actively signposting 33% of patient (who would have previously had a phone call) to another service or clinician that could meet their need. Because we had used quality improvement methodology to make the change, we had some excellent data to prove the difference this had made. We decided that the National Association Primary Care awards would be a good platform to demonstrate the work we had done – we reached the finals!
Despite the awards being held 150 miles from the practice this is where I met Dr Richard More, MD of Xytal. I say despite because at the time Richard was a GP in a practice in the same town! In the days before Primary Care Networks , and this being very much the nuts and bolts of delivering Primary Care, Richard had no idea that this innovation was occurring just up the road from him. We agreed to meet for coffee the following week.
As we sat down with a filter coffee in hand Richard told me about the quality improvement work that Xytal had been delivered alongside Primary Care since 2004. Richard invited me to support Xytal to develop the active sign posting work into a Quality Improvement Programme that could be delivered at Practice and Locality level. I jumped at the chance to spread the impact across as many practices as possible.
Over a series of real-world meetings (zoom wasn’t really a thing back then!) Xytal team members came together to produce version 1 of the active sign posting programme. When sharing our practice’s story with the team’s resident psychologist, Dr Charlotte Hilton, it became very clear that we needed to partner the Quality Improvement with person centred skills-based training for the reception team. We saw an immediate positive impact in patient acceptance of the change in the practices who adopted this training. Over the years the programme has been refined, naturally evolving into enhanced care navigation programme. The complete package brings both people and process change to realization.
Then…. March 2020, a new virus is rapidly spreading across Asia, getting closer and closer to our borders. Eventually the mandate is issued, move to total triage. In an instant we are back in 2016. When I look back now, we didn’t have to unravel all that work, but we did. Things were changing every 5 minutes. I think I went without sleep for 72 hours at one point, digesting, planning, implementing - rinse and repeat with each update. To be fair it was quiet for about a week, only a handful of people called us each day. The patients listened; they heeded the request to give Primary Care some space to adapt. There didn’t seem much need to redirect demand, besides our Directory of Service was shot with every other service in just as much flux as us!
As the public shock settled, and needs cropped up, the numbers started to rise and rise and rise. We wondered if it would ever stop! We had weeks where demand was 20%-30% up on pre-pandemic levels. As time passed it felt like the threshold for contacting the GP dropped and dropped. Things that people would normally look after themselves, they would contact the practice. Our major external sign posting opportunities were compromised, our pharmacies for example had constant 30 minute to 1-hour queues. Likewise, our telephone wait times increased, as did the complaints.
In response we decided to shift as much work online as possible, freeing up the phones for those who could not move online. We implemented an online consultation front door, with all patient requests flowing through this system.
So… again with hindsight, this did wonders for patient access, but demand was now 50% up. It did, however, restart our care navigation journey. We adopted the Xytal programme and redesigned our system with care navigation in mind. We delivered person centred skills training to all team members and re-established our directory of services. This skills training really supported the team through the wave of “I’ve had enough of lockdowns” frustration that patients transferred onto our team. It also allowed us to deal with the abuse robustly, knowing that our team had used the skills to attempt to defuse the situation. Through rapid PDSA cycles we were able to establish the changes that worked well for our team and patients alike. Despite continuing levels of high demand, we felt more in control of the flow and our reception team were once again able to support patients to find the right service or clinician to help.
It felt like a massive ask, to pull together the team and block out 90 minutes of their time each week. The fact is the change wouldn’t have been possible without this forced “headspace”, something that had been lost to the busyness of the pandemic. When I left the practice back in March 2021 the struggle was still very real, increasingly difficult to meet the rising demand. Working alongside practices I see many have still not had the opportunity to review their patient led demand systems (it is so much more than appointment booking!) since COVID tore up the rule book. This is totally understandable given the asks that have been made of Primary Care over the last two years.
My recommendation is to take action today to get the Quality Improvement session times blocked in your team schedules for April – June 2022. Do this before Q2 where you will likely be working on your LTC review systems to recover QOF for March 2023.
If you need any help with your care navigation, or if any of this speaks to you and you want to take action, you can book a free meeting with us here.
This blog was written by Daniel Vincent.