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10.10.16

So, what can I do for you today?

Source: NHE Sep/Oct 16

Emeritus Professor Angus Wallace, a leading figure in British orthopaedic surgery, academic research and former chair of the National Osteoporosis Society, considers how GP consultations are being held back and what could be changed to improve the experience for both the patient and doctor.

One of the most common introductions used when meeting your GP for a new consultation is: “So, Mr/Mrs X, what can I do for you today?” This is a gentle invitation to the patient to tell the GP why they are there and allows the GP to explore what might be wrong with the patient and what problems they have. But, is this the right place to start? Would it not be better for the GP to have a bit more information before the consultation starts? 

Let us consider how we book our car in for a service. The telephone exchange below is fairly typical. 

Car Owner phoning the garage: Good morning, can I please book my car in for a service?

Garage Receptionist: Yes sir, we are busy this week but we should be able to fit you in next week. Can you tell me which service the car needs and provide me with all your car details – make, model, registration number.

Car Owner: Yes, here they are...

Garage Receptionist: Thank you sir. Is it just a routine service or do you have any other problems?

Car Owner: Yes, thanks, a routine service but I have noticed that I have a flat spot while accelerating and the battery seems a bit tired, so can they all be checked as well please?

Garage Receptionist: Yes, I have noted these on the list, if there is anything else please either email them to me or write down the details and hand them in when you drop your car.

Car Owner: Thanks very much – which date?

Garage Receptionist: Monday next week at 8am – can I text you a reminder?

Car Owner: That would be very helpful, thank you. 

Here’s how a first GP appointment might be made by phone: 

Patient phoning the GP Practice Centre: Good morning, can I please arrange an appointment with my GP?

GP Receptionist: Yes sir, are you registered with the practice? Can I just take your details please?

Patient: Yes. My name is... and my date of birth is...

GP Receptionist: Can I please have your postcode to confirm that you are registered with us?

Patient: My postcode is... and my house number is...

GP Receptionist: We are busy this week but we should be able to fit you in in three weeks’ time.

Patient: Is it not possible to see the doctor sooner?

GP Receptionist: I am sorry, we are fully booked until three weeks’ time unless it is an emergency. Is it an emergency? What is the problem?

Patient: I have tummy pain but I don’t think it is an emergency. Can I tell you more about my tummy pain?

GP Receptionist: No that is enough, I am the receptionist and that is all the information I need.

Patient: But would it help if I give you more information?

GP Receptionist:  No that is OK, I have noted you have tummy pain. If you wish to give us more information, write down some notes and bring the notes with you.

Patient: Could I not send the notes in advance of my meeting with the doctor?

GP Receptionist:  Well, I suppose you could send them by mail or Fax them but I cannot guarantee that your GP will get them.

Patient: I thought Fax machines were now phased out, can I not send an email?

GP Receptionist:  Fax machines are the only fast communication permitted by the NHS, we are not allowed to use email communication, so I cannot accept an email from you.

Patient:  OK, can you text me my appointment time please.

GP Receptionist: Sorry, I know some GP practices are texting appointment times but we do not have that system up and running yet. It is scheduled for next year. 

The regulation and red tape preventing GP progress 

Quite correctly, patient diagnosis, treatment and information should be kept confidential. 

However, the regulations are now so stringent that it is really difficult for the GP to improve the efficiency of their consultations because of these regulations. In fact, the GP’s first consultation is remarkably similar to a church confessional as carried out over the last 50 years. 

The GP gets minimal information before the consultation starts and the first two or three minutes are focused on trying to identify the patient’s problem(s).

 How can we move forwards in 2016? 

The guidelines for a GP first consultation in England were 10 minutes up to 2013, when this Quality Outcome Framework (QOF) requirement was dropped. However, many GPs still use the 10-minute guide for their first appointment time. If the first few minutes are used to try to work out what the patient’s complaints are and to write them down, this eats significantly into this 10-minute slot.

 

Would it not be better firstly to give the patient the option of a five-minute or 10-minute appointment depending on their problem or needs and, in addition, to get the patient to document their symptoms before the consultation starts, and then any modification to the patient’s notes can be made by the GP? How could this be done? 

Option 1: Prior communication from home – the pre-consultation questionnaire 

When the patient phones for a GP appointment, could they not be sent a questionnaire about their condition aiming to identify their complaints or symptoms, how long they have been present, and how they are disabling or inconveniencing the patient? Such a questionnaire is shown below as developed by the Haughton Thornley Medical Centre. 

The pros and cons of Option 1 include: 

  • Some argue that this form of communication, transmitted by the patient to the GP practice, contravenes Standard ISB 1596 for secure email transmission and, therefore, should not be used
  • Elderly, frail and IT illiterate patients would need help from family or friends to complete the form
  • Transferring this form to the patient’s electronic record may be a hurdle
  • This completed form means that if the patient has a serious condition, as highlighted by the details in the form, then the GP becomes medic-legally responsible from the time of receipt of the form
  • The GP has some of the clerical work they normally have to carry out completed by the patient, leaving them with more time to focus on the patient face-to-face
  • Inaccurate statements or assumptions made by patients may not be corrected

Option 2: Completion of the pre-consultation questionnaire in the GP surgery via computer tablet 

This would require the patient to attend their GP appointment 20 minutes before their actual appointment time to complete the form in the waiting room prior to their consultation. This is very attractive because the confidentiality issues are addressed. 

The pros and cons of Option 2 include: 

  • Transferring this form to the patient’s electronic record may be a hurdle
  • Elderly, frail and IT illiterate patients would need help from one of the GP team who was appropriate to help with personal information and a privacy cubicle may be required
  • The GP has some of the clerical work they normally have to carry out completed by the patient, leaving them with more time to focus on the patient face-to-face
  • The computer tablets are in danger of being stolen
  • Inaccurate statements or assumptions made by patients may not be corrected 

Improving the face-to-face consultation 

The emphasis on electronic records has, in some cases, harmed the GP consultation. Instead of sitting and looking at the patient face-to-face, the GP spends more time looking at their computer keyboard and typing in the information which they are mandated to do through the previous QOF and more recent CQC requirements. Ideally ‘voice recognition software’ would step in here as it has for NHS Radiology, but unfortunately the GP practice environment is not sufficiently quiet to allow this as an option at the present time. The development of intuitive software, which will reduce the amount of keyboard documentation, is a challenge for the future. 

Improving written communication between the GP and patient 

The perceived NHS restrictions on using email communication with patients is currently damaging the efficiency of general practice. At a time when banks, insurance companies and essential services are all using email communication with their customers, NHS Digital now needs to urgently review and revise its advice to GPs and hospitals on how to use email communication effectively for NHS patients. GPs perceive that they are allowed to send letters by Royal Mail and by Fax but not by email, and although they do have support to use text messages to remind patients of appointments, they believe they are not supported to use emails. 

Is this perceived blank ban on email communication justified in 2016? 

In 2016 it should no longer be necessary for the GP to ask the question: “So, Mr/Mrs X, what can I do for you today?” In fact, if the GP does have to ask that question, it means that he or she has not developed the pre-consultation pathway properly and they should then be challenged to do so. 

Professor Wallace’s next article will focus on how the hospital out-patient experience can be improved with both present time and futuristic developments.

Training & Development Focus

Haughton Thornley Medical Centre –

Pre-consultation questionnaire 

  • Do you have access to the internet? (at home, work, friends, family, library) Yes/No  
  • Have you registered for ordering repeat prescriptions or booking appointments online? Yes/No - If not and you would like to be able to do this, please ask the receptionist at your Practice for your internet login information and PIN NUMBERS. Please note the receptionist or other member of staff may require 2 forms of identification to be shown to confirm who you are. 
  • Have you registered to access your medical record online? Yes/No - If not and you would like access to your records, then please fill in your details below – please print carefully: Name/Date of Birth/Email address 
  • Who is the consultation with today? 
  • How long is the consultation planned for? 
  • What issues do you wish to raise in the consultation (ideally ONE please)?  
  • Please give a brief summary of what has been happening until now

Training & Development Focus

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