We visited Rosewood Medical Centre in March 2016 in response to concerns from patients about what they considered to be poor service. The Medical Centre was aware of the concerns and was keen to co-operate and support the visit.
In the course of the visit, we were able to interview a number of patients, whose views are summarised in the report. The concerns centred around the use of a telephone triage system for obtaining appontments; the practice has modified its approach and has made more appointments available. In order to respect patient confidentiality, the exact date of the visit has been witheld, and patients' details have been anonymised.
A To the practice:
The following recommendations are aimed at supporting the patients and the staff in the Medical Centre to improve its service model.
1) Develop a service which is easy for patients to navigate
The better informed the patients, the better they will make the best use of the service available to them. The vast majority of patients do not want to waste their time or that of the Medical Centre, so helping by providing straight-forward, clear and simple information in an accessible format for all patients will facilitate the reduction of time-wasting and unnecessary cost.
Accordingly, the Medical Centre will benefit from devising and supplying clear, simply explained information leaflets about
- Opening times and what services are available during this time
- The days and times when the GPs are running clinics
- The triage system times and what the triage system aims to achieve
- What constitutes a “bookable appointment”
- What constitutes a “non-urgent appointment”
- Improved repeat prescription times (aiming for a maximum turnaround of to 48 hours) and a robust on-line repeat prescribing request system
- How to use the on-line booking system
In addition, it is essential to update the Medical Centre website to provide current, consistent and, above all, accurate information.
2) Invest in front line staff to improve the service
The Medical Centre needs to develop a programme of regular staff meetings to provide a forum for collaborative and open dialogue enabling the Medical Centre to achieve a patient–centred approach to delivering care.
A comprehensive training programme, embracing all aspects of the Medical Centre’s services and which ensures that all members of staff are able to provide consistent and supportive advice to patients and carers, should be designed and implemented.
In addition, there is need to ensure the staff are knowledgeable about other services available to support patients, sufficiently so that they can provide details and times for services such as NHS 111 and the GP Hub when the Medical Centre is not able to provide an appointment.
All recorded verbal and written complaints from patients should be reviewed and responded to as quickly as possible.
The need to reduce the turn round time for repeat prescriptions: the local chemist has reported that the advertised turnaround time is sometimes exceeded and is at variance with information given on the Medical Centre website, which itself is in urgent need of updating.
For patients who require blood tests, details of the locations at which that is available should be provided when a blood test request is issued, and a poster displayed in the waiting areas.
3) Patient engagement
GP practices are a very important part of people’s communities so the Medical Centre should now consider ways in which it could widen its engagement to get new voices heard.
B To the Havering Clinical Commissioning Group (CCG)
The patients’ expressions of concern that gave rise to the visit now reported were primarily the result of inadequate preparation for the implementation of the triage system. It has become clear that a particular issue was a failure to explain the principles or operational requirements of the system to both staff and patients, leaving staff in particular with difficulty understanding what was required of them and how to explain it to patients.
But these difficulties revealed a further issue. Reception and administrative staff in GP practices have traditionally been treated as employees of independent, small enterprises whose training is a matter for the GPs as their employers.
The evidence of a recent survey commissioned by the CCG and carried out by the local Healthwatches in Barking & Dagenham, Havering and Redbridge is that many people are unaware of the alternative services to GPs and hospital A&E departments. GP staff need to be able with confidence to refer patients to alternative sources of medical support when appointments at their practice are unavailable immediately; the evidence suggests that many staff lack the confidence or knowledge to do that authoritatively.
As more and more functions are shared across the health economy, however, GP practice staff are likely to find themselves having to respond to patients’ questions across a range of health activities of which they have scant knowledge. It is vital that patients across the whole of the local health economy get similar, if not the same, access to authoritative and consistent advice about GP services from practices’ staff; this can only be achieved by ensuring that all of those staff members, administrative and clinical, are trained to the same – high – standard and receive regular and accurate updates. In this way, it is likely that patients will have greater confidence in, and understanding of the limitations of, GP services and be more likely to await an appointment than refer themselves inappropriately to alternatives such as A&E services. Healthwatch Havering believes that the CCG is best placed to arrange this centrally, either by providing suitable training itself or by commissioning an appropriate training provider to do so.
Healthwatch Havering, therefore, recommends that the CCG consider what might be done to provide all GP practice staff with training and up-to-date information in general issues relating to the health economy.
While this may be costly in the first instance, in the longer term it should result in a more effective use of resources by avoiding unnecessary expenditure resulting from patients failing to understand where best they can obtain services, not least by reducing (if not eliminating) unnecessary attendance at hospital A&E departments.
 Urgent Care Services Survey, BHR CCGs, March 2016
Response of Rosewood Medical Centre
Following our report, the practice has told us that they want to work closely with us to improve the service that they render to their patients, that they have particularly noted the points made by patients as set out in the Appendix, and to the CCG about offering training for reception staff.
In addition, the practice arranged for an audit to be carried out of the improvements to access to their services. A copy of a presentation of the findings of that audit is available at the link below. Particular attention is drawn to the following slides:
6 - Setting standards
14 - Change in waiting times
17 - Did you see your usual doctor?
19 - Overall satisfaction
22 - Overall, is the new system better?
27 - Potential for future improvements
31 and 32 - Post-audit changes implemented
We carried out a follow-up visit, at the invitation of the practice, on 3 December 2018, following complaints from some patients about difficulty in making appointments.
The team discussed the arrangements for appointments at lenght with a senior partner and the Practice Manager. Contrary to the experience of the patients who had been complaining, the evidence presented suggested that imrpvements had been made and were continuing. the management team at the practice were clearly laer to the need for further improvement. The average waiting time for an appointment was now four days.
All in all, the team felt that the surgery had made, and was continuing to make, changes in the way they worked to deal with the criticism they had been subjected to. The team fed back this view to the senior partner and and asked that that praise should be filtered back to staff
We carried out a further visit to the practice in February 2020.
The team was able to speak to four patients, who were all happy with the practice: all had been able to make their appointments for that day by telephone. When asked whether they could get an appointment when needed, they replied “no”, adding that they found difficulty seeing a specific GP but accepting that this was not unusual. They did tell the team that they felt that more needed to be done to accommodate urgent requests to see a GP, because by the time a call was answered, all same day appointments might have gone!
Most Doctors would run late, as elderly people always had more than one health problem, which meant that sometimes the standard ten-minute time slot could not be adhered to. Nurses’ appointments had a fifteen-minute time slot. A three week wait for an appointment was definitely not liked: one said “Give us back the olden days when we could just go and sit and wait at the surgery!”
Patients said that a ten-minute appointment was not long enough; it did not allow time for them to explain their symptoms fully and led to them forgetting to mention key points. Staff were always kind but, because everything was rushed, they would end up wishing they had been able to say more.
Overall, patients told the team that the practice was good, but that it was very stressful sitting waiting for the clock to tick round to 8am if they were trying to get an urgent appointment, knowing full well that going elsewhere for advice some distance away was not possible, especially if the patient was feeling unwell.
Summing up the visit, the team had a really good overall impression of the practice. Staff were lovely and accommodating and the determination to move forward wherever possible came over very clearly. The team followed up with the Practice Manager patients’ comments about making appointments, confirming that it would be referred to in the report.
He accepted this, pointing out that this was a problem across the country and that, with an older population in Havering, this is not likely to change any time soon.
The team recommend that:
- Value added focus groups be set up as a way of moving the practice on to Outstanding.
- Consideration be given to providing a designated phone line for priority patients to facilitate their contacting the surgery for advice on health problems and to make appointments made.
- Consideration be given to introducing advice sessions for people with long-term conditions, such as training sessions for newly diagnosed diabetic patients on how to cope.
See the CGC inspection report for this practice
See the practice website