Making Doctor's Appointments

[craigwalsh]

It is my honour to post the first message on this new forum. I started this forum because I was irritated by the treatment I received from the NHS, but couldn't find a place on the internet to post my comments.

A few years ago I was irritated by our former bank, and found the process of creating the www.couttssucks.com (http://www.couttssucks.com) website to be very therapeutic. It didn't matter whether anyone read the website or not: I felt much better having created it. Similarly, I hope that posting comments about problems with the NHS will make people feel better.

So, with the distinction of the first posting, here's my grumble about our GP's practice.

When my wife and I go to see the doctor, they will often say, "please make an appointment to see me in a month." We then go to the front counter, and inevitably they don't have the calendar "on the system" for the next month. This means we need to remember to call them in a few weeks, and their few telephone lines are always engaged.

If they had the calendar "on the system" for the rolling six or seven weeks, it would greatly decrease the burden on their already stretched telephone receptionists. I raised this matter on my last visit with the senior doctor at the practice (the practice manager was "out for a few days"). The senior doctor said that many patients complain about the same thing, but he was having a hard time getting his colleagues to provide their own schedules that far in advance.

With online systems such as Microsoft bCentral Appointment Manager (http://www.microsoft.com/smallbusiness/online/scheduling/appointment-manager/detail.mspx) patients could make their appointments without the need to make telephone calls. Yes, many patients might not be comfortable making an appointment online, and they can still telephone and battle the switchboard. But I know I'd prefer to book my appointment online.

Will any of this happen? No. The surgery will fret about patient confidentiality, and will be frightened to make any sort of change. And I will continue to be frustrated when the doctor suggests that I simply make an appointment to come back in a month.

[ATUNLEY]

At our practice, you have to ring the triage line, from 8.30 a.m. to obtain an appointment with the Doctor of your choice. Try phoning at 8.30, it can take up to 1/2 hr, and then you cant get the appointment time or Doctor you want. It is also amazing that the Doctors who always seem to be there Mon-Fri now do less hours. There was a note in our Doctors saying that 63 appointments had been missed this month, how does this happen, are the patients concerned notified???

There are notices saying no abusive behaviour permitted towards staff, how about the staff being pleasant on the phone, and what about helpful.

I feel that our Local Doctors have gone down hill recently and that the system put in place by this Government are making the situation alot worse.

[Renal]

Mmm...

At the risk of being found out on the wrong forum.

What you describe is unpleasant, useless and unwelcomed - by both the patients and the doctors.

When the government forces GP Surgeries to use various items of software and forces surgeries to provide an appointment with a doctor (not necessarilly your doctor or even a regular doctor), these things are going to happen and continue to happen.

[craigwalsh]

I'm confused. It seems that the NHS tells us that our GP's surgery is semi-independent when we have a grumble about it. "That's nothing to do with us," says the NHS.

But yet if a surgery wants to be innovative and use (for example) on-line appointments software, then the NHS can say, "no, no --- not approved."

And, in the meantime, as patients were told to go to the front desk and make an appointment "in a month." And the poor receptionists on the front desk are forced to tell us, over and over again, that next month's schedule isn't on the computer yet.

It's just such a shame, because it seems so very easy to fix.

[mark1baker]

1. GPs no longer have control of their IT. We had a letter from the PCT stressing that we must not install any programmes on out system that have not been OK'ed with the PCT. So we aren't allowed to bolt on new bits of software.

2. I don't know anything about the online appointment making software in question. I have no problem with the concept, but it's easy to gloss over confidentiality issues when you won't be the one who is hauled up before the GMC if you inadvertently get it wrong, and risk losing your career.

3. Any surgery that can't or won't make appointments a month in advance has serious managerial or capacity problems.

Mark
GP

[craigwalsh]

Hi, Mark ---

Welcome to this new forum. I look forward to your thoughts in the weeks and months ahead.

I have found that the Data Protection Act is frequently cited by various organisations (including the NHS) as a reason for not doing something. It seems that by saying, "Sorry, we can't do that because of the Data Protection Act," people will nod sympathetically and go away. Clearly nobody wants to violate the Data Protection Act --- whatever it is.

I'm retired (and disabled) now. In my previous life, the company we owned handled a tremendous amount of data for a large number of individuals --- a million transactions each month. I was responsible for our compliance with the Data Protection Act. The Act is fairly limited in its scope. And it rarely prevents organisations from doing things: it just specifies a framework for the handling of data (much of which is common sense) and contains regulations for the disclosure of data.

The Information Commissioner's website has a fact sheet (http://www.ico.gov.uk/upload/documents/library/data_protection/introductory/data_protection_myths_and_realities.pdf) on Data Protection - Myths & Realities.

At my GP's surgery, I don't think the problem is really one of software. I gather that the individual doctors are slow to provide their schedule for the coming month, so a calendar can't be put into the system until the last minute. And when I spoke with the senior doctor, he seemed powerless to fix this. He said this was a source of constant complaints from patients, and he wanted it fixed --- but he was resigned to the fact that it just couldn't be fixed.

Yes, it's easy for me --- watching this externally --- to say that I could have this fixed in a twinkling. But it does seem rather easy to fix. And it doesn't seem to be a problem at our veterinarian or the hairdressers.

[mark1baker]

Hi Craig

The Data Protection Act was extended from 2000 to cover health records, so it may have extended its scope considerably since you were involved with it. IIRC previously medical records came under the Access to Health Records Act.

Having said that, personally I have never had any difficulty with the DPA myself: on the whole it's fairly clear what our duties and responsibilities are.

We have no difficulty in providing appointments 2 months ahead. All it requires is for staff to give 2 months' notice of leave, not unreasonable in my view.

My perception* is that you are quite right as to the source of your problem. It's nothing to do with Acts of Parliament, PCTs or Microsoft, it is that the surgery hasn't got its act together on this.

Mark


*From what you say, knowing nothing of any other side to the story!

[craigwalsh]

Hi, Mark ---

Since you seem to have a view from the other side of the counter, can I ask you another question?

At the same meeting with the senior doctor at my GP's surgery, we discussed the GP Out-of-Hours Service. At one time we could call the surgery, and a doctor from the surgery would come around to the house to see the sick patient. We're only a couple of miles from the surgery, and this was very useful when my wife had pneumonia a several years ago. (She was ultimately admitted to the hospital, and spent 10 days there --- and recovered fully.)

These personal visits seem to have now gone away, and have been replaced by what's called the Out-of-Hours Service. The local PCT handles the telephone calls from this geographic area with a nurse. She's in a rented suite in the local hospital. There seems to be one doctor there to see patients.

The senior doctor at my surgery said that this system had been imposed upon them, and that he and his colleagues miss going out to see patients. I got the impression that his surgery had to somehow "fund" the Out-of-Hours Service with some form of assessment. He described the quality of the service as "awful."

I was under the impression that most GP's did not want to make house calls. Is the consolidated Out-of-Hours service something that's been imposed upon GP's by the PCT, or created by the PCT in response to GP's requests? And how is it funded?

Just trying to understand this convoluted system a bit better. :)

[mark1baker]

Craig

When I started in GP all GPs had 24/7 resposibility for their patients. Some city GPs could use deputising services, and contract out the service, but most of us could not.

This was highly onerous. As well as my day job, every 4th night and weekend and every Saturday morning I was on call, ever 3rd night when one of my colleagues was away.

On an on call night typically I would get back home at 1900 after an 11 hour day, do 2-3 visits during the evening and on average get out of bed twice during the night. Then I would do a full day's work next day.

I don't suppose I was the hardest working person in the county, but I bet I came close.

I am sure most patients thought this was a good service, but I can think of no other country that did it this way. Not everybody did mind you.

In the mid 1990s we were allowed to get together to form co-operatives, where most GPs were able to work much shorter shifts from a central location covering many pracvtices, in our case 25-30 GPs. By this time we were expecting patients to travel to us unless they were unable to.

Another driver was the declining popularity of GP as a career with increasing difficulties in recruitment. The nature of GP on call was a major factor in deterring recruitment.

The 2004 GP contract allowed GPs to opt out of providing a 24 hour service (at a financial cost). In return for this we had the box-ticking Quality and Outcomes framework and other sundry stuff foisted on us. Almost all GPs, myself included, did opt out.

Once opted out we can't opt back in again, so even if we wanted to (which I don't) this would never be put back in our contract.

At the same time the Government introduced financial rules for Out of Hours (OOH) providers. Our co-op would not have been able to continue as constituted because we weren't big enough and well enough financed, never mind that it had operated successfully for 8 years.

Now there is a market for OOH provision, and the service has turned out to be worse and more expensive than the one we provided. We were, of course, providing the service very cheaply, and doctors working OOH shifts now want to be paid the market rate. See how much it costs you to get a vet out at night (and I have every admiration for my veterinary colleagues).

The OOH system will never go back to the way it was. Personally I would rather find another job than go back to being on call as described above, and in cany case a large proportion of the GP workforce is now salaried, and such hours would breach the European Working Time Directive.

Mark

[craigwalsh]

Hi, Mark --

Thanks for taking the time to provide a detailed explanation. That's pretty much what I thought: I was confused when the doctor at my GP's surgery lamented the out-of-hours service was now handled by others.

Working a full day and then being called out several times at night does not seem worthy of lamentation ....

The senior GP at my surgery had a theory that this change was being led by "female doctors." In his view more and more GP's are female (shock, horror!) and he theorises that female GP's want a 9-5 job so they can raise their families.

I was in the States in 1998 and became very ill (we later learned it was food poisoning). Nobody wants to call an ambulance --- they're for really sick people --- so my wife called the doctor and asked if he'd come and see me. We thought there was no way I could get to the doctor's surgery. My wife's request was almost met by laughter. House calls were something quaint --- from 1950's television programmes. She was told that if I was that sick she would need to call an ambulance, and they would take me to the emergency room.

In the end I stumbled to the car and she took me to the doctor: it was a very painful experience, and, in retrospect, perhaps we should have called the ambulance.

Of course in the States the cost of an ER visit is a powerful factor. Most insurance companies won't pay for an ER visit unless it was (in their view, and with the benefit of retrospect) absolutely necessary. My last ER visit in the States in circa 2001 was for a kidney stone, at 3:00 AM. Yes, my insurance company thought it was necessary --- and it cost them nearly $3,000. (Just a doctor visit, x-rays, and some medication.)

Speaking of money, a private GP visit at BUPA Bristol costs £85 for 30 minutes. A private GP visit at the Cromwell Hospital in London is circa £50. How much does the NHS pay my GP's surgery to look after me for a year?

[mark1baker]

How much does it cost for GP services per patient year? There is no exact figure because GP remuneration is so arcane and depnds on so many things, notably the Quality and Outcome Framework referred to above.

Looking at a copy of our draft accounts, and in our practice we get about £140 pa for every patient. From this we must pay for certain drugs (vaccines mostly) all rent, expenses and salaries of staff.

[craigwalsh]

Hi, Mark ---

Thanks for sharing that information.

To hear our GP talk about it, I thought they only received a few pounds per patient per annum. The senior GP told me the cost of one visit to the private GP at BUPA (£85) was equivalent to the amount he'd receive from the NHS to treat me for almost ten years.

A little hyperbole me thinks . . .

I marvel at how today's politicians talk about not wanting to have two medical systems, separated by economics. Do they not think we have that already?

I had a blood test that showed a sugar level that was a bit elevated, so I needed a glucose tolerance test. At the local hospital (the Worcester Royal) there is a six month queue for GTT's. Thanks to BUPA, I called the Cromwell Hospital in London, and had the GTT the next week. I could have had it the next day if I'd wanted to go to London that quickly.

I have also come to the sad realisation in the past few months that my NHS GP is not the central point in my care and treatment. BUPA is happy for me to be referred to a specialist by any GP, not necessarily my NHS GP. (And to facilitate this process, BUPA has its own GP's-for-Hire who will happily handle referrals.) Unfortunately, I have been unable to locate any private GP's near my home in sunny Worcestershire. Yet.

I've been good about having the specialists send their findings back to my NHS GP to be kept in my chart, but when I see the GP (and it's rarely the same one -- usually a locum, or a young registrar) they only have a chance to look at the very last entry in my chart. True "transactional" medicine --- not a "relationship."

Thanks again, Mark, for sharing this information with me --- and other visitors to this forum.

[mark1baker]

I'm a bit surprised by this. We have no difficulty at all doing our own GTTs, and I had assumed most other GPs thought the same.

I wouldn't dream of referring someone to hospital for a GTT. We do it and interpret the findings ourselves, usually the same or the next week.

Nor do we refer people who turn out to have diabetes, except for the occasional one with problems we can't deal with.

Mark

[Elen]

Looking at a copy of our draft accounts, and in our practice we get about £140 pa for every patient. From this we must pay for certain drugs (vaccines mostly) all rent, expenses and salaries of staff.

Do you know what the cost is per patient per year for only providing essential services? I wrote an article a few months back and there's a marked difference between GMS and PMS funding and very little in terms of quality of care given (as measured by the QOF - not without its flaws, obviously).


To hear our GP talk about it, I thought they only received a few pounds per patient per annum. The senior GP told me the cost of one visit to the private GP at BUPA (£85) was equivalent to the amount he'd receive from the NHS to treat me for almost ten years.

If this is a recent quote from your GP, it's rubbish. Even if we're just talking about essential services, if your practice is GMS it will get between £50-80 per patient per year; if it is PMS or PCT-run, it will get in excess of £85 per patient per year (and usually wildly in excess of this figure).


When I worked in primary care, we were able to book appointments for patients around 1 month in advance. Any further and the patient had to ring back. I don't see the problem with that: patient takes a little charge over his/her own health. We never had problems with routine on-the-day appointments, emergency appointments were (and still are) available every single day after both AM and PM surgeries and the doctor does home visits every day during the week for those unable to get to the surgery (the local PCT-run on-call service took over weekends and weeknights).

I've seen the way an efficiently-run surgery is run, so have real problems getting my head around my own GP's surgery, which is poorly-run, infuriating and just generally naff. I can't make same-day appointments unless I ring between 8.45-9am or between 2.30-2.45pm. The phones are on answerphone for almost half the day. Considering I had to answer the phone for the whole time the surgery was open, this makes me extremely cross.

[craigwalsh]

We never had problems with routine on-the-day appointments

Oh to have a GP's surgery where this is true. At my now former GP's surgery, there were no routine appointments available within the next month. But then the following month wasn't up on the system yet. So you had to call. But you could never get through on the main telephone number because everyone else was calling.

I will, however, give them a bit of credit. When I did need an urgent appointment they were able, remarkably, to assist. But when I then got to see the doctor, the message was "you've cut into the queue --- make it fast --- very fast --- and then get out."

Yes, SIR!

[Elen]

Oh to have a GP's surgery where this is true.

Yes, I know of only the one where I used to work. Unfortunately the usual availability of 'on-the-day' appointments does give rise to a rather demanding practice population. It makes patients very cross if they have to wait, oh, a whole 24 hours before seeing a GP for a routine appointment.

I accept that this surgery is not the norm, but the fact that it exists suggests that it isn't impossible for all surgeries to offer such a service.


But when I then got to see the doctor, the message was "you've cut into the queue --- make it fast --- very fast --- and then get out."

Yes, SIR!

This is what it's like at my own GP's surgery. "We can offer you an emergency appointment, but it's only 5 minutes". Yes, because it's a really good idea to cram as many (supposedly) acutely ill patients into 5-minute slots, isn't it??? :rolleyes:

[craigwalsh]

it's a really good idea to cram as many (supposedly) acutely ill patients into 5-minute slots, isn't it???

During the period after I'd fractured my back, but before it was correctly diagnosed (by the private sector) the pain was unbearable, and the pain killers just not working. I called my GP's surgery. "Yes," I was told. "He can see you if you come right down."

That's fantastic. Who could possibly grumble about that?

My wife was just returning from Waitrose. I hobbled out to the car and said, "We have to go to the doctor's surgery --- now." With some of the groceries in the car we dashed the few miles to the St. John's House Surgery.

"Sorry, you're too late."

It couldn't have been more than ten minutes between the time I called, and the time I arrived.

As I was in the car, and in pain, I told my wife to please take me to A&E. They looked at me, and made yet another misdiagnosis: in the NHS World falling on my back had somehow caused a kidney or bladder infection. So I was given antibiotics.

Paracetamol and antibiotics --- the universal panacea for all ills. Step right up --- get your prescription now. Next . . .

[Elen]

I can only say your experience has been dreadful. I once made the mistake (whilst a locum was in the surgery) of telling patients to "come right away" and having them turn up anything from 5 minutes to 1 hour later. It was awful!! Really very bad telling you to come straight away and then not seeing you - 10 minutes is nothing.

I went back to my old surgery this evening - over-running as usual as everyone wants to be well for Christmas! - each patient had at least 15 minutes with the doctor and despite running 20 minutes behind, not a complaint from anyone. I guess because they know they'll get a decent consultation at the end of their wait.