[I sent the following paper to the Tower Hamlets LMC (Local Medical Committee). It gives the context and needs to be read together with the Tower Hamlets PCT document on patient registration, see link at end of page]
The problem of patient registration in Tower Hamlets: one GP’s view (George Farrelly, The Tredegar Practice), 6 May 2009
I am writing to raise concerns specifically about the issue of patient registration, and I will perhaps mention wider concerns as well.
We were recently sent a document entitled ‘Guidelines for registering with a practice in Tower Hamlets’. My understanding is that this document was drafted jointly by the PCT and LMC.
It raises again an issue which has been present for many years and has not, to my mind, really been addressed. That issue is how can the PCT plan General Practice capacity so that it deal effectively with the population of Tower Hamlets.
I will speak about our practice and our personal experience. The specific issue is registering patients, adding patients to the list. (The PCT document also alludes to providing emergency, and immediate and necessary treatment, and this is another issue which I will not address directly now).
In about 2002 or so the ideas for the new GP contract were in the air. The idea which appealed to Isabel (Hodkinson) and me was that our job description would be more clearly defined, that we would be paid for work we were already doing but was unpaid (in essence the sort of work we undertook under the ‘Healthy Eastenders’ project which then became the Clinical Effectiveness Group). In essence, an updated, modern GP contract which would pay for a quality service. We welcomed this idea. My thought was: Great, we can look after a smaller population but actually do it well.
(We are not in it for the money: our prime aim is to offer a ‘gold standard service’, of which all practice staff can be proud. We obviously have to pay the mortgage and cover expenses, but we do not aspire to expensive cars and second homes).
When the new contract actually arrived (by way of the Carr Hill formula madness which occurred at the same time as the invasion of Iraq: a very good time to bury bad news), it included a stipulation that we could not close our lists. Now this is not a problem for a practice which is aiming to increase its list size but is a problem for a practice which feels it is at its correct size (see below). People high up in the planning chain were keen to promote the ease of changing practices so that patients could leave practices they were not happy with and join the ‘good’ practices in their locality. But inherent in this model is a basic flaw: if demand exceeds capacity, then if this model is adhered to then the ‘good’ practices will implode. Why? Because in this ‘free market’ model patients will move to the more desirable practice; because as capacity is exceeded, the quality of this ‘good’ practice will fall and its performance will decline. Gradually, if the system truly works as a free market, the ‘good’ practice’s quality will reach a stage when it matches the quality of the ‘undesirable’ practice; then flow between the two will cease. Of course, if capacity exceeds demand then the planner’s dream will be realised: practices will compete with each other and thereby raised their standards. But in the real world of Tower Hamlets that situation simply does not pertain.
In my conversations with other GPs in the last few years, I have never heard of a practice (unless they actually wanted to grow and were actively seeking patients) who did not in some way limit the number of patients they took on. Yes, we were registering patients, but not in the manner that the ‘free market planners’ would have wanted us to. Because had we done so, practices would have self-destructed. And so, sensibly and wisely under the circumstances, so as not to self-destruct, practices rationed registrations in whatever way they had to.
The plannners should be asked: imagine your favourite restaurant. You like it because of its ambiance, the good service, the excellent food. Other people like it, which is understandable, so you have to book in advance. You have to book because there is a limit to how many diners they serve, this you can understand. But now imagine this: the Minister for Dining Out wants to make good restaurants accessible to all and a decree goes out: you cannot limit the number of diners at your restaurant, you have a responsibility to seat anyone who wishes to eat at your restaurant. Now you don’t have to book, you just go. You can imagine the scene: they have crowded in more tables, there is a pressure to eat quickly because disgruntled people are milling around on the pavement impatiently; the quality of the food has dropped; the owner is stressed and irritable. Where has your favourite restaurant gone?
The basic reality of our practice is that we have a limit to how many patients we can look after well. If we exceed this limit, then the system becomes stressed; if the system is stressed it functions poorly and those within the system (patients, staff) are less satisfied. There then comes a time when the system becomes unhealthy: unhealthy for patients, unhealthy for staff.
The planners behave (in their communications, in their planning, in their priorities) as though they do not understand this.
The document on patient registration (see link below) is concerned solely with registration.
I think it is essential to broaden the picture and to look at other areas as well: Access (which will obviously include registration but also the access that already registered patients have); Quality (the quality of the overall service for the patients; the quality of working conditions for the staff [support, training, development]; the quality of the structures of the practice [IT, for example]; ‘Organisational Development’ would fit into this area; quality of communication: between practice and patients, between staff within practice; etc); Capacity (what is the point beyond which Quality and Access decline?); and Resources (what are the resources available to the practice: staffing, financial, etc?).
Once vital thing to remember is that these areas inter-relate (hence the arrows). If one area changes, it will have an effect on the other areas, or for change to occur in one area you will have to make changes in another area. Access will depend on capacity; capacity will depend on resources; resources can be enhanced if the quality of planning is good; to have high quality planning within the practice requires time and resourcing; and so on. It is a system, it interacts. We should see it as an ecology; we should think ecologically about it.
I do not think the planners have this perspective. We need to ask them to adopt this perspective, otherwise the system will suffer: we will all suffer. In fact, we are all currently suffering and we need to try to reverse this.
About a year ago, we agreed with the PCT to increase our list size by 400 patients, taking our list to 3,516. We were given some money to do this. We have undertaken building works to create an extra consulting room. This development has cost us: the actual building costs has exceeded the money advanced to us by the PCT; it has required a significant amount of time by staff (uncosted, not resourced); it has caused a considerable amount of disruption. We have increased our staffing, which we are funding. Our impression is that our (IH and GF) income will fall.
Our working hours have expanded: at least one of us (sometimes both) stays later than 9pm in the evenings to deal with basic administration (results, post, repeat prescriptions, reports, phoning patients); I go in at weekends (one or two days each weekend; the Easter weekend I went in on 2 days; the early May Bank Holiday 2 days, notwithstanding the fact that we are officially on leave this week, and so on). I have reached my limit. There are no more hours in the day, no more days in the week; I must sleep, I must go home, I must rest.
We have reached capacity (really, we are exceeding capacity…). So we cannot grow. We are a small practice and choose to remain that way; our patients like the way we are, and do not want us to increase the list size: access falls, the friendly small practice ethos is undermined.
So how do we deal with this requirement to register all patients who present themselves? The only way we can see forward in this slightly mad situation is to shrink our practice area boundaries. We will have to adjust the boundaries so that we reach an equilibrium: find a practice area size which allows a balance so that our list size remains a constant 3,520, give or take a few. It will probably require that we periodically re-adjust the area (widening, shrinking) from time to time.
It seems to me that the PCT needs to assess the demographics in the various areas of Tower Hamlets. For example, what is the projected growth in population in Bow? Will the current capacity (local GP practices) be able to register these patients? (To determine this the PCT will have to have a dialogue with practices). It is simply not possible to just say to practices: you must register them all, it is your responsibility. Which in essence seems to be the current stance.
These notes are meant to be the beginnings of a conversation. A conversation between us and the PCT; us and GP colleagues; us and our patients. There are wider issues such as the ‘Resourcing General Practice’ project which need to be discussed as well but I have restricted these notes to the issue of patient registration.
The Tredegar Practice
(written while ‘on holiday’ because there was no time to do so when ‘at work’)
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23.5.09: The following are a few more notes added to the above document in order to give some simple, concrete examples of the way growing the list size has impacted and continues to impact on quality. I have been advised to forward this document to the PCT and so add this to illustrate the problem.
Our baby clinic: IH has always led on our baby clinic. Originally this ran every Tuesday afternoon and was staffed by IH, our practice nurse, a health visitor and an auxillary, and one of our receptionists. At the end of each baby clinic there is (was) a meeting between the professionals to share information and concerns about given children/families.
A few years ago, there was a centrally decided reduction in health visitor time (resource) so that the baby clinics were cut from weekly to the 1st, 2nd, (and 3rd when there was one) Tuesday of the month. This of course reduced access, reduced capacity, and reduced quality (the baby clinics were busier, there was less time to listen to concerns). The immunisation schedules in the meantime increased, which put further demands on capacity.
Now add to this an increase in list size: we have had a 50% increase in births due to the demographic changes in our list (a higher proportion of people joining the list are young due to housing changes locally). So we are fitting the increased workload into the same (reduced) baby clinic resource. Baby clinics are hectic: the waiting room area is overcrowded, the waits longer, the time taken to talk reduced; IH does not feel she can spend time with parents discussing their concerns; the clinic frequently overruns so that there is less time for the post-clinic meeting.
So this is an example where access, quality, resource, and capacity are negatively affected by an increase in list size without thought being paid to these other areas. But, of course, it has a wider impact than this: if parents cannot get their concerns addressed in the baby clinic, then they have to book a slot in normal surgery time. Then add to the mix that the PCT has essentially seconded IH (reduction in resource) to work on the wider diabetes project and she is therefore less available: parents therefore are more likely to see a GP who is not as skilled in dealing with baby clinic issues and concerns…..
An increase in patient registration (access from the point of view of unregistered patients, call this Access 1) will (if not accompanied by an increase in capacity) lead to a reduction in access for those already registered, call this Access 2. (I have had that complaint from patients: they have reported that the access has worsened: but of course it has, think of the restaurant example).
With the increase of our list size by 400 over the past year, inevitably our overall access is poorer. Will this be reflected in the access MORI poll? Will we who were once green turn amber or even red? Oh, those slackers at the Tredegar Practice!
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Going back to the patient registration document. In essence what this document is asking us to do is to offer 48 hour access not only to our currently registered patients (which is in itself a considerable challenge) but to all people in our practice area, even those who are not registered. The document asks that we register these people when they first present and be in a position to offer them an appointment within 48 hours. Without a very significant increase in resourcing (to allow an increase in capacity…) this cannot be done. And in a system where the total population (registered and unregistered) currently exceeds capacity (and the projections are for population growth), then to follow the patient registration document to the letter would be self-destructive, a march of lemmings.
5.7.09: A further added note which is quite relevant but only given a brief mention above. In fact, it should be added to the Access, Quality, Capacity, Resources ecogram. This is the question the Safety. There comes a point where when capacity is exceeded and the strains on the system are such that mistakes are more likely. Some of these mistakes may be benign, but some mistakes may have potentially serious effects.
I have noticed in the past few months a quite noticeable increase in mistakes (in prescribing; delays in referrals, labelling abnormal results as normal) which were previously rare.
This adds another reason to resist the pressure to grow the list beyond a practice’s capacity.
 The 48 hour access target is something that would merit some discussion but it is not discussed. My understanding is that it was the brainchild of Mr Tony Blair: evidence-free policy making which then ended up being a planning priority and leading to choices which impact quite significantly on the health economy as a whole. The PCT’s Access LES quotes the ‘Ipsos-MORI patient survey’ in much the same way as other LES’s quote QOF which at least is evidence-based. It is really quite shocking and shameful, much more significant, I believe, than the issue of MPs’ expenses. But this is another issue and I must restrain from letting it intrude here.