General Practice Patient Priorities 13th February 2013

General Practice Patient Priorities 13th February 2013

Agenda • Background • Literature review • Workshop and survey results • How NW London is doing in these priority areas

In October a programme of work was established by the CCG Chairs of North West London to support the development of General Practice The reasons for the establishment of the programme are outlined below: 1 The Out of Hospital Strategy • Each CCG has described in their Out-of-Hospital strategy how more care will be delivered in Primary Care settings, such as the GP practice, than has been done previously • Each Out-of-Hospital strategy describes how General Practitioners will have a role to play in a more integrated care system 2 Feedback from previous consultations and research • Primary care and General Practice were a recurring theme in consultations held with the public around the Shaping a Healthier Future programme • Data shows that patients make use of Urgent Care Centres for conditions which could be dealt with in General Practice • Patient experience surveys in North West London have indicated issues with getting access to care 3 CCG boards are taking on a new role in Primary Care • CCG Chairs are elected by their own member practices and have a key role in leading Primary Care • The establishment of the National Commissioning Board as the new commissioning body for General Practice could result in new opportunities and challenges for practices

The vision and principles of the programme have been agreed, recognising the good current provision of care but also identifying a few key projects to take forwards • To recognise the good current provision of care • To focus on a few, key projects in General Practice but also variation in • To be positively and developmentally performance and gaps in quality focussed, encouraging innovation and • To put patient experience and entrepreneurship need at the centre recognising the need for it be more consistent • To recognise the need for • For General Practice to infrastructure improvements own the agenda including estates, workforce, • To only commission information, IT, training and Delivery Principles additional services from OD (including networks) practices that deliver • To work in partnership against agreed core with practices quality standards • To recognise the role of • To focus on issues CCG chairs as leaders of identified by patients and transformational change, that will address inequality working on behalf of • To have a vision that Governance Vision constituent practices works at: • To work with patients as key Practice level o partners Network level o CCG level • To engage early on with the NHS o CBL • To make use the previous research • To establish a relationship with the LMC as a foundation • To provide more services in the community, closer to patients, where possible

The first step of the programme has been to understand patient priorities for the population of North West London The process we have gone through to understand patient priorities is as follows: • Stage 1: Literature review (October) • A thorough review of the literature was conducted to identify aspects of General Practice important to patients, from this a list of over 200 aspects was compiled • This was consolidated to a list of 59 distinct things which were grouped into categories. (Relationships with professionals, access, healthcare setting, information and communication, co-ordinating with the wider healthcare system) • Stage 2: Workshops (10th and 12th November) • Two workshops were held with a combined attendance of 93 people, reflective of the population of North West London in terms of demography • Some PPAG and PPE representatives were also invited and chose to attend • The outcome of these workshops was a ranked list of the 59 priorities along with a record of the discussions from the day and a video recording patient experiences • Note: • The following additional patient engagement has been carried out: • Discussions with CCG patient representative groups • Workshops with patients with learning difficulties and non-English speakers • Patients from a variety of BME groups • Stage 3: Street survey (Late November) • A a representative sample of North West London’s population (1,040 people) was surveyed • The survey included a question to rank the top 10 priorities identified in the workshop and additional questions about access and use of UCCs • The survey provided a robust data set for analysis • Stage 4: Final list of patient and public priorities (December) • The results of the workshop and survey were analysed and a final priority list established • The patient priority list was compared the GPPS data to evaluate how we are doing on the factors which patients find most important

Patient literature was reviewed in order to identify a long-list of factors important to patients about their General Practice To develop a comprehensive long list of potential priorities for patients in NW London factors were extracted from a wide range of data sources: Literature review • Feedback from patients and their representatives • National Voices - 'What Patients Want From Integration' • Harrow Primary/ Urgent care review • Report from Brent deliberative event Jan 2009 • Shaping a Healthier Future (Patients and clinicians) • PALS / complaints to PCT - B&H, K&C/W/H&F last 12-18 months • Patient survey questionnaires: • Ipsos MORI - National GP patient survey Oct 11- March 12 • Picker Institute - National GP patient survey 2002 • Search functions of patient feedback websites • NHS Choices • myhealthlondon.nhs.uk • National Guidance • DH Patient Experience Framework • NICE guidance - Patient experience in adult NHS services (QS15) • Institute of Medicine definition of patient centred care • Academic articles and reviews • King’s Fund reviews of primary care – national (Goodwin et al 2011) and London (Raleigh et al 2012) • King’s Fund Point of Care review ‘Seeing the Person in the Patient’ (Goodrich and Cornwell 2008) • Poole et al 2011 – Exploring patients’ self-reported experiences of out-of-hours primary care and their suggestions for improvement: a qualitative study. • A list of over two hundred items was compiled which, after removing duplicates and consolidating similar themes, was reduced to a list of 59 items to be presented to workshop participants. Workshop Top 10 Survey Top priorities

The literature suggests patients trade off speed of access, convenience and continuity based on their circumstances Literature review Workshop Top 10 Survey Top priorities • Academic research has shown that while patients value speed of access, they are prepared to wait a few days on average for a convenient appointment and up to a week to see the doctor of their choice • Circumstances, (e.g. the perceived urgency of symptoms and the amount ofanxiety they generate) have a substantial impact on patients’ priorities: • Patients tend to trade off both continuity and convenience for speed ofaccess in the case of urgent but relatively minor health problems. • Almost all patients value relationship continuity in ongoing, high-worrysituations such as discussing the future in the face of serious illness. • Management (including information) continuity is chiefly important tothose with complex and/or ongoing conditions. • Demographic and socioeconomic factors have a relatively minor effecton patient preferences: • Most patients value relationship continuity but older people, women and those with a long-term condition value it slightlymore than others. • Working people place a relatively higher value on convenience. • Parents of young children particularly value speed of access. • Personality may also play a part, for example some patients with a long termcondition do not particularly value continuity of care and may not be prepared tosacrifice speed of access to consult a particular professional. • To maximise patient satisfaction, appointment systems need to be sufficientlyflexible to allow individual patients to trade off continuity, convenience and speedof access based on their particular circumstances and preferences.

A review of the complaints patients make showed that clinical competence & communication as common themes • NHS Health & Social CareInformation Centre • 36% of complaints about GPs were ‘clinical’, followed by ‘communications / attitude’ (22%) and general practice administration (19%). • Just 1% of written complaints reported concerned premises.. Literature review Workshop Top 10 Survey Top priorities • The Patients Association • The Patients Association Helpline receives 8,000 calls each year, and in the 6 months from January to June 2012, 25% of calls related to GPs, with the most common issues being: • Communication with GPs – 26% of calls • Referrals – 12% of calls • Deregistration from GP lists – 10% of calls • Integrated Care- 3% of calls • Local Data • Complaints data from five of the NW London boroughs show that clinical care/treatment, followed by attitude of GPs and staff are the most common cause of complaints in NW London. • Few (<10%) of complaints concerned difficulties in getting appointments, or unfair removals from practice lists. Sources: 1. GMC report: ‘The state of medical education and practice in the UK 2012’ 2. Patients Association report: Primary Care: Patients and GPs – Partners in Care? September 2012 3. Brent, Harrow, Hammersmith and Fulham, Kensington and Chelsea and Westminster PALS 4. NHSIC website • GMC • . • The most common themes of complaints investigated by the GMC in 2011 across all types of doctor were: • investigations or treatment (2,643) • effective communication (789) • respect for patients (679) • The number of complaints made against doctors has been rising since 2007, but investigations of effective communication allegations about respect for patients rose by two and three times the overall increase between 2010 and 2011.

The majority of workshop participants reported a positive experience of general practice Literature review Workshop methodology: The long-list of 59 factors was presented to patients during two half-day workshops. At the end of the workshop participants picked their top 10 most important factors. There were three main elements to the workshop: Participants discussed the pros and cons of their General Practice generally and completed some starter voting questions Participants discussed how they felt about 59 aspects of general practice, identified from the literature review and they chose a top 10 from this list Participants discussed whether they would feel the same way in situations where they had a number of different health concerns. General comments from the workshop: Many patients rate the care they receive form their GP highly with 81% of the workshop participants rating the care they received from their GP as ‘excellent’, ‘very good’ or ‘good’. • Opinion was divided on whether services are getting better or worse with 32% of workshop participants feeling they are getting worse and 26% believing they are getting better. • Different people have different priorities - all the 59 items presented at the workshop received at least one ‘top 10’ vote, none were found to be a unanimously low priority. • Circumstances (e.g. having a long term condition, sudden health scare or a dependent) had a greater impact on choice of priorities than age Workshop Top 10 Survey Top priorities

The workshop also provided qualitative information about patients’ experiences Literature review “I have the same doctor as my mother. There feels a sense of continuity. I feel I am developing my own relationship with the GP and can confide in him exactly how I feel” • “My GP does not provide screening or prevention services. I think it is my responsibility to maintain my health, but this sort of information would be really useful to help me understand what I can do to prevent getting ill” • “You have to be really persistent and challenge them to get to see your GP…there is no long term relationship, they have sort of weaned us off that, I don’t expect it any more, I am just grateful to be seen” Workshop Top 10 Survey Top priorities • “I don’t want to tell the receptionist what is wrong with me; it is private and my business. Receptionists pry too much” • “It would be helpful to know more about where to access healthcare and the options available. We are not always sure who else can help” “Even when I have an appointment I am often kept waiting for over an hour” • “It seems really difficult to get an appointment that suits you unless you are prepared to cause a fuss. I have to be prepared to do this or I would never be able to get to see a GP because I can’t get time off” “My practice has online appointments and this is really great” • “You have to keep going round the system to get what you want. Sometimes the NHS feels like a massive haystack of people that you have to find your way through. You have to really take yourself seriously to get the care you need” • “I had to have surgery on my spine and I had a very quick referral to a consultant and the practice followed up my care. I felt really cared for by my practice” Check out the workshop video at http://closeupresearch.com/gp_practice_vox_pops.html

Participants votes during the workshop were used to identify an overall top ten set of priorities Literature review Votes Top 10 items identified from the workshop: Workshop Top 10 Survey Top priorities

The workshop results informed the questions used in a wider survey of 1040 patients registered with GPs in NW London Survey Methodology: Patients were asked for four categories of information in the survey. This was based on the results of the workshop. As access registered so strongly in patients qualitative comments this was included as a separate section on the survey. 1040 participants took part in the survey. Interviewers roamed a variety of busy street areas in each of the 8 boroughs of North West London. The populations asked were representative of the demographics of the North West London area. Literature review Workshop Top 10 Survey Top priorities Survey questions: Patients were asked to place the ten items identified from the workshop into a rank order of importance to them. Patients were asked to place six items relating to access into a rank order of importance to them Patients were asked about the importance of being able to book appointments of different types (urgent, non-urgent but convenient, far in advance) and also their confidence that they currently able to book this type of appointment Patients were asked if there was anything which had not been mentioned that they would rate as a priority for their General Practice Patients were asked if they had ever used urgent care (A&E or UCC) for a consultation they could have received from their GP and if so why Patient demographic was recorded

The workshop identified 10 overall priorities for patients, which were ranked using the survey Literature review The top 10 items from the workshop were ranked as follows during the survey phase: Workshop Top 10 Survey Top priorities * The average rank from all respondents – this measure has been used to order priorities ** % of patients who ranked this item as their top priority (shows the distribution of answers) *** % of patients who ranked this item as one of their top 3 priorities (again shows the distribution of answers)

The highest rated aspects of access were being able to get through on the phone and get a same day/ urgent appointment Literature review Workshop Top 10 Survey Top priorities The importance to patient’s of being able to get different types of appointment at their GP, compared to whether they currently feel able to get that type of appointment • 25% of respondents had used urgent care (e.g. A&E or an Urgent Care Centre) for a consultation they could have had at their GP practice. • The reasons given were: • an urgent medical need (70%); • could not get access to GP (22%); and faster, • more efficient service (5%) • This shows how strongly patient’s perceptions of what services are available affects their behaviour and service use

Focus groups were used to explore in detail the problems that some groups of patients experience in particular • Discussions with patient representative groups within CCGs highlighted that: • Patient groups would like to be involved in an on-going way with this programme • Engaging with carers throughout the process will be important • Appointment length is a strongly recurring theme in patient complaints about their GP • Confidence in the GP is key and also that it is frustrating when GPs are not receptive to referrals from other specialists (e.g. optometrists and dentists) Literature review Discussions with BME groups highlighted the following: Using urgent care services for consultations available at the GP: Around 30% believed they may have used A+E for services available in their GP, confirming the survey finding that 34% of people describing their ethnicity as black had done so (9% more than the population overall). However, further examination of patient experiences indicates that patients do not have a clear idea what their GP provides because they are inaccessible; and not ‘there when they are needed’. Non-registration: There was a notable non-registration issue with Black Africans and Eastern Europeans, with reasons cited including immigration concerns, macho culture, lack of understanding of the system and shame regarding sexual health. Extreme faith also played a part for some Black African communities where seeing a doctor was seen as a lack of faith. Its has been shown that targeted communication campaigns and use of voluntary organisations can increase registrations. Discrimination: Muslim Somali and Sudanese women frequently reported feeling that they were treated differently front of house due to their dress. Further interviews showed that language barriers played a key part in this. Language was a particular issue for older residents. What would encourage use of GP services: When asked what would encourage them to use their GP more often patients named being able to be seen on the same day, trust that will have a high quality consultation and trust that they will be treated with respect and dignity. Workshop Top 10 Survey Top priorities Discussions with patients who do not speak English are on-going. The results of this work will be available mid February

Focus groups were used to explore in detail the problems that some groups of patients experience in particular • Hammersmith & Fulham stroke network • The group felt GPs did not take their concerns seriously or give them enough time, especially those left with communication difficulties. Some had low trust in their GP, an were concerned that their GP did not really know what was wrong with them, withdrew medication for financial reasons, did not share test results openly and did not refer to specialists when needed. • Patients felt that nether GPs nor hospital doctors gave them the information they needed to manage their own condition. Poor communication at discharge between the hospital and their GP have led to a variety of negative experiences for patients. • Patients also placed a high value on continuity of care, and were frustrated when seeing different GPs meant they had to tell their story again and again, or received inconsistent and confusing advice. • Patients also highlighted the need to consider the psychological as well as the physical impact of a stroke, considering the patient as a whole person. Literature review Workshop Top 10 Survey Top priorities People with learning disabilities in Brent Patients most valued their doctor listening, being polite and kind, and seeing their own doctor who knew their case. Talking to their GP: Patients associated being listened to, clear explanations and seeing their own doctor with finding their doctor easy to talk to. Being unable to understand the doctor, having trouble explaining and having to repeat themselves were sources of frustration, as was the doctor talking to a carer rather than to the patient themselves. Getting an appointment: Many participants found it easy to make an appointment, though often because a carer did it on their behalf. Proactive approaches from their GP surgery were associated with finding it easy to get an appointment. The difficulties patients mentioned with making an appointment included having to use the phone, getting through on the phone and being able to see their preferred doctor. Talking to receptionists: Most patients found it was easy to talk to receptionists provided they understood what to do. Difficulties could arise, however, when they had not had the process adequately explained, or where language or other barriers hindered communication.

Although all top 10 priorities were important they can be grouped into three key areas, consistent with those previously identified by Chairs • Confident GP can diagnose & treat • Treated with dignity & compassion Literature review • Enough time in appointment Workshop • Consistently good service Top 10 Improved quality & reduced variation Survey Top priorities Timely, appropriate care • No big gaps in diagnostic process • Get an emergency appointment Better integrated services Flexible access • Easy access to specialists • Easily get through on the phone • A continuing, trusted relationship • A good range of tests & services

Access is consistently raised by patients, research and policy as a priority for improvement, however it is a complex issue to resolve • What we know about getting an appointment… • Patients in our survey rated being able to quickly get an emergency important when they need one as most important feature of General Practice • Only around 15% of patients strongly agreed that they felt able to make a same day appointment at their practice • 25% of respondents had made use of urgent care (A&E or UCC) for a consultation they could have received at their General Practice • However, the literature shows that patients trade off convenience, speed and continuity based on their circumstance and will sometimes wait days to see a GP of their choice, therefore fast access is not the only priority Literature review Workshop Top 10 Survey Top priorities • What we know about other aspects of access… • In other areas of access being able to get through to the surgery by phone to make an appointment or ask advise was one of 74% of patients top 3 priorities for access • Patient’s valued being seen punctually for an appointment. National data suggests that patients in London value this more highly than patients in other parts of the country • Patients also highly valued having variety in appointment types, including walk-in appointments, and provision of this in North West London is lower than average Source: Scherset al 2002 and Turner et al 2007

Agenda • Background • Final list of patient priorities • How NW London is doing in these priority areas

Patient surveys show that views are similar across all 8 CCGs in relation to quality, access and integration Sources: 1 – Ipsos MORI GPPS Jan-Sept 2012 (CCGs) 2 – Ipsos MORI GPPS Jan-Sept 2012 (PCTs) 3 – Picker GP National Patient Survey 2002 (PCTs) –the latest available data

Quality of consultations is generally seen as good although some practices fall far below the average Note: The charts show, for each CCG: The total range of patients’ evaluations of their practice (thin bar). The mean +/- 1 standard deviation (thick bar). Overall this is an area in which practices nationally and in NW London are achieving a high standard. There is no data on variability of a single patient's experience in the same practice. England average 93% England average 86% England average 83% A few practices fall well below the average Sources: Ipsos MORI GPPS Jan-Sept 2012

In every CCG there is a wide variation between practices in patients’ experience of access There is a lot of variability between CCGs in how easy patients find it to get through on the phone. Some CCGs have much less variation between practices than others. Every CCG is highly variable in % of patients who wanted a same day appointment and got one England average 78% England average 77% Sources: Ipsos MORI GPPS Jan-Sept 2012 * Includes un-weighted and estimated data for 39% of practices, due to the suppression of answers with low numbers of respondents by Ipsos MORI

NW London practices offer very little walk-in access and patients find it difficult to book ahead England average 91% England average 60% England average 39% England average 3% England average 89% England average 28% England average 80% England average 76% Sources: 1 – Ipsos MORI GPPS Jan-Sept 2012 (practice level data) 2 – Ipsos MORI GPPS Jan-Sept 2012 (PCT level data) 3 – Picker GP National Patient Survey 2002 (PCT level data)

The patient surveys show a similarity in CCG results for a number of other aspects of access Sources: 1 – Ipsos MORI GPPS Jan-Sept 2012 (CCGs) 2 – Ipsos MORI GPPS Jan - Sept 2012 (PCTs) 3 – Picker GP National Patient Survey 2002 (PCTs)

Preference for seeing a particular GP varies with age, ethnicity, gender and circumstance Breakdown by ethnicity Preference by situation Breakdown by gender Breakdown by age Source: Scherset al 2002 Sources: Ipsos MORI GPPS Jan-Sept 2012 – All London

There is wide variation in patients’ ability to see their preferred GP, but no current data on experience of referrals Note: • No data on the range of diagnostic tests and services available to patients in primary care • No data available on patients’ experience of the diagnostic process Sources: Ipsos MORI GPPS Jan-Sept 2012 (practice level data) Picker GP National Patient Survey 2002 (PCT level data)

There is consistency between the literature, patient surveys and the results of our research • While most patients’ have confidence in their GP’s clinical skills, measures show: • Perceived unacceptable variations in care and variable clinical outcomes • That hospital care is used when prevention or treatment in general practice would be more appropriate. Improved quality & reduced variation Timely, appropriate care Better integrated services Flexible and differentiated access Most patients value continuity of care. Integration is chiefly important to patients with complex and/or on-going needs, who account for a large volume of service use. Current models of access to general practice are unlikely to satisfy the requirements of patients in all circumstances and will not enable GPs to deal with the steadily increasing demand on their services

General Practice Patient Priorities 13th February 2013