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Priority Health Care Providing patients with individual and personal care there by reducing A&E attendees

Kaushik N Sudra 18 November 2013 MDes Service Design Innovation


With many thanks to the Ferryview staff especially Glenna, Rianna and Rebecca. Special thanks to David Townson for providing support and opportunity to take up this project. Finally, I would like to thank Alison Prendiville and Cordula Friedlander for providing unparalled suport and helping me navigate through the project.


Summary The NHS was formed in the year 1948. It was aimed

at providing a free healthcare to all regardless of their social or financial situation. The NHS has been providing life-saving support ever since and this has come at an average cost of £100 billion a year. The service has always experienced an increasingly overwhelming demand, which has forced the NHS to constantly increase its budgets to make supply meet demand. The increasing demand is rising concerns on its existence and is looking at innovative methods to improve its services. A&E is one of the department’s which has been suffering with demands raising constantly and they are failing to achieve the set targets. Patient’s turning up at A&E for unreal emergencies which can be treated at home or by visiting their local pharmacist or GP, are a threat for its existence. Priority health care is a service design project which looked at the overuse of A&E services by patients registered with Ferryview. The GP practice has 25,000 patients registered with them and they have managed to identify the top 100 patients who need special care as they are living with atleast one chronic condition and are anxious regarding their health which leads to calling an ambulance or visiting the A&E. Shadowing and interviewing the GP staff helped in understanding how the surgery works. Co-designing with the patients of Ferryview helped in understanding the patient’s perspective in choosing the A&E over their local GP. The insights from the research hinted at developing a new service which would enable the GP to have a more personal relationship with the patient, where a named doctor would see the patient every time he visits the GP, and provide a fast access to these patients in case of emergency. This service additionally also provides patients with a more pro-active approach from the GP practice. Priority health care aims at improving the understanding between the patients and their GP resulting in reduction of patients obtaining A&E care.


Contents

Background Research Project outline...............................................1 Perception Of Health....................................3 Root of GP services......................................5 GP service Achievements............................7 Addressing the increasing demands...........9 Essential NHS services..............................10 Choose well................................................11 Primary Research The Reception............................................14 The front desk............................................16 Clinical Assistants......................................17 Shadowing CAs.........................................18 Patient CA communication gap.................19 The Q.O.F...................................................20 Ferryview’s QOF performance...................21 Change of direction The shift in the project................................23 Secondary Research What is A&E................................................27 A&E crisis....................................................28 A&E as the first port of call........................ 30 Difference in opinion; GPs and A&E...........31 Measures to reduce A&E attendees...........33 GPs efforts in reducing A&E attendees......34 Co-designing The need for co-design..............................37 The co-design session...............................41


Insights

Co-design insights.........................................44 The need for ‘Reassurance’...........................45 Understanding reassurance...........................46 Stakeholder map............................................47 Personas...................................................... 49

Idea generation Concepts.......................................................53 Concept Development...................................55 Final Design Impact Value

Overview.........................................................57 Storyboarding.................................................59 Service Touchpoints.......................................63 Service Blueprint............................................67 Conclusion.....................................................69 Service Design Impact...................................71 Service Design Innovation.............................72


Project Outline Priority Health Care is a project that looks at improving the relationship between local GP’s and families. The main aim of the project is to cater to patients with chronic conditions and provide emergency care support. The project began in alliance with Design Council, when NHS England approached them to address the issue of primary care in England. The project was at Ferryview Health Centre, a surgery located in Woolwich. The problem as appearing on surface was that the surgery was experiencing a very high usage of A&E services by the group of patients, especially families with young children and patients with chronic condition. It needed immediate attention to understand their needs and shift it towards a more affordable model, which would still satisfy the needs of the patients. Patients arriving at the surgery had to wait longer even after obtaining their appointment. The main cause for this, in the opinion of the staff working in the surgery was that patients would usually supersede the time allotted for their appointment. As a part of the improvement programme, the surgery decided to appoint a two new people for a new role called the Clinical Assistants/Clinical Navigators. The two key components of CA’s were: 1.Improve care for patients with long term conditions through self-management support and guidance on local services and gain better understanding of their needs. 2.Providing real time clinical support for GPs enabling them to allocate more time for patients with complex problems and to address gaps and co-ordinate care more effectively. Additionally research revealed the problem wasn’t limited to Ferryview and was prevalent across UK. David Townson was appointed by the design council to take the job at hand of improving the healthcare at Ferryview. I was grateful to have been offered an opportunity of working with Ferryview and David in order to improve the primary care on offer to patients of Ferryview. Ferryview Health Centre is based in Woolwich, with a patient base of 25,000 people. They have a variety of patients out of which they want to concentrate on providing a better health service to patients living with chronic conditions and patients who need to be taken care of in emergencies. They want to be more proactive and prevent patients from turning up at A&E for emergencies which can be addressed to by them.

Research 1


Background Research Understanding the history of NHS and how it works...


Perception of Health In order to identify the healthcare needs of people in the UK and what are the best ways the NHS could address these, it was important to understand the perception of health. This exploration was done in order to understand what health means to people. Historical efforts to define health have typically been concerned with two major objectives: 1. Articulating ideals of health that may serve as targets or goals to which individuals and societies may aspire. [1] 2. Defining the scope and boundaries of health.[1] “A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” (WHO 1948, Bulletin of the World Health Organization 2002)

“A healthy individual is a man who is well-balanced bodily and mentally, and well-adjusted to his physical social environment…Health therefore is not simply the absence of disease; it is something positive, a joyful attitude towards life, and a cheerful acceptance of the responsibilities that life puts on an individual” (Henry Sigerist 1941, cited Health Systems Performance Assessment) Drawing perspectives from the definitions we can see there is a lot of contradiction. Critics have argued that health is a component of well-being, not identical to it and that WHO definition of health medicalized non-health elements of everyday life. With continuous efforts to define health more narrowly than well-being, two contrasting positions have often been adopted: the descriptivist and the normativist. Health is conceptualised in terms of integrated human functioning within a social context and is culturally relative and others argue that health has some intrinsic value and on pragmatic considerations may be focused on and differentiated from other aspects of well-being. (Cited Christopher J. L. Murray & David B. Evans)[1] All of these make a huge impact on the decision making of a patient on receiving healthcare from the available sources. Patients are forced to believe that illness is bad health and only doctors or health professionals can help them out which results in overuse of the health services. A person’s definition and perception of good health influences largely on the services available and the access to them and the way he uses it.

[1] Health Systems Performance Assesment Debates,Methods and Empiricism Edited by Christopher J.L. Murray & David B. Evans Research 3


From losing weight to keeping fit, a wealth of information at your fingertips Visit www.nhs.uk/livehealthy Your NHS, online.

Your online health encyclopedia Get trusted information covering 850 conditions, treatments and medicines Visit www.nhs.uk/health Your NHS, online.


Root of GP services General practice can be regarded as the core of primary care team which includes nurses, GPs and other practice-based staff. However, there is no clear definition of a general practice. Since the NHS was formed in the year 1948, general practice has been responsible for all personal medical care. Soon general practices became a gateway for individuals to access hospitals, specialist care and sickness benefit. Even in the early years, these practices lacked explicit standards and very few medical practitioners took the role of a GP and the rapidly growing demand for the services was recognized as challenges. (Collings 1950)[2] GPs have been constantly evolving as being part of the health care system. GPs took on responsibility for covering the entire population and controlling access to special care in 1948. Within a month, 90% of the population had registered with a GP. They chose to remain outside the NHS as independent contractors and also they had very poor standards of care and bad working conditions and isolation from other professionals. (Collings Report). The Royal College of General Practitioners gave GPs an official representative body in 1972 for the first time. The 2004 GP contract was a turning point which represented a new relationship between the NHS and the GPs, putting emphasis on performance-related pay, as measured by Quality Outcomes Framework (Q.O.F).

Having undergone many changes since the establishment, GPs have two main concepts to be addressed to which are patient centeredness and holism. Patient centredness means that the individual patient’s priorities must be identified and respected in order to reach an appropriate clinical decision – a process facilitated through the development of good doctor–patient relationships over time (Howie et al 2004). Good medical Practice identifies the following as a key to partnership between a patient and a doctor: • be Polite, considerate and honest • treat patients with dignity • treat each patient as an individual • respect patient’s privacy and right to confidentiality. One of the related concepts to be understood is family centredness, which can be explained as a need to explore the illness and needs of a patient so that the care provided is culturally responsive, flexible and relevant to each individual in the context of their family. [2] The evolving role and nature of general practice in England, The King’s Fund 2011 Research 5


Good medical Practice identifies the following as a key to partnership between a patient and a doctor: • be polite, considerate and honest • treat patients with dignity • treat each patient as an individual • respect patient’s privacy and right to confidentiality. One of the related concepts to be understood is family centredness, which can be explained as a need to explore the illness and needs of a patient so that the care provided is culturally responsive, flexible and relevant to each individual in the context of their family.

Since 2004, patients have been registered with a practice, rather than with an individual. So, the patient of today increasingly has a relationship with a general practice team rather than with ‘their own’ GP. First contact with a care professional may be provided in a range of ways, including (Jones et al 2010)[2]: • GP consultations • nurse practitioner triage • practice nurse and health visitor consultations • telephone consultations with ‘duty’ doctor • deputising services that provide out-of-hours care.

Health secretary Aneurin Bevan opens Park Hospital in Manchester. The birth of NHS. Source:nhs.uk

Christiaan Barnard, the world’s first heart transplant in 1968. Source:nhs.uk

[2] The evolving role and nature of general practice in England, The King’s Fund 2011 Research 6


Achievements of GP services GP services have been doing a great job at providing immense primary health care to people. A 2008 report by the NHS Workforce Review Team forecast that demand for primary care services would continue to increase, and that more training provision was needed to avoid ‘a significant medium-term risk of GP shortages’ (NHS Workforce Review Team 2008). The NHS Next Stage Review, recommended that at least half of all doctors should train as GPs to meet the increased demand (Department of Health 2008a).[2]

62% 62% out of 300 million consultations were handled by the GP practices in the year 2008.

5%

GP’s made just 9.3 million referrals to secondary care, which adds upto 5% of total GP consultations referred to secondary care.

[2] The evolving role and nature of general practice in England, The King’s Fund 2011 Research 7


Achievements of GP services

GP practice teams have been growing larger with care provided by many multi skilled professionals such as nurses and health care assistants. This broader skill mix has enabled GPs to relinquish many routine and non-clinical tasks. Nurses have already assumed a range of responsibilities that would previously have been undertaken by GPs.

Nurses have contributed to 21% of GP consultations in 1995, which increased to 35% by the end of 2008 (HippisleyCox and Vinogradova 2009).

21%

35%

Financial Status

Despite GP services providing up to 90% of patient consultation, the funding received by this department of NHS remains lower than that of other departments of NHS. As per the GMS contract of April 2004, a practice gets a global-sum based on a needs-adjusted capitation. The average payment is ÂŁ63.21 per patient per annum. (Department of Health 2010b).[2]

8%

90%

GPs provide 90% of the consultations to patients and recieve just 8% of the annual NHS fund.

[2] The evolving role and nature of general practice in England, The King’s Fund 2011 Research 8


Addressing the increasing demands‌

The NHS has been constantly experiencing high demand for the services provided and has led them to think of innovative ways to reduce the pressure of each department in order to provide quality care to every individual. There have many innovations and interventions such as telephone consultations with GPs, walk-in centre’s etc. to ensure patients get the best of service at all times. Walk-in Centre Walk-in centers were a part of improving primary care. They are managed by a NHS body or a GP co-operative. Nine walk-in centres were opened in London during 2000. Six of these walk-in centres are located in hospitals. The main aim of these walkin centres was to provide treatment and assessment for minor illnesses and injuries and also provide information on other services. Walk-in centres ease off the pressure on the GP services by providing out of hours care. For e.g.: Edgware NHS walk-in centre is open from Monday to Friday from 7 a.m. to 10 p.m. and 9a.m. to 10 p.m. on weekends. [3] Telephone Consultation The growth in the use of telephone consultation for healthcare problems has developed partly in response to increased demand for GP and Accident and Emergency (A&E) department care (Bunn F, Byrne G, Kendall S, 2005)Demand for appointments commonly outstrips supply so daytime telephone triage has become the norm for juggling appointment systems, waiting times and prioritizing emergencies. Government incentivised directives, in the form of Advanced Access and now Extended Access, have driven changes in consulting practice with an increasing number of clinical contacts being provided by phone.( Edwards A, Neal RD, GMS contract 2008). The direct benefits to the patients were increased access and less trips to the surgery, especially if they had a physical disability. The doctors were benefitted with more free appointments which can be used to treat the patients who are in much need of having a face to face appointment with the doctors. [4] [3] NHS Walk-in Centres in London, The King’s Fund 2001 [4] Telephone Consultations, patient.co.uk

The Soho NHS walk-in Centre located at 1 Frith St, London W1D 3HZ. Source:google.com Research 9


The essential NHS services‌

NHS is a huge organization which caters to all the individuals through a lot of different services based on one’s needs. It can be considered a huge blanket which envisages the following key components to perform:

NHS Hospital Services NHS hospital services are managed by NHS trusts. This ensures that the hospitals provide the patients with quality health care and the funds given are spent efficiently. These services can be accessed through GP, dentist or opticians which are an active part of the NHS services. The patients also have the right to choose the hospital nearest to them in order to see the referred specialist by the GP. Accident & Emergency (A&E) centers or Urgent Care services This department caters to patients with serious injuries or life threatening situations. This department is the most crowded, with attendees figures adding up to 21 million each year. Minor injuries unit (MIU) is also a part of this department which provides treatment for patients with minor injuries such as sprains. GP surgery GPs can be considered as the first point of contact for receiving any kind of health treatment. They deal with a whole range of health problems and are also responsible for providing health education, smoking advice and give vaccinations. A GP service is usually comprised of a team of doctors, nurses, healthcare assistants amongst the admin staff. GP practices are also doorways for people to seek any further treatment from hospitals, which is not available at their GP. Walk-in Clinics Walk-in clinics were opened in 2000, and operate long hours than the GP services and also provide support on weekends. A patient can seek medical advice or treatment from an experienced nurse or a doctor (not all walk-in clinics have a doctor) without having to take an appointment. They are popular for providing immediate care for minor injuries and acute illnesses

Research 10


Choose well Choose well as the name suggests is an initiative by NHS wales which helps patients in deciding which service is best suitable in case they need to seek medical attention. It also explains each of the NHS service in brief and when they can be used. This enables the patients in receiving the best treatment for a particular illness and also allows busy NHS services like A&E to cater to people who need them the most. Choose well quiz is an interactive way of educating patients on choosing the right service. The quiz has a series of questions and a person is supposed to choose from the available services; it also gives reasoning on which service is appropriate if he/she happens to choose the wrong service for a particular question.

Choose well explaining the services offered by NHS and when to use each of the service. source: choosewellwales.org

Research 11


Primary Research Getting a feel of the surgery


The Reception The Project began as a part of patient-doctors meeting at Ferryview Health Centre. The meeting was held in order to introduce the new role of Clinical Assistants (CA’s) at the surgery. The meeting gave a surface introduction to the project and who the primary stake holders might be. However, it was important to understand the way of working of the surgery in order to clearly understand the introduction of the new role of CA’s. The first visit to the surgery was quite insightful and revealing. The reception was crowded with patients and the staff at the reception was immensely busy attending to the large patient inflow. Looking at this scenario, it was decided to spend a few hours behind the reception to understand the kind of jobs being performed at the reception. The reception is split into two zones, with one taking the form of a back office. The back office is responsible for handling all the incoming calls and booking appointments and responding to the patients queries over the phone. This area is also has a lounge which is a resting area for the other staff working at Ferryview. The back office or extended reception provides continuous assistance to the Front reception helping them manage prescriptions and real-time support to patients.

The reception desk, off peak times, when the inflow of patients reduces.

The extended reception, provides great support to the reception. Primary research 14


The reception desk has 3 counters, where the receptionists are deployed based on the number of patients queuing up.


The Front Desk The front reception is the first point of contact for any patient visiting the surgery and they provide any information in regards to the services offered. The front reception manages the long queue of patients via three counters and provides assistance to both new and old patients. However, they are relinquished of duties to answer the telephone calls as that is handled by the extended reception. Few hours were spent behind the reception desk in understanding the duties performed by them. The following are a few of the most important tasks at hand of a front reception desk: • • • • •

Updating appointments(cancellations, booking new appointments) Registering/arriving the patient for appointments Registration of new patients Managing prescriptions and medications to be given to the patients Appointment cancellations The different touchpoints at Ferryview

The waiting area has two TV’s out of which one constantly plays news/ health program and other one displays the next appointment. It was observed that a few people fail to notice their appointment.

Appointment arrival machine placed at the entrance. A few people queued at reception, even after using the machine for arriving for their appointment


Clinical Assistants

Clinical assistants are the new role that Ferryview is added to its league of health care professionals. They work under direct supervision of a doctor, providing real-time support to them. They are trained to perform a number of clinical roles in diagnosis and management of patients. CA’s are able to carry out routine management and care management tasks, which in turn frees up the time for skilled health professionals to attend to more complex activities. CA’s are appointed as part of the exercise to improve Primary care and provide support to those with chronic health conditions. As part of the GPs 2004 contract, there was the introduction of QOF (Quality and Outcomes Framework), to reward practices for providing high-quality care. QOF payments account for up to a 1/3rd of an average practice’s earnings in 2005[2] Q.O.F Heart Diseases

Smoking

Diabetes

Asthma

Clinical Assistants are responsible mainly to improve the quality care as per QOF and provide assistance to patients with chronic conditions such as diabetes asthma etc.

[2] The evolving role and nature of general practice in England, The King’s Fund 2011 Primary research 17


Shadowing CAs The shadowing and interviews led to the development of journey maps, which enabled in having a clear understanding of the way of working of CAs and also provided information on how the relationship between the doctor-CA-patient. Research Plan-Scenario 3

The CA arrives at the surgery

Looks up the list of patients for the doctor she would be assisting for the day

Finds a patient who needs any tests in regards with the QOF.

Calls out for the patient in the lounge area.

Meet the patient and brief why he/she is being called.

DESMOND

He/she awaits for their turn in the lounge after the session with the CA.

Greet and ask him/her to wait in the lounge to be seen by the GP

If he/she is interested, make referrals and provide information to maintain their health

escort him/her to the consultation room and do the required tests

Journey map of a Clinical Assistant

Aims/Context

The doctor carries out the The CA keeps in constant touch required tests and has enough to ensure good health and if any time as the pre requistions are further assistance is required, The will look at providing a books good service investigating the issues through shadowing and mapping the journeys and providing a precise solution to fulfilled by theproject CA another by session.

the issue by prototyping and co designing.

Ferryview Health Centre

Book an appointment via phone or online

Arrive at the surgery

Arrive for your appointment by Self Check in or at reception

13

Wait in the lounge for GP

Meet the GP and get the required assesment.

Leave the surgery

Without Clinical Assistant

Journey map of a patient

Book an appointment via phone or online

Journey map of a Ferryview patient

Clinical Assistant’s Intervention

Arrive for your appointment by Self Check in or at reception

Arrive at the surgery

Leave the surgery

Wait in the lounge for GP

The patient is sent to wait for the GP in the lounge area

Meet the GP and get the required assesment.

The CA looks up the list and calls out fot the patient

CA carries out regular checks and gives relevant advice

Ferryview Health Centre

Primary research 18

5


Patient-CA communication gap

CA’s point of view Clinical assistants are a part of the system and actively assist doctors. They encounter communication issues when they approach a patient to assess their health condition or gain some information. Also, CAs work backstage where none of patients can see what they do and what their part of the role is.

Patient’s point of view A patient is bombarded with surprises when a CA approaches a patient waiting in the waiting area as that is unusual. When the CA asks the patient to come along to assess their health etc. the patient gets restless as he seems to believe that he won’t be able to see the GP and would be assessed by the CA.

Primary research 19


The Quality and Outcomes Framework(Q.O.F)

The General Medical Services contract introduced a pay-for-performance scheme known as the Quality and Outcomes Framework (QOF). It was a voluntary incentive scheme for GP practices in the UK. The QOF contains groups of indicators, against which a practice scores points according to their level of achievement. This scheme enables the practices to put in more effort to deliver a high quality care across a range of areas, through having a reward scheme for the practices. The rewards gained are proportionate to the points earned by a particular practice. A body national Institute for Health and Care Excellence (NICE) in involved in the QOF scheme. NICE plays a vital role in developing the clinical and public health indicators for QOF. It also involves prioritizing areas for new indicator development and also ensuring consultations individual stakeholder groups. The key features of QOF are as follows: • • • •

improving the management of chronic diseases such as asthma and diabetes (clinical) improving how practices are organised (organisational) enabling patients to feed back their views of the surgery offering ‘additional’ services such as maternity and child health.

The QOF, as currently structured, has not given general practice incentives to undertake primary prevention and public health activities. It has promoted a medicalised and mechanistic approach to managing chronic disease, which does not support holistic, patient-centred care, or promote self-care and self-management.[5] Concluding from the above information it can be said that the surgery has to maintain a good point system which would enable it to earn more reward. The QOF is one of smaller areas of the service but can prove to have large impact on patient’s health.

[5] Impact of quality and outcomes framework on health inequalities, The King’s Fund 2011 Primary research 20


Ferryview’s QOF performance

The performance figures of Ferryview Health Centre based on QOF indicators for the year 2011/2012. source:nhs.uk Primary research 21


Change of direction Project development.


The shift in the project The project was initially was concerned with the role of CA ad how they could be made transparent in order to provide better service to their patients. It also looked at improving the environment using technology to make life easier for the receptionists and doctors. However, the project was shifted slightly from what it had started out to do. The surgery was experiencing very high usage of secondary and A&E care by a few patients. This group of extensive users included patients with life threatening chronic conditions and also young parents with children. As a part of the reviving primary care this issue was of utmost priority and needed immediate attention. The surgery had managed to identify the top patients who used A&E services more than GP services with the help of IT audit. It was important to understand why these patients rushed to A&E when they could have received a much better care at their local GP. To understand the patient’s point of view, it demanded secondary research. Secondary research involved looking at present usage of NHS services by patients and why A&E was used so extensively. It was equally important to know the reason for not considering the GP as an option, which will be explained later on. Despite the changes in the project, a few things remained in common that was, how can Ferryview improve its services and how can CA’s be an active part of managing these complex patient groups. Conversely, the research question changed to “How can Ferryview better its services in order to cater to the needs of complex patients, who seek more immediate treatment?”

Primary research 23


Context Research A&E department


Whittington Hospital Emergency Department. Source: telegraph.co.uk


What is A&E? Accident & Emergency department is a part of the NHS services in the UK.

They provide 24 hours care to the patients in case of emergencies. A&E services act as gateways to hospital for most of the general public. This open to all behavior of the department had led lot of problems. A&E attendances have been rising considerably every year. This ride in attendees is raising concerns on the govt. and the NHS. A&E dept. treat about 21 million patients every year. Accident & Emergency department is a part of the NHS services in the UK. They provide 24 hours care to the patients in case of emergencies. A&E services act as gateways to hospital for most of the general public. This open to all behavior of the department had led lot of problems. A&E attendances have been rising considerably every year since the past decade. The A&E dept. treats 21 million patients every year. This rise in attendees is raising concerns on the govt. and the NHS. A&E is categorized into three main categories, type 1, type 2 and type 3. Type1 units essentially refer to the major A&E units which cater to life threatening illnesses. Type 2 and type 3 can be best defined as smaller emergency care units which include Walk-in clinics (WiCs) and Minor Injuries Units (MIUs) along with specialist emergency departments. Based on the evidence from the figure we can conclude that A&E attendances have seen a rise from the past decade. However, the statistics included only major A&E units until 2003/4 and the later statistics include the attendees from the WiCs and MIUs. WiCs and MIUs were introduced with the intention of diverting the minor emergencies away from the larger and more expensive major A&E units.[6]

Figure showing the statictics of increase in A&E attendees from 1997/98 to 2012/13 Source: The King’s Fund [6] The King’s Fund, Are accident and emergency attendances increasing? Context research 27


A&E crisis NHS emergency care services are overstretched and raising concerns. The

NHS struggles to meet the set targets by the govt. As discussed earlier on, A&E departments have a surge of patients flowing in with various illnesses and numbers unceasingly increasing year after year. This increase is concentrated mostly in urban and industrial areas. The attendees included a major number of patients turning up at A&E for conditions which were neither accidents nor emergencies and a few of which needed hospital treatment. Further it is discussed that there no particular definition as to what is to be treated as an ‘emergency’. According to a survey conducted, the nurses disagreed upon 5 cases out of 21 sample cases about their visit to A&E dept. (Murphy 1998). [7] “People have come with period pains, in growing toenails and wanting sets of false fingernails removed,” “I once even had a young woman arrive – by ambulance – asking for a pregnancy test when she could have just got one in Boots.”[8] It is argued that the main cause for this overburdening of A&E is the new NHS111 helpline. Health professionals (Dr Wilson and Spencer) believe that with the occurrence of a major generational shift, there is a lot of young population turning up at A&E the moment they fell ill. This concept gets clearer when Dr Wilson was approached by a 74 year old man, who had broken his left femur about three months ago; on asking why he had ignored visiting the hospital despite the substantial pain, he answered ‘I thought I was getting better’.[8] “Three hundred and fifty million years of evolution means the human body has learned to deal pretty well with most ailments. Yet no one is willing to give things time to get better. They access emergency practitioners for advice when all they really need is two or three days, or a week, to get better,”[8] Dr Brad Wilson Clinical Head A&E, BRI

[7] ‘Inappropriate’ attenders at accident and emergency dept. Andrew W Murphy [8] The Guardian, A&E Crisis. Context research 28


ONLY ONE OF THESE PEOPLE NEEDS A&E

Severe chest pains? Call 999

Cut finger?

Use a plaster Need stitches? Go to walk-in centre

Morning after pill?

Go to pharmacy

Go to walk-in centre

Bad earache? Call NHS Direct or GP

For less severe symptoms

Know your choices

Choose well NHS line up A2 poster.indd 1

Flu?

Stay at home and take flu medicine

Minor sports injury?

A&E or 999 Walk-in Centre GP Pharmacy NHS Direct 0845 46 47 Self-care

For more information visit: www.brentpct.nhs.uk

8/12/10 10:45:32


A&E as the first port of call Evidence shows that A&E attendees have been rising over time and that the

dept. is not able to cope with and meet the targets of seeing patients within the 4 hour time limit as mentioned in the 2004 contract. However, least effort is made in understanding why A&E is seen as a part of primary care by patients. Most of the patients turning up at A&E are either with acute/ illness which can be treated at home or by visiting their local GP. There are a number of reasons behind a patient opting to visit A&E. Also, it is quite complex to understand the patients decision on going to A&E in preference to going to the GP. Social, Psychological and medical factors are highly involved in the decision making by a patient. It is also explored through interviews that social circumstances influence the demand on the services used by a patient. It can be hence concluded that that the criteria for defining ‘appropriateness’ of A&E patients must include social as well as medical terms.[7]

“The element of emergency attaches not only to the clinical severity of the illness…but also to the social circumstances under which the illness occurs.”(Calnan 1982) [7]

There is a huge controversy between the medical professionals and patients in regards with emergencies. Out of 835 attendees, 175 (21%) of patients who considered their condition to be an emergency were turned down by the nurses, and categorized to be more appropriate for GP services. On the other hand, there were 117 (14%) of the patients who considered their condition was less serious were perceived to be in need of immediate care by the medical staff. (Driscoll 98)[7] Concluding from the statements and evidences, it can be said that a patient has to think a lot before he actually decides wisely as to which is an appropriate service for his situation. However, in real-life emergencies as perceived by patients, it is not an easy call for a patient to arrive at a logical decision for the same and one has to be tactful to change this behaviour of patients, in order to reduce AE attendances.

[7] ‘Inappropriate’ attenders at accident and emergency dept. Andrew W Murphy Context research 30


Difference in opinion; GPs and A&E A lot of patients visiting A&E are a result of not being able to see local GP, which

indicates that improvements to primary care could help reduce A&E attendees. A study conducted looked at an ideal situation, to understand if a more accessible GP had fewer A&E visits. Further the survey conducted supported the hypothesis that registered patients who were unable to see a GP within two weekdays (considered as timely access for primary care) self-referred them to A&E departments. Additionally, patients who had issues obtaining a convenient appoint in their last attempt, reported to A&E or walk-in centres without considering GP as an option.[9] Jeremy Hunt, the health secretary outlined a series of long-term and short-term fixes to reduce the number of patients visiting A&E. He discussed that the number of people going to A&E rose to 32% in the past decade. One of the reasons for people turning up at A&E was either because of limited access to their GP or the patients do not trust the NHS call-centre system. As a result of this, hospitals get congested and are dominated by elderly people. Hunt discussed about renegotiating the GP contract of 2004, which according to him had abandoned the whole idea of personalised care to such an extent that some of the A&E staff knew the patients better than their own GP. He suggested that GPs should provide same day appointments and also provide a clinical care co-ordinator for over 65’s who occupy 68% of NHS beds. Having discussed about the effect of GP services on A&E, it is important to understand the issues GPs face. The distribution of GPs across England is varied, ranging by primary care trust from loss than 50% to more than 80% per 100,000 people. Also, the number of single handed GPs dropped from 1,949 in 2004 to 1,226 in 2009, which is approximately 35%. It is also said that the demand for primary care would continue to increase over the years and more training provision is needed to avoid ‘a significant medium-term risk of GP shortages’ (NHS Workforce Review Team 2008). [2] The change in social context also burdens the GPs considerably. Ageing population is one of the factors which will greatly impact the GP services. People over the age of 65 years consult their GPs more than twice that of a person aged 15-44. (Stationery Office 1995, cited in Royal College of Physicians 2010).[2] It can be established based on the available evidence that the NHS as a whole is experiencing issues addressing the demands and the whole system needs to be reformed.

[2] The evolving role and nature of general practice in England, The King’s Fund 2011 [9] Access to Primary Care and Visits to Emergency Departments in England: A Cross-Sectional, Population-Based Study Context research 31


Overcrowded A&E units forced to turn away ambulance calls on 350 occasions. Source: independent.co.uk

Patients forced to wait outside A&E dept. in ambulances for 2 hours. Source: telegraph.co.uk

Patient at A&E; doctors reporting their inefficient care due to rise in A&E attendees Source: dailymail.co.uk

Context research 32


Measures to reduce A&E attendees NHS Direct

There are a lot of measures undertaken by the NHS to reduce the soaring A&E attendees. One of the outcomes is the introduction of NHS direct. Research by London based IFF shows that NHS direct is constantly reducing pressures off GP and A&E depts. The research further addressed that nearly quarter of the people who called the service for assessment, who were advised self-care would have gone to A&E and nearly half of them would have visited their local GP.[10] 4% 3% 5%

The NHS direct’s callers data

41%

28% 11%

41% were advised to self-care at home 11% were referred to A&E 28% were referred to their GP 5% were referred to walk-in centres 4% were referred to dentist 3% were referred to a pharmacist

The NHS direct’s referral process

65% had a new health concern (illness/injury) 22% wanted general information 12% had an existing concern or complain which was getting worse.

12% 22%

65%

[10]http://www.nhsdirect.nhs.uk/news/newsarchive/2008/easingthepressureongpandaand-eservices Context research 33


GPs efforts in reducing A&E attendees According to one of the leading newspaper publisher in the UK, patients

shouldn’t directly visit A&E; instead they should first contact their GP for medical assessment. This saves a lot of time and the efforts off the hospital’s A&E depts... In addition it also provides the patient to get a one-to-one assistance from the GP and it also helps the GP to understand more about the disease and the problem the patient has. The newspaper article also added that the MPs were stunned when the NHS Confederation boss Mike Farrar said that contacting GPs online instead of in person would reduce the pressures on hospital casualty units. His primary goal was to solve the ‘state of crisis’ in the A&E departments, which are struggling to cope with a huge surge in patient numbers. Additionally, Mr Farrar also suggested that a pilot scheme of patients being given ‘immediate access’ proved to reduce A&E attendees by 20%. [11]

An article published in the Health Service Journal demonstrated that telephone access to GPs can significantly reduce the incorrect use of A&E. A case study conducted at Thurmaston Health Centre, Leicester, proved that the availability of appointment reduced from 5.5 days to the same day. Furthermore face to face appointments decreased by a massive 50%. The use of this had a huge impact on the patients visiting A&E depts. The surgery saw an enormous decrease in patients using ambulatory care services to 64% and 49.5% in patients visiting A&E. Likewise, another case study at Elms Medical Centre, Liverpool was seen to have reduced AE attendees through a system called ‘Patient Access’. This was a way of telephone consultation, which enabled the practice to achieve targets of seeing 90% of the patients the same day with an average consultation time of 5 and 10 minutes over the phone and face to face respectively. The surgery has been able to sae about £37,000 a year and also the patients visiting A&E have reduced to 40% amongst the other surgeries in Liverpool.[12] One can easily conclude that A&E and GP are closely linked and how a small intervention can ease off pressures on the vulnerable A&E departments of hospitals. The case studies mentioned above clearly validate the point that if patients had a way of interacting with their GP at the earliest convenience, they would be reassured, which will renounce the patient from visiting A&E or seeking medical assessment from any other NHS dept.

[11]http://www.dailymail.co.uk/news/article-2328723/Dont-visit-casualty--email-GPinstead-NHS-chief-Mike-Farrars-astonishing-answer-A-E-crisis.html [12] Health Service Journal, Better GP access, better A&E outcomes Context research 34


GPs efforts in reducing A&E attendees Patient Access

Patient access is a system of telephonic consultation used by the Elms Medical Centre located in Liverpool. This system enables the GP instead of the receptionist or any other admin staff from determining the emergency of the patient and the doctor calls the patient on the same day. Over 60 practices across UK, accounting to half million patients are now believed to be using the ‘Patient Access’ service.[12] 2 July 2013

19 August 2013 21 August 2013

Patient Access

27 August 2013

Patient access is a system, redesigned and developed over time by the GP’s. This is a simple system of telephonic conservation.

The patient calls up the surgery and asks for their doctor

The request is noted on a list for that particular GP

The GP works through the list and calls the patient to discuss the request

The outcomes may be advice, referral to the practice nurse or nurse practitioner, or a face to face appointment with the doctor

The face to face appointment is given directly by the GP depending on the requirement of the patient.

http://www.hsj.co.uk/home/innovation-and-efficiency/better-gp-access-better-ae-outcomes/5061857.article Major Project

Kaushik Sudra NAR12353014

Ferryview Health Centre

Visual Representation of the ‘Patient Access’ mode of telephone consultation

[12] Health Service Journal, Better GP access, better A&E outcomes. Context research 35


Co-design

co-design with Ferryview patients


The need for co-design Having explored the present state of the NHS and the pressures on A&E

departments, it was important to understand the state-of-mind of a patient. As discussed earlier on, there are a number of schemes trying to reduce the pressures off urgent care services of hospitals. There was a need for interaction with the patients at Ferryview and to understand their way of decision making. This interaction had to as informative as possible and the idea was to collect maximum information about the decision making of the patient. In order to complete this task, a few patients using the A&E service were a prime requirement. The co-design templates were designed with a vision of understanding the rational thinking of a patient. The idea was to gain information on the patient’s usage of NHS services. In order to do this, a series of visual templates were designed to gain information. The templates were as follows:

1. 2. 3. 4. 5.

Name and personal Information. Personal and family networks Networks of advice GP storyboarding A&E storyboarding Ferryview Health Centre

Name Card

Name:

Gender:

M

F

Age Band:(please tick the appropriate age band) 20-30

30-40

>50

40-50

Please state the number of times you have used any of the following services in the past year:

Ambulance

GP

A&E

Hospital

If you have used hospital services for yourself or a dependant, please state the reason:

How would you describe yourself? Here are some words to help you describe yourself. Please feel free to add your own words. (circle the words that describe your personality) Happy go lucky / optimist / worrier / emotional / anxious / intuitive / self-aware

Co-design Session

Date:

The Name card required the personal information of the patient including his age, usage of services and type of person he/she considers to be. Primary research 37


Ferryview Health Centre

Personal & family networks

Please provide details about your family and network of friends... with my family

My contact lives in...

my family lives in...

In emergencies the first person I contact is...

with friends, in a shared house.

The reason I contact him/her is...

I live... by myself

My Status is... Working parent

by myself and I’m a single parent

I happily discuss my health issues with the following people

Who lives in

Employed Unemployed Housewife

Any other please specify...

and is/are my

Retired Other Please specify

Name:

Co-design Session

Date:

Ferryview Health Centre

Networks of advice

Please provide details about where you first look for information in case of an emergency... (please prioritize) These are the websites I generally access...

123

I Use the internet services...

I contact my local GP... The healthcare applications I use...

123 123 I use healthcare applications on my smartphone...

Pharmacist I take my decisions myself to the best of my knowledge

123

123

People I ask for making a right decision for me...

I go to my nearest pharmacist for advice... I prefer asking my family/ friends...

Co-design Session

Name:

Date:

Primary research 38


Storyboarding

Ferryview Health Centre

Narrate an episode when you visited A&E... How did You arrive at the A&E?

Time of day:

What triggered you to go to the A&E?Were the GP services not available at the time?Were the appointments full at the GP?

Did you consult anyone before making a decision to go to the A&E? Whom did you consult?

How far is the closest A&E from your house?How did you arrive at the A&E centre?How long did you have to wait to be seen by a doctor/nurse?

Ferryview Health Centre e

Were you reassured by the visit? If so, why? If not, why?

Co-design Session

Were you asked visit your GP after your visit to the A&E?What were your feelings after visiting the A&E?

Name:

List the high’s and low’s of your visit to the A&E.

Date:

Storyboarding

Ferryview Health Centre

Narrate an episode when you visited your local GP... How do you travel to your GP for your appointments?

Time of day:

Were you able to get an appointment at the desired time?

Did you consider any other options before going to the GP?

Can you describe how you got to the GP?

Ferryview Health Centre e

Was it a scheduled appointment or walk-in? If a scheduled one, did you meet your routine GP and if a random one, who attended you ? What was the outcome?

Co-design Session

Were you asked for a follow up visit to the GP or recommended to any other NHS services?

Name:

List the high’s and low’s of your visit to the GP.

Date:

Primary research 39


The Details

1. The personal and family networks template would provide information about the current status of the patient and where he/she lives. Additionally, it also explores the places where they would seek emergency advice from. 2. The Networks of advice would provide information on the advice networkof the patient and also provide good evidence on the preference of their networks of advice. 3. A&E and GP storyboarding would be helpful in understanding the key points in decision making of the patients, when they decide going to A&E or GP. 4. Reassurance Journey was a later addition to the templates which was to provide information about where they seek reassurance. This will be discussed later on in depth. These templates are being used at the surgery presently, by doctors to communicate with the patients. Additionally, a health professional also said these templates would be helpful in understanding the patient needs and get an in-depth understanding of the decision making of the patient.

Ferryview Health Centre

Reassurance journey... Please create a pathway joining the phrases to illustrate how you seeked reassurance in an emergency. Feel free to add to the phrases.

Called the GP

wasn’t feeling any better whilst waiting Called an Ambulance

Was askeed to drop in the same day

Got worse

Didn’t bother...

had to wait for ______ days forr appointment

Dialled Ambulance

When I was unwell...

Got better soon

Had to wait for______ hours before being seen by the doctor

Rushed to A&E

Called the GP had to wait for ______ days for appointment Spoke to a friend who had suffered a similiar ailment

Advised to _________________

Followed his/her advice.

was seen and reassured...

A&E...same day treatment

Felt better doing what was advised

nothing improved

Called an Ambulance

Called the GP Co-design Session

Name:

Date:

Primary research 40


The co-design session The co-design was organized at Ferryview with the patients who had been

frequent A&E visitors. The session was supposed to have at least 6 patients, who were to be interviewed in order to get a broader perspective of the patient’s decision making. Unfortunately, the day turned out to be wet and just two patients arrived for the session. Ferryview’s staffs along with Alison were present at the venue to help the patients fill the information in the templates. The two patients that arrived at the surgery were both living with at least one chronic condition. There weren’t too much difficulties as the templates were visual and self-explanatory.

Primary research 41


Primary research 42


Insights

Drawing perspectives from the gathered information

Insights 43


Co-design Insights An amazing lot of information was gathered from the co-design session. The

patients provided specific details on their forms and this evidence was used to identify the issues and gaps in the system. The patients used A&E services mostly when the GP services were available and not out-of-hours which reveals that there can be some intervention where the GPs can provide support. The ambulatory care services used by patients were at times when they panicked and needed immediate access, as they assumed it to be an emergency. One of the patients who came for the co-design stated “I called for the ambulance just 4 times”, which suggests that people think it a service for them and there is nothing wrong in them using them if they feel it’s appropriate. However, as discussed earlier on and based on the evidence provided it is unsure of what a real emergency is and if there was way of contacting the GP before they would decide of going to A&E would prove to be helpful. Likewise, the patients forms also provided information on their use of ambulances when they encountered a new illness which they had never experienced before and also for recurring pains. The patients described themselves to be ‘happy go lucky’ , conversely, the information provided by them suggested they were more of a worried well, who would panic for minor illnesses, which cannot be overlooked to be an emergency as substantial evidence suggests. Proceeding further, personas were created from the information obtained to create a design that responds to the need of the identified patients.

Ambulance and emergency care services are seen as an immediate acces by the patients, as compared to GPs where they have to wait for atleast a week to get an appointment to see a GP.

Insights 44


The need for reassurance The data collected from the co-design session was insightful. Patient’s anxieties

raise sky high especially when they are living with a chronic condition. On analysing the information, one of the main themes that emerged was, ‘reassurance’. The patients needed some reassurance form time to time and at point of emergency, or someone to tell them ‘you are fine’. As per the article published in The Guardian, it was told that health anxiety is not a joke and that it can ruin lives. Additionally, it stated that a few patients seek constant reassurance form their GPs to ensure there is nothing wrong with them. A 32 year old patient told the newspaper, “I was living with this constant fear that I would be dead in three months”, and despite his GP being certain that it wasn’t cancer. “..But we do know that reassurance only works in the short term. It isn’t long before those fears return.” (Catherine O’Neill, services manager, helpline charity, Anxiety UK)[13]

A photograph published in The Guardian, a GP assessing a patient

[13]http://www.theguardian.com/lifeandstyle/2010/jul/27/health-anxiety-on-theincrease Insights 45


Understanding reassurance Since reassurance was the strongest themes emerging out of the primary and secondary research, it was decided to understand reassurance more deeply in terms of what reassurance means to people and at what different stages on life they seek reassurance. This was done by asking friends and family to know what they think reassurance is to them, and when do they most seek reassurance.

A few Colleagues and friends were asked to express their views on reassurance. The phrases highlighted shows that people are always in need of reassurance in term s of their health and can be considered as one of the major aspects to be addressed to in the design.

Insights 46


Stakeholder mapping

keholders

Ambulance Core Stakeholders

NICE A&E NH NHS HS Trust Ferryview Health Centre

TAXI Service COPD Online Support Smoke Free

CA’s Health alt Visitors isit

Patients Nurse

Pharmacist

Community

GP’s P’

Receptionists Admin Staff

DAFNE DESMOND

Invisible External

Aspire

Internal Possible stakeholder

Insights 47


Insights 48


Personas

Martin Henry -Aged in his late 30’s. -Lives with his wife and children. -House husband. -Suffers from asthma. -Has a problem in communication. -Has recurring chest pains; urges him to rush to emergency. -Not too many friends in close proximity. -Attends all the recommended follow up’s. -Nurse or GP doesn’t matter; a quick and reassuring service is all he seeks. -Wife plays a key role towards his health decisions. -Would be obliged for GP telephone consultation. -Usually makes his appointments through nurses/GP’s. -He is located close to both GP and A&E.

Insights 49


Personas

Kate William -Aged in her late 60’s -Lives with her husband and kids -Retired -Suffers from chronic conditions (asthma diabetes and arthritis) -A&E and GP are both in close proximity to her place of living -Uses internet to know more about any new treatment or condition -Doesn’t particularly like waiting long hours at the GP -Likes to contact GP via phone -Discusses her medical issues with husband and family -Prefers seeing a particular doctor for all her appointments made at the GP.

Insights 50


Idea Generation Developing concepts


Idea Generation Insights from all the primary and secondary research generated sufficient

inspiration for developing ideas. There was ample information suggesting there was a need to improve minor aspects of the service. The reassurance theme was really strong and it was decided to test ideas along the idea of providing reassurance to patients. Also, there was the initial idea of the project which looked at improving CAs position in the surgery and how they could play an important role in providing support to these patients. All the ideas were about giving quick access to the patients in need of emergency. These ideas were to be tested at the Ferryview, along with the staff and the patients registered with them. The feedback from both the patients and the staff would then be used to improve the services accordingly. It was of absolute importance to test the ideas with the surgery as they would be in a better position to know what would work and what wouldn’t.


Concepts Appointment Card An appointment card will provide

information to the receptionists and other admin staff to know that the patient needs to see the doctor immediately as there could possibly be a problem.

In the co-design session, one of the patients mentioned that when he visited the GP as one of the nurse gave him immediate treatment on arrival and was nebulised, he felt reassured.

Have you heard about our Clinical Assistants who can help you with your Long term conditions...

Promote CAs

CAs can be promoted with giving leaflets and having a placed on the receptions desk, to enable people to know about CAs existence. This would enable the patients to have appointments with CA and discuss their problems with much more time as compared to the doctor. CAs are currently directed towards the problems that are on the surface to enable the surgery resolve the issue. However, they can be utilised to resolve patient anxieties and also help relieve the doctors of their duties in reassuring the patients.

Heart Disease

Smoking

Diabetes

Asthma

COPD

Want to know how to improve your health condition? Why not book an appointment with our Clinical Assistants to live a healthier life. Contact Rianna/Glenna on 02020202020 Ferryview Health Centre

Concepts 53


Text the GP/CA/Nurse The patients would message their doctor or the CA or nurse to discuss their health condition. This would enable the health professionals to decide on patient’s behalf and recommend the best service they should be using for the situation they are in. Primary research proved that having a telephone consultation with the GPs considerably reduced the number of patients visiting A&E. This service would also enable the GPs and CAs in understanding the patients.

I am experiencing chest pain and feeling very uneasy. Please advice if I should go to A&E.

please teak deep breaths and lie down, if it doesn’t help come down to the surgery immediately.

Priority Access

Patients will be given priority card enabling them a swift access to the GP services. They can call the CA/ nurse on the number provided and will be given assessment over the phone and if required would be asked to visit the surgery. The primary research and the codesigning insights delivered solid material that patient’s needed some kind of rapid access to primary care which would relieve them off their health anxieties.

Concepts 54


Concept Development Priority Health Care

The busy schedule of the surgery due to the winter around the corner had diminished the opportunity of having a co-design session with the surgery. However, the idea priority care was tested through service design tools (prototyping). The act included a patient, patient’s friend, a receptionist, a mail man and a doctor. The actors role-played as each actor and this method was used to identify any faults within the service. The Cast:

Patient’s friend

Doctor

Receptionist

Mailman

Patient

Nurse/Patient Concepts 55


One of the problems identified was that there may be other patients who may get to know about the service and hence should be more discreet.

There may be issues when the patients calls the surgery for assessment and also with the taxi service that the surgery would be providing as a part of the service.

The patient may or may not get to see the named doctor he/she is assigned with. Also there has to be a provision to accommodate these emergency appointments. Concepts 56


Final Design Priority Health Care Overview

Priority health care is service that offers the patients a quick access to their GP in case of emergencies. Further the service enables building a good relationship between the patients and doctors by having a named doctor for every patient with a chronic condition. Priority healthcare spreads the workload over the whole healthcare system and hence reduces the pressure build up on any of the health professional. Also, the service facilitates a more pro-active approach by the surgery, which makes the patient feel secure and reassured. The service is basic and in a non-digitalized form as it was observed that the patients were hardly using any technological gadgets and hence the old school method of letters and telephone consultation was decided to be the best in order to address to the needs and requirements of the patients.

Priority Card

Patients Name: Mr Martin Henry Address 13 Frances Avenue London SE18 7QB DOB: 25/06/1978 NHS No: 123 123 1245 GP Name: Dr Brown DOI: 18/10/2013 DOE: 18/10/2014 Please call the number provided below in case of an emergency.

0208 000 000

TM Cars...0208 317 2000 Ferryview Health Centre

Priority Card

If required please call this Taxi service

Final design 57


Mr Martin Henry Male 65 years

Date Of Birth 10 August 1968

Patient on QOF registers. Physical Activity report pending. Last Blood test July 2012. Recently diagnosed with Diabetes.

EMIS:Message To: Dr Brown From: Eilene Dear Doctor, Your patient Martin is here as he was suffering from chest pain. I have done the assessment and seems to be alright. But, he is really anxious and would be great if you could have a look. !

Final design 58


Storyboarding

Ferryview Health Centre

i

Martin is already a registered patient at Ferryview.

ii

iii

Martin receives the letter and decides to register for the service.

iv

The IT staff identifies the patients and sends letter about priority health care.

Martin arrives at the surgery and signs up for Priority Health Care. Final design 59


Pre service

v

ii

Martin receives the letter in a couple of weeks with his Priority card.

He suddenly feels chest pains and panics. Asks his wife to call the GP surgery on their emergency number.

Service Encounter

i

iii

Martin is watching TV following his daily chores.

Martin’s wife speaks to the nurse and on assessment, the nurse asks them to come down to the surgery.


iv

Martin is taken to a room and the nurse does all the medical assessment and tells him everything is normal.

v

Martin is not reassured and he says he wants to see a doctor...

Message from Nurse:

v

The nurse messages the doctor on EMIS and tells him his patient is here and wants to see him.

vi

The doctor reads the message and asks the nurse to send Martin to his room next.

Final design 61


vii

Martin talks to the doctor and is explained about the cause which puts him in a better state of mind.

viii

Martin and his wife are reassured and pleased about the quick and personal care they received.


Service Touch Points

Priority Card

Patients Name: Mr Martin Henry Address 13 Frances Avenue London SE18 7QB DOB: 25/06/1978 NHS No: 123 123 1245 GP Name: Dr Brown DOI: 18/10/2013 DOE: 18/10/2014 Please call the number provided below in case of an emergency.

0208 000 000

TM Cars...0208 317 2000 Ferryview Health Centre

Priority Card

If required please call this Taxi service

The priority card is given to patients who are identified by the surgery to be the top 100 patients, who need extra care and individual support. The main aspect of the card is to make the service more tangible and have physical evidence about the patient’s condition. Further the priority card is given to the patient has their named doctor on the card, which will direct the Ferryview staff without any hesitation.

Final design 63


NHS incurs a lot of loss when people use the Ambulatory care services for minor injuries and low priority health issues as discussed earlier. This restricts the use of ambulances to cater to real emergencies and accidents. One of the patients in the co-design session mentioned that ‘I waited for an hour for the ambulance to arrive despite the fact that I live just a mile from the hospital’. This highlights the issue that the ambulance service in the UK are constantly overstretched and there needs to be an alternative for emergencies. Priority health care tries to address this issue by having a taxi service for the patients who need emergency care. This service will offer the patients a free ride to their surgery from their homes for a limited time every year.

Final design 64


A pro-active approach by the surgery was one of the main aspects of the service. The CAs play a vital role in delivering this service to the patients. The surgery takes active part in patients’ health by being in contact through SMS’ and phone calls. This reduces the unplanned visits by the patient. CA calls the patient from time to time to know about their health condition and also provides useful information on maintaining their health over the phone and or in the surgery depending on the patient’s needs. This type of service helps in reassuring the patient and also reduces the unexpected visits to the surgery and A&E for issues which can be addressed to over the telephone.

Final design 65


Ferryview Health Centre Date: 04/10/2013 Priority Health Care

Dear Martin, We are writing you in regards with your usage of the NHS services this year. We would like to thank you for not using the A&E services and considering our Priority Health Care service instead. This has enabled Ferryview to help the NHS in saving money. We are pleased to inform you that Ferryview Health Centre has been ranked amongst the top 10 surgeries in Greenwich area. This includes providing a good service to the patient and also making sure patients with chronic conditions are provided a good health service at time of emergency. Please ďƒžnd enclosed the statictics of the usage of A&E service by patients in the Greenwich area. Please support NHS by using GP service to reduce the overload on NHS’ A&E services.

Regards, Ailene

Head Admin Ferryview Health Centre

Patients need to be rewarded in some way for saving the NHS funds by not visiting A&E and using the ambulance services. This is done by sending a formal letter to the patients every year of benefits the patients, the surgery and the NHS enjoys. The surgery posts a letter every year stating the performance of the surgery and how the introduction and usage of the Priority health care service has helped Ferryview in achieving the goals and targets set by the NHS. Final design 66


Touch Points

Line Of Interaction

Background Process

Line Of Visibility

Person in Contact

Line Of Interaction

Patient Actions

The IT team along with Doctors & Nurses identies the patients who need the extra care. They send out the priority card registration letter to the identied patients

The receptionist reads the letter and hands him a form to complete the registration.

Martin comes to the surgery and hands the letter to the receptionist

London College Of Communication

They inform the admin staff and they prepare the letter to be sent out regarding the priority card

The receptionists are informed by the IT/admin staff about the priority card.

Martin receives the letter and decides to visit the surgery and register for the service.

Service Blueprint- Pre-Service

On collecting the lled form, receptionist also informs about the card’s processing time.

Martin lls the required details on the form and hands it back to the receptionist

The Admin staff prepares the priority card and the letter to be sent along with it to the registered patient

The receptionist forwards the lled form to the admin staff processing

Final design 67

Kaushik Sudra

Patients Name: Mr Martin Henry Address 13 Frances Avenue London SE18 7QB DOB: 25/06/1978 NHS No: 123 123 1245 GP Name: Dr Brown DOI: 18/10/2013 DOE: 18/10/2014

The admin staff posts the letter along with the priority card to Martin

Martin recieves the letter and decides to use for his future emergencies.

Ferryview Health Centre

Priority Card


Final design 68

Touch Points

Line Of Interaction

Background Process

Line Of Visibility

Person in Contact

Line Of Interaction

Patient Actions

Martin is watching TV as part of his daily chores and suddenly feels chest pain...

The Nurse meanwhile checks to see who is free to assess Martin.

The nurse calls Martin and gives him the room no. he is supposed to go, on arrival

London College Of Communication

TAXI

With the details on the system, the admin staff sends a cab for Martin.

The admin staff is notied of the need for a taxi.

He is offered the free taxi service as nurse believes it to be critical.

Based on the assessment, Martin is asked to come down to the surgery immediately.

She asks Martin’s DOB and other questions to know about his health condition.

The Nurse at the emergency helpline answers the phone call.

Martin and his wife believe that they should visit A&E, but realise they can get a quick service at their local GP as a part of priority health care.

Patients Name: Mr Martin Henry Address 13 Frances Avenue London SE18 7QB DOB: 25/06/1978 NHS No: 123 123 1245 GP Name: Dr Brown DOI: 18/10/2013 DOE: 18/10/2014

Martin panics a lot and thinks he may get a heart attack and calls his wife.

Service Blueprint-Service Journey

Priority Card

The nurse checks him and makes sure he is in good health.

The Nurse knows about Martin’s arrival and is waiting for him...

Martin Arrives at the surgery and goes to the room no. he was provided on the phone by the nurse.

The nurse asks Martin to go to the doctor’s room after doctors positive reply.

The nurse messages the doctor to see the possibility

Martin Is still not reassured and wants to see the doctor.

Kaushik Sudra

The Doctor Examines Martin and makes sure he is ne and reassures him.

Martin is reassured

Ferryview Health Centre


Conclusion Priority Health Care

Priority Health Care aims to improve the lost relationship between GPs and patients in order to reduce patients turning up at A&E for minor ailments and health concerns which can be addressed to by their local GP. The project kick started with the introduction of CA (Clinical Assistants) to the system of health in GP to assist the doctors and also improve the surgery’s rank based on QOF, which in turn improves the funds given to the surgery by NHS. Moving further the project took new direction and included the CAs in the service to ensure a seamless working condition for both the staff at Ferryview and the patients using the service. The research for the project was mainly looking at evidences on A&E attendees rising considerably over the years, and also understanding the complex health system of UK, which has seen enormous increase in demands over the years. To understand the health system all the different parts of the health system such as primary care providers (GPs, walk-in centers) and secondary care providers (hospitals, urgent care systems) were also studied to acquire data on the evolution of these services and how the increasing demand has changed these services. In unison it was also of utmost importance to look at the patient’s side of the story. The combined research was a necessity as any design solution to a problem had to address the issues faced by both the parties. Personal care is what patients seek in most if the cases, which is a key aspect of Priority Health Care. Additionally, the service also encourages pro-active approach by the surgery which increases transparency. The concept is yet to be tested at the surgery with the patients and the health professionals working at the surgery, due to time constrain and packed schedule at the surgery. However, the service prototype was discussed with the GPs at Ferryview and the positive feedback indicated the service can make a difference once it is on pilot. Further, the service was also tested through ROLE-PLAY (a service design tool) to understand the difficulties and the gaps in the service. All the positive feedback from the collective sources was used to improve and arrive at a final design.

Final design 69


One of the investigations for the design which will have to be made over time, with more patients falling under the criteria of “Priority Care� and the surgery having to free up as many slots to accommodate these high numbers of patients. IF the service copes up with the high demand of the Priority care patients, it can called a success. Furthermore, CAs can become a prime part of the service by providing health care and advice to the patients which would reduce the time spent with the doctors, freeing up more appointments. Priority Health Care is a service which enables the GPs to understand their patients and their need to be treated as individuals. The NHS is a massive healthcare system catering to millions of people living in the UK, and over the years it has expanded beyond imagination. In the pursuit of providing efficiency, there are many new health professionals at patient’s disposal who can approached for all kinds of health issues. Priority Health Care enhances GP-patients communication enabling the doctors to provide a more personal individualistic care to all the patients with chronic conditions.

Final design 70


Impact Service Design Impact Priority Health Care is an ideal service which modifies the current health care scenario in several ways. It allows the doctors to change their behavior in terms of interacting with their patients. Furthermore the service will also help the patient in developing trust in their local GP, to discuss their illness in detail which shall result in a very good relationship between a Doctor and a Patient. Priority Health Care is already achieving success, as the surgery has started to use the co-design tools developed to interact with the patients. As one of the health professional at Ferryview Health Centre said, it enables them to gain a deeper understanding of ‘what the patient wants and what he is being given’. Not all the patients are on the same lines, and a select few require a little more than just medical reports suggesting that everything is just normal. Priority health care aims to expand to other surgeries facing similar problems with regards to understanding their patients resulting in reduction of A&E attendees. Further the service will change the behavior of the staff towards the patients and provide them with them more individualistic and personal care. The short term impact can be seen by the surgery when the A&E attendees fall down to a considerable number, amongst the patients who have a Priority Card. The service can considerably also improve patient well-being as they can be given individual advice based on their condition. Additionally, the service opens up A&E for real emergencies catering to the patients who are in need of emergency care.

Final design 71


Value

Service Design Innovation The main aim of any service design project is to add value to any product/ commodity, which is at the core of Priority Health Care service. It adds value to the surgery by giving patients an immediate access, when required in an emergency situation. There are four key values which a service addresses to: 1. Economic value 2. Social education 3. Cultural value 4. Environmental value A lot of amount is spent on health care in UK and most of it directed towards A&E (approximately 1 million every year), Priority Health care proves to be a service that adds a lot of economic value to the NHS. With the service starting to pilot in Ferryview and spreading to many surgeries across the UK, the GP and primary care services can effectively reduce the number of A&E attendees which would not only provide a better care for people in emergencies but also help A&E achieve targets set by the government. Priority Health Care deeply improves the doctor’s behaviors against the patients who are in need of constant reassurance and need extra care. It is supportive from the evidence gathered that patients living with chronic conditions are usually under the thought that there is something wrong and if they encounter the minutest of health issue they feel it’s the end of their life. Additionally patients are not convinced by the medical reports, but need a person to reassure them that everything is perfectly normal. The surgery using the co-design templates to understand the patients provides concrete evidence that the service is already changing their culture that has long been followed and trying different ways in order to understand patient needs. Finally, Priority Health Care responds to the environment indirectly by reducing the number of patients calling for an ambulance, who can be treated at their local GP as a part of priority care. Priority Health Care is a package that improves the whole surgery’s health system and in due time can be observed reforming the NHS and the primary care support providers. The patients can hence assist in retaining the image of NHS in saving lives by having the A&E and urgent care services providing support to the needy.

Final design 72


References [1] Health Systems Performance Assesment Debates,Methods and Empiricism Edited by Christopher J.L. Murray & David B. Evans http://whqlibdoc.who.int/publications/2003/9241562455.pdf(Accessed 25 September) [2] The evolving role and nature of general practice in England, The King’s Fund 2011(Accessed 4 November) [3] NHS Walk-in Centres in London, The King’s Fund 2001 (Accessed 4 November) [4] Telephone Consultations, patient.co.uk http://www.patient.co.uk/doctor/telephone-consultations (Accessed 14 August) [5] Impact of quality and outcomes framework on health inequalities, The King’s Fund 2011 (Accessed 25 August) [6] The King’s Fund, Are accident and emergency attendances increasing? http://www.kingsfund.org.uk/blog/2013/04/are-accident-and-emergency-attendancesincreasing (Accessed 24 August) [7] ‘Inappropriate’ attenders at accident and emergency dept. Andrew W Murphy Family Practice Oxford University Press 1998 (Accessed 13 September) [8] The Guardian, A&E Crisis. http://www.theguardian.com/society/2013/jun/25/a-and-e-emergency-medicine (Accessed 21 August) [9] Access to Primary Care and Visits to Emergency Departments in England: A Cross-Sectional, Population-Based Study http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal. pone.0066699#pone.0066699-Agarwal1 (Accessed 20 September) [10] http://www.nhsdirect.nhs.uk/news/newsarchive/2008/ easingthepressureongpandaand-eservices


References [11] http://www.dailymail.co.uk/news/article-2328723/Dont-visit-casualty--emailGPinstead-NHS-chief-Mike-Farrars-astonishing-answer-A-E-crisis.html (Accessed 21 August) [12] Health Service Journal, Better GP access, better A&E outcomes http://www.hsj.co.uk/home/innovation-and-efficiency/better-gp-access-better-aeoutcomes/5061857.article (Accessed 23 August) [13] http://www.theguardian.com/lifeandstyle/2010/jul/27/health-anxiety-ontheincrease (Accessed 25 September) [14] www.nhs.uk [15] www.choosewellwales.co.uk [16] http://www.notalwaysaande.co.uk/


Clinical Assistant Mapping

EMIS

EMIS

Valentine Health Partnership Appointments

Room 1 Room 2

Dr Brown Dr Tony

Search Quick Pick

Dr Brown

Dr Emily

Appointments

Dr

9:30

Mr Jacob

9:30

Mrs Jessica

9:30

9:30

Mr Harry

9:30

Mr Joseph

9:30

9:30

Mrs Olivia

9:30

Mr Tony

9:30

9:30

Mr Lewis

9:30

Mrs Lucy

9:30

9:30

Mrs Hannah

9:30

Mrs Emma

9:30

9:30

Mr Joseph

9:30

Miss Amy

9:30

9:30

Miss Amanda

9:30

Mr Sam

9:30

9:30

Mr David

9:30

Mr Muhammed

9:30

Mr Joseph Watson Male 65 years

Date Of Birth 10 August 1948

Patient on QOF registers. Physical Activity report pending. Last Blood test July 2012. Recently diagnosed with Diabetes.

Search Quick Pick

!

BP 95/150-July 2012

!

Smoking Data Required

!

Blood Test pending

!

CA arrives at the surgery

Room 3

Vacant

Room 4

Dr Emma

Room 5

Vacant

Looks in the back reception for empty room to occupy

Looks through the list of patients whohave appointment and selects a patient

If there is a pop up at the bottom suggesting any wotk that the CA has to do, she goes to the waiting area to find the patient

If the patient is old or unable to walk he is taken to the POD where the necesary details are taken. As the age of the patient is known to the CA, she carefully looks through the waiting area and approaches the person.

DESMOND

If the patient is able bodied then the CA takes him to her room and takes the necesary details and checks for BP etc. Clinical Assistant Mapping

EMIS

Appointments

Search Quick Pick

Dr Brown

Dr Emily

Dr

9:30

Mr Jacob

9:30

Mrs Jessica

9:30

9:30

Mr Harry

9:30

Mr Joseph

9:30

9:30

Mrs Olivia

9:30

Mr Tony

9:30

9:30

Mr Lewis

9:30

Mrs Lucy

9:30

9:30

Mrs Hannah

9:30

Mrs Emma

9:30

9:30

Mr Joseph

9:30

Miss Amy

9:30

9:30

Miss Amanda

9:30

Mr Sam

9:30

9:30

Mr David

9:30

Mr Muhammed

9:30

Seen by the doctor Being seen by the doctor Not arrived for appointment Arrived and waiting to be seen


Clinical Assistant Mapping

EMIS

Appointments

Mr Jacob Watson Male 65 years

Date Of Birth 10 August 1948

Patient on QOF registers. Physical Activity report pending. Last Blood test July 2012. Recently diagnosed with Diabetes.

Search Quick Pick

!

BP 95/150-July 2012

!

Smoking Data Required

!

Blood Test pending

!

Clinical Assistant Mapping Clinical assistant mapping was done in order to understand clearly the working of CA while providing realtime support. It was observed that thesoftware EMIS used at the surgery proves to be helpful to identify the patients and also to contact the doctos should there by any issues. Priority Health Care uses this messagin service as a touch point for CAs and nurses to deliver a great service.


Ferryview Health Centre Date: 04/10/2013 Priority Health Care

Dear Martin, We hope you are in good health. We would like to take this opportunity to inform you about a new service that Ferryview Health Centre has started and is called the Priority Health Care. We are pleased to inform you that you are eligible for this service. Please drop in at your earliest convenience to register yourself for the service. Also, there shall be regular health checks to support you in maintaining your health at all times. Here are a few benefits of the service: • Priority card • Direct access to a nurse/CA* • A 24 hour direct helpline access to a nurse in order to assess the situation. • Telephone consultation with a doctor. • Immediate/ fast track access to a nurse or GP* • No more waiting to get an appointment.* • Taxi Service to your GP.^

emergency

(*Depending on the emergency situation, ^available only four times a year and will be charged a nominal amount on exceeding the usage) Regards, Ailene

Head Admin Ferryview Health Centre


Ferryview Health Centre Date: 04/10/2013 Priority Health Care Card

Dear Martin, We would like to thank you for registering for the Priority Health Care. We have all the formalities completed and would like to inform you that your Priority card is ready and is enclosed in this letter. Here are a few important tips on using your card: • In an emergency, please call the number provided on the back of the card and give full details asked by the person on the line. • A face to face appointment with the GP will be provided depending on the emergency situation. • The taxi service is provided based on the assessment by the CA/nurse over the phone. • This card is a service initiative to provide a fast access in case of an emergency and is not to be used for obtaining regular appointments. • This card can be used only at Ferryview Health Centre. We hope this service will help us provide you with a new point of contact at times of an emergency.

Regards, Ailene

Patients Name: Mr Martin Henry Address 13 Frances Avenue London SE18 7QB DOB: 25/06/1978 NHS No: 123 123 1245 GP Name: Dr Brown DOI: 18/10/2013 DOE: 18/10/2014

Priority Card

Head Admin Ferryview Health Centre

Your Priority card


Priority Health Care  

Priority Health Care is a service design project at Ferryview Health Centre in association with NHS England and Design Council. It looked at...

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