Dulwich Medical Centre - Late patient policy

[Gimme]

No. Because the time of the next person's appointment would more than likely have been about 18 minutes before I was seen by the doctor.

[Penguin68]

On any one day an unexpected emergency can cause a particular doctor to run very late - a good receptionist lets waiting patients know what is happening - if you are waiting and know someone may be close to death in the surgery you are far more likely to put up with the wait.

However when over-runs become a regular feature (as reported, and as experienced I have to say by me as well - not at DMC) then the booking algorithm being used needs revision - there is perfectly good maths to suppport this (look up queueing theory). I would guess that 'average' times vary with time-of-year, and possibly time of day, as well as with particular types of patients. So the elderly (multiple problems), the very young (communications issues, parental concern) may need longer 'casual' appointments than adolescents and working age patients. By allocating time for these as they occur (flagging them by type in a database), taking into account seasonal and time of day variations, a very simple programme could allocate 'sensible' times for patients mitigated by a 'no show' factor probably based, again, by patient type.

A very simple booking programme could easily be created which would allow appointments to be booked so that most people would get in to see their doctor within 5-10 minutes of appointment time - and a strict 10 minute rule would then be seen by most as wholly justified and surportable.

It just needs good data-capture and conscious thought to be applied - I bet such programmes are available off-the-shelf already.

[Gimme]

Alternatively, charge ?5 per visit to put people off seeing the doctor with a cold or sniffle.

That would reduce waiting times due to doctors seeing less time-wasters and then being able to spend more time with the genuinely ill.

[Penguin68]

Unless you are a trained medical person a symptom with which you are unfamilar may be trivial or life threatening. A ?5 charge for a single mother on benefits is not trivial - should she ignore her children's illnesses (which may well be new to her, if not to someone trained or with more experience) or risk being fined for being a good and conscientious mother. Or do you want to bring in the cost of operating a means-tested system? I am happy to stand corrected, but my guess is that the largest consumers of NHS GP services are children and the elderly (both of whom would be likely on political grounds to be exempted from consultation charges as they are from prescription charges). Means testing would also exempt those on benefits.

So the payers would be the employed, who normally find it difficult to take time-off to see doctors and are probably the least likely to be able to afford (time-wise) being the worried well.

Hence the ?5 charge would fall most heavily on those who could certainly benefit from reduced waiting times at surgeries, but are least likely to be able to (being often constrained to take over-running end-of-day appointments because otherwise they are at work).

[Gimme]

Or how about introducing a ?10 charge for appointments between 8am and 9.30am and between 5pm and 7.30pm, but with a guarantee to be seen within 5 minutes of appointment time. That would mean that those who are time rich but cash poor could go during the day and those who are cash rich but time poor could pay to go at times that fitted with their working arrangements. Everyone's a winner.

[Cassius]

What about a charge for no-shows?

[Moos]

So... in other words, you would get the NHS you can pay for? Convenient appointment times for the wealthy, the rest for the rest. A Cabinet Ministry awaits.

[Penguin68]

The wealthy, through graduated taxation, expect to pay more for the same state service; where it becomes difficult to swallow is where they are expected to pay more for a worse service. By charging to attend in 'popular' times (i.e. those times that working people, who actually often aren't that wealthy, can most easily attend in), but then offering just the same old extended waits you would be doing just that. That's the problem with 'easy' solutions of rationing through price etc.

Actually planning and making appointments in ways (as I have suggested above) which reflected actual times available and 'real' typical consultation times would reduce waiting times 'on the day' (although it would also tend to reduce patient slots available each day which would mean you might have to wait longer to attend the surgery at all). My surgery used to have, but seems to have dropped, 'drop-in' slots where patients who wanted to be seen urgently could turn up and might have to wait a long time, but at least knew that in advance, and could bring a book, or two.

My grown-up child always 'prefers' being ill at the evening and on weekends when Seldoc seems to provide an excellent service.

[Gimme]

It would just mean that the 'wealthy' (i.e. those who choose to pay for convenience) would be contributing more for their healthcare while the less wealthy (or those who choose not to pay for convenience) would continue to get their healthcare for free.

Bringing in more funds would allow the surgeries to stay open later, thereby reducing the number of people attending during the day; this would improve their service too. So this in actual fact a brilliant idea. The 'wealthy' pay and the 'less wealthy' get better service on the back of that.

Everywhere we have choices to pay for convenience so why not the NHS. It is not just the rich who pay for convenience (see McDonalds as a perfect example - you could make the most amazing nutritious meal for 4 people for half the price of 4 Maccy D meals but many less well off people still choose to pay for the convenience of Maccy Ds).

Moos Wrote:

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> So... in other words, you would get the NHS you

> can pay for? Convenient appointment times for the

> wealthy, the rest for the rest. A Cabinet

> Ministry awaits.

[sophiesofa]

Are you joking Gimme?

[HonaloochieB]

sophiesofa Wrote:

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> Are you joking Gimme?

I've run the old satire detector over Gimme's post SS, the needle remained as steadfastly in place as Eamonn Holmes studying the dessert trolley.

So I'm guessing not.

[Penguin68]

I am guessing all bets are now off on this, as the Government drops the 'see in 48 hours' target for GPs. Unless some other satisfaction target is introduced we will be back to 2 week booking for surgery visits.

If you are actually ill, in 2 weeks you are either better (so you don't go to the surgery and are a 'no show') or much worse, so you are already in hospital/ the undertakers.

The only ones turning up will be the malingerers or the worried well. Hey ho.

[sophiesofa]

Thanks HB, I think I need to get me a satire detector - they sound very handy.

I'm a patient at DMC and it's by far the best practice I've been a patient at. I always (unless urgent) book a 6.50pm appointment in advance and yes sometimes I have to wait a very long time but that's why I take a book. Sometime my appointment has taken 2 mins, sometimes 20 mins so there's no way of timing everything perfectly at a doctors.

[Sue]

sophiesofa Wrote:

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> Sometime my appointment

> has taken 2 mins, sometimes 20 mins so there's no

> way of timing everything perfectly at a doctors.

xxxxxxx

Yes - exactly :-S

[Jeremy]

Gimme Wrote:

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> those who are time rich but cash poor

> could go during the day and those who are cash

> rich but time poor could pay to go at times that

> fitted with their working arrangements. Everyone's

> a winner.

How about people who are time poor and cash poor?

[Penguin68]

sophiesofa wrote: Sometime my appointment has taken 2 mins, sometimes 20 mins so there's no way of timing everything perfectly at a doctors.

Yes, and over time your various appointments will have an average - as quoted currently by you that is, over 2 appointments, 11 minutes - about the amount I was quoting earlier (12 minutes) - that is what statistical averaging is all about. On the occasions when you are having an 20 minuter an alternative sophiesofa will be slipping out in 2. Of course, at different times of year averages may differ, as they will with different types of patient - hence my suggestion for a slightly more sensitive algorithm to be used than a 'one-size-fits-all' allocation.

If a doctor plans to see 20 patients in a 4 hour session on average he/ she will be able to fit them in in the planned time - although individual appointments may over-run, and on occasion patients will have to wait, but not by a large amount and not on every occasion. My belief is that patients are being scheduled at 6 an hour (one every 10 minutes) when the reported run-rate by most people here suggests 5 an hour is more appropriate.

[sophiesofa]

I don't think anyone, unless they have asked DMC, can say whether they see 6 patients each hour, although I appreciate you did say it was your belief, not a fact.

I just do not think health can be fitted into an successful algorithm there are far too many variables. Family history, age, sexually active etc.

[Penguin68]

I don't think anyone, unless they have asked DMC, can say whether they see 6 patients each hour

I have already said I don't go to DMC, but in the surgeries I have attended appointments are normally offered 'on' the 10 minutes (10:00; 10:10; 10:20 etc.) - hence my suspicion that the appointments are slotted in 6 to an hour.

Simple record keeping can tell you for instance whether there is seasonal variation in consultation times and of 'averages' for groups of patients (say the elderly, the very young etc.). A dynamic allocation system would then allocate time based on type of patient/ time of year. A doctor with a lot of time-consuming appointments would be booking fewer in a given period than one with many quick in and outs. It is the 'one-size-fits-all' approach which leads to queues; as does 'targets' (must see 20 patients in 4 hours).

This is actually a very simple queueing problem, a programmer and a statistician could very easily produce a workable application for this - indeed I suspect, as I have said, that such applications exist off-the-shelf and just need customising.

There are always problems when patients expect to see a particular doctor at a particular time (both of their choice) but generally where there is some patient flexibility these things can be sorted.

[sophiesofa]

Penguin68 Wrote:

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> I don't think anyone, unless they have asked DMC,

> can say whether they see 6 patients each hour

>

> I have already said I don't go to DMC, but in the

> surgeries I have attended appointments are

> normally offered 'on' the 10 minutes (10:00;

> 10:10; 10:20 etc.) - hence my suspicion that the

> appointments are slotted in 6 to an hour.

Apologies I thought you were saying you thought DMC book 6 in instead of a usual 5, but my mistake. I always assumed (although it is purely a guess) that every 2 hours or so there would be an empty slot to try and cover for potential over running appointments.

I just don't see why if this is such a wonderful solution why they/all GPs don't already use one.

[sophiesofa]

Does anyone know if you can book double appointments at any surgeries, like at the dentist when you've been told to book in a double appointment? Just wondering.

[Penguin68]

Sophiesofa wrote: I just don't see why if this is such a wonderful solution why they/all GPs don't already use one.

Sadly, I believe, that they don't because, for the doctors, the system is working - they never have to wait for patients, there's always one there waiting until the end of surgery, they are not worried about patient inconvenience and they don't want the bother of capturing the appropriate data and allowing receptionists to operate a dynamic system.

The system they operate is simple (some might say mindless - as in the application of the punishment for late attendance) doesn't require any, or much, training and, as I have said, from their perspective works. It just doesn't from ours.

[Gimme]

But to consistently time everything badly, every day is just poor management.

Unless my continual long waits for in the waiting room every time I go to DMC are just darn bad luck (i.e. a repeated blip) and everyone else is seen within a few minutes of their appointment, then the management need to work out how long to leave for appointments and reduce the number of appointments they try to cram into an hour. They would then need to increase opening hours or increase the number of doctors to meet demand but that is how everyone else deals with demand so why shouldn't they. Or they reduce demand by charging for appointments (a suggestion already shot down in flames earlier...).

The problem with public services is that they think that their customers have no choice and therefore they can deliver poor service with impunity. Think what would happen if a restaurant always made people wait 45 minutes past their alloted booking time. Their customers would go elsewhere. But because there is so little choice of doctors surgeries and all the alternatives have the same public service attitude, the service tends to be terrible.

On the positive side though, DMC is 10 times better than Melbourne Grove Medical Centre so I suppose that's something to congratulate them on....

Sue Wrote:

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> sophiesofa Wrote:

> --------------------------------------------------

> -----

> > Sometime my appointment

> > has taken 2 mins, sometimes 20 mins so there's

> no

> > way of timing everything perfectly at a

> doctors.

>

> xxxxxxx

>

> Yes - exactly :-S

[tulip]

sophiesofa Wrote:

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> Penguin68 Wrote:

> --------------------------------------------------

> -----

> > I don't think anyone, unless they have asked

> DMC,

> > can say whether they see 6 patients each hour

> >

> > I have already said I don't go to DMC, but in

> the

> > surgeries I have attended appointments are

> > normally offered 'on' the 10 minutes (10:00;

> > 10:10; 10:20 etc.) - hence my suspicion that

> the

> > appointments are slotted in 6 to an hour.

>

> Apologies I thought you were saying you thought

> DMC book 6 in instead of a usual 5, but my

> mistake. I always assumed (although it is purely

> a guess) that every 2 hours or so there would be

> an empty slot to try and cover for potential over

> running appointments.

>

> I just don't see why if this is such a wonderful

> solution why they/all GPs don't already use one.

As I said, most GP practices do (I believe DMC do too)! They block every 3rd or 4th appointment or have a 30 min catch-up midway depending on what suits the practice, but keep to 10 min slots (it would be ridiculous to give people appointment times at 12 minute intervals). Who would want to be discussing their very presonal problem or painful diagnosis to be thown out when 10 minutes is up? Remember it is a delicate balancing act and that if you extend appointment length you have fewer appointments to offer.

All it takes is someone who is elderly and needs a while to get undressed and dressed to put the dr behind, let alone a patient with a serious diagnosis or bereavement who needs the extra couple of minutes. Again, most practices do tell patients to ask for double appointments if the know the patient will need that long and when needed they will routinely book doubles for non-english speakers or antenatal etc.

I disagree about choice- there are many practices to pick from - all different. Pratcices for the last 2 years have been paid based on patient satisfaction with access, not actual access so it is in their interests and is in fact essential they try and please people. However, each GP practice cannot be all things to all people.

I suggest if anyone who is unhappy asks to speak to the practice manager. You could even join your practice's patient participation group rather than spouting off on here. Or why not volunteer your services to create 'a dynamic allocation system' for your practice? As I said previously, practices put a lot of thought and energy into managing their appointment books and do try and predict demand, but there really are too many variables and until the patient is in the room the dr won't know what they need to do for them or how long that will take.

[James Barber]

I recall having to fill in lots of forms when I registered at GP and those forms would give a suitable indication of how long an appiontment on the average would be. If I was 90 with a known heart condition then clearly the appointment would be longer. etc. etc.

It must be stressful for GP to see a sea of expectant faces waiting. Stressful for patients hanging around mentally working out how they can amend their day to cope with the delays. Keeping kids from causing mayhem while parents wait.

I'd suggest the problem is in practive management not implimenting clever scheduling systems. Such a system could also text/email people their appointment has slipped by 20 minutes. This is not hi tech.

Eitherway if you want to influence things contact the pratice manager for DMC Crystal Palace Road ? Annie Lawlor [email protected]

[tulip]

I forgot how hi-tech the council are.... perhaps you could demonstrate some clever scheduling ideas to the practices.

It would help if you knew in advance the dr would be late, but they won't know that far in advance- eveything could be running fine until the patient right before you and by then you are sitting in the waiting room anyway! As yet that hi-tech predicting the future system hasn't been invented. However, receptionists should be courteous and update the waiting patients. If it was that simple do you not think the practices would be doing it?