A system to match the route of access to being the most appropriate for patients - using the most appropriate mode of consultation to resolve the patient's problem.

1. Dr Daniel Kerley
The College Practice
Multimodal consultations – not
just for acute problems

2. What is wrong with the
traditional model?
The case for change

4. An aging population

5. Ill-health in old age
1

6. Multimorbidity

7. Funding for GP has been cut

8. A real terms decrease

10. Workload vs safety

Decision fatigue

European studies suggest a safe limit of 25 clinical
contacts per day (BJGP 2016)

12. Summary

Rising demand

More complex patients

Falling funding

Less GPs

Safe working levels are unachievable

13. A new model
Addressing the challenges

14. A new model
Funding "There is no magic money tree"
GP shortage Multidisciplinary team
Demand Maximising efficiency
Complexity Consultant-led not consultant-delivered
Safety More funding is essential

15. A new model

We need a system to safely manage more patients
via a multidisciplinary team

We need to know what the patient has contacted us
for and triage to the appropriate person/team

Signposting can start the process

But cannot differentiate safely on clinical
presentations

Clinical triage

16. Efficient clinical triage

Allow the patient to provide the history before it
even enters the system – a "zero time" step

Weed out non-clinical queries and those that don’t
need an appointment

Send the issue to the most appropriate team
member first time

Use the most appropriate mode of consultation to
resolve the problem

17. Online consultations
Not just for acute problems

18. Online consultations

Zero-time history step

Effective triage

And little documentation afterwards

Shorter consultation pathway on average

Maximises multidisciplinary working
• Efficiency
• Cost-effectiveness

19. Not just for acute problems

Effective triage

Faster and more efficient

Maximises multidisciplinary working
• Why not use it for all problems?

20. Signposting and redirection

Signposting and redirection can happen even
before talking to the patient – the first person to
speak to the patient is the right one

21. Appointments
An appointment may clearly be needed after initial
triage
With Engage consult a clinician may identify this
before even speaking with the patient

22. Follow-up
Follow-up appointments are needed for a variety of
reasons
Patients are often willing to update the surgery after a
specified time period
E.g. stress-related problems

23. Medication review
Medication review scenario
I am awaiting an operation in 3 weeks time; the
naproxen and codeine I was prescribed
previously is working alright, I just need more
whilst awaiting my surgery

24. Gain of additional information

Non-acute problems eg GAD7, PHQ9

Domestic violence scenario

25. Part of multimodal consulting

Online is not a replacement for face-to-face

Some patients still need seeing

Online only is not a universal model
"one of the first merits of this Bill is that it provides a
universal health service without any ... qualifications
of any sort. It is available to the whole population"
Aneurin Bevan

26. Patient feedback
The online service is an excellent way to
communicate, I have used this twice and both
experiences have been positive. I have also used
the telephone service and this also is a positive way
of communication.
Engage consult is quick and easy to use especially
outside of opening hours. I am really impressed by
the service and I always get a call back or
assistance within 24 hours

27. Efficient clinical triage

Allow the patient to provide the history before it
even enters the system – a "zero time" step

Weed out non-clinical queries and those that don’t
need an appointment

Send the issue to the most appropriate team
member first time

Use the most appropriate mode of consultation to
resolve the problem

28. Patient feedback
It made me think more about my symptoms and I had
time to think about the answers and go back and
change them
I feel that I have time to give a more thorough
explanation of my symptoms - aided by the relevant
questions which appear, and by being given the
opportunity to put in my own words all that I wish to
say. This is an excellent service since I can submit it
in my own time and not have to wait to get through
by phone, only then not explain myself fully

29. Patient feedback
I used it as I felt I did not need to actually see a doctor
and take up an appointment time unless the GP felt
it necessary. I could explain my symptoms clearly
online and await a response
Good so far - I don’t like to take up Doctors time
unnecessarily so this is a good way of
communicating for non urgent cases

30. Patient feedback
Easy to use. Asks the relevant questions and a good
system for someone like me that finds it hard to
discuss certain things face to face
I've used engage consult to describe a problem that
I've had in order to get an experts opinion on it as I
am unsure of my symptoms and therefore would not
have been able to give a clear explanation over the
phone.

31. Patient feedback
Better than waiting to get through and more
confidential
I like the fact I don't have to find somewhere private
during the day to make a call to the surgery, in all
honesty I don't want my colleagues overhearing my
medical problems

32. Patient feedback
Used it because I feel unable to attend the Surgery,
also Influenza is Contagious, so would be unfair to
expose other folk with it.
Used it as to not call the reception unless full
emergency
a good way of communicating for non urgent cases
Report a non urgent health issue

33. Multimodal consultations
Maximising accessibility

34. Maximising efficiency

By moving to a consultant-led model and
channelling simpler issues to other team members
with a more restricted skill set

35. Minimising waits

Allows us to see the right patients as quickly as
possible

No 2, 4 or 6 week waits

36. Uncapped access

Many practices simply turn away patients when
slots are full – the 8am rush

37. But...short-cuts in care?

More antibiotics for phone consultations?

No, actually less – despite a jump in consultation
number due to moving to uncapped access

Telephone triage did not impact the quantity of
antibiotic prescribing
– n2015=2147
– n2016=2042
– n2017=2061

38. Better cancer care

Cancer wait time audit – a shorter pathway

Once seen by a clinician referral is swift regardless
of system

Much shorter waits to see a clinician

39. Multimodal not unimodal

Restricting access to online-only, phone only (or
services such as smartphone-based providers) or
walk-in only constrains access and results in worse
care

Multimodal consulting maximises access, rather
than restricting it

40. Endnote ...

Necessity is the mother of invention

General Practice is still underfunded

Safe working levels are not achievable currently

Many experienced GPs are voting with their feet

GP numbers are actually falling

Cutting funding whilst asking primary care to take
activity away from hospitals is perverse and
doomed to failure