A short story of mail filtering


Urban practice NE has approximately 14,000 patients, five partners and four sites spread across its ‘patch’. The patch is centred on a traditional market town that is becoming a commuter town but still has areas of high deprivation. The original two site practice took on a smaller practice about five years ago – due to contract issues, these two sites are effectively separate from the main practice.
One of the issues facing the partners at the practice, indeed any practice, is the amount of extra information they have to absorb in addition to the workload from their consultations during the day. This (mainly) comes in the form of paper, and this extra absorption comes at the point in the day when they have time – more often than not – at the end of the day when the capacity for making decisions is often overwhelmed with the second guessing that occurs at the end of any work day that consists of making what could be crucial decisions. Hence the basket and email box gets left for tomorrow because tomorrow has to be better, right? Only it doesn’t and that basket starts to overflow…. Email programs can automatically label and filter so some of that focusing can be done automatically but unfortunately paper doesn’t have that function and  never will.
This frustration came to a head within urban practice in the autumn of last year with all the partners feeling submerged under paperwork, they discussed the situation and out of this discussion they asked me in to help with the problem. I was already working within the practice as the bookkeeper for the practice, have a background as a nurse / midwife (although long out of clinical practice) and an academic background in information management (one of my areas of interest just happened to have been information overload). My husband also happens to be one of the longstanding partners in the practice. And then he had to have a shoulder operation so we decided to trial the filter process while he was ‘on the sick’.
Within urban practice there were already staff allocated to scanning letters into the system, staff who had the job of data entry, and a pharmacist has been employed to help with med reviews, med requests and so on and obviously admin staff. After discussion, we decided that seven things could happen initially to letters:
1. Ones that had to go to a GP
2. Ones that needed to go to a nurse (the smaller site is auditing all A & E consultations to see whether the A & E /OOH visit is necessary)
3. Ones that simply needed the meds reviewing or discharge meds adding
4. Letters that needed some sort of action by admin staff
5. Work that could be handled by secretaries
6. Letters that simply had some data to be entered eg. Diagnoses, blood pressures, lab results etc.
7. Letters that could just be scanned.

We ended up with the following stamp


For auditing purposes we had a date stamp made to highlight the fact it had been filtered and had a small space for initials. (I now know why Dr’s signatures are usually a scrawl…).


We also had a red DNA stamp made so we could highlight this on letters that came from trusts etc.


We started. First hitch was using the wrong highlighter colour – anything other than yellow we found obscured the very data we were seeking to extract when scanned. This was quickly rectified and yellow highlighters acquired, oh and lots of paperclips.


The basic process from the beginning has been the same (with a few tweaks) a letter arrives into the practice (by post, fax or hand) and it is put into a post basket. Once the post has arrived and has been date stamped, I collect it, stamp, date it and then read it. Highlighting key phrases / sentences paragraphs.

Rule of thumb:

1. Goes to a GP first– complex diagnosis, review required, test results (unless it is negative and consultant has dealt with it), safeguarding issues, frail elderly and dementia cases. Any mental health & CAMHS letters (unless simply copies of appointment / waiting list letters). After discussion and prompting by myself, it was decided to get two more stamps – a ‘GP Action required’ and ‘GP information Only’ to help the decision process about how urgently something must be dealt with. Also – here is the flexible thing and tricky area – things that the reader thinks the GP will want to know – maybe someone being admitted from A & E or an out of hours issue that may need them to follow up.

2. Goes to a Nurse first – this is complicated. Essentially any letter that requests food supplements prescribing needs to go through the nurses for them to authorise. In one surgery A & E / OOH consultations go to them, the main surgery doesn’t have that project running.
3. Goes to MED Check first – when medication has been changed by a consultant but letter doesn’t need reviewing by a GP. Or if a patient has a long list of medication or is on complex hospital prescribed medication – it is then sent for review to ensure that everything is correct and correct information is on the system to ensure that system triggers are deployed when clashing medication is prescribed.
4. Goes to Admin Action first – ‘dodgy addresses / probably not our patient’, letters from screening services asking for confirmation of population data, if there is a simple request for bloods / results / screening from a hospital. DNA letters from everything apart from MH, CAHMS and child development got to admin (unless they have clearly got another appointment booked already). Complaints are sent in a sealed envelope to the practice manager. All A& E / OOH that require a child safeguarding trigger form are sent to Admin to have that done before being passed to the Child safeguarding lead in the practice.
5. Goes to Secretary first – requests for patient notes from ins cos / solicitors. Requests from opticians for referral to local eye services where there is no other medical condition being queried and the request is straightforward e.g. ‘this patient is elderly and has a cataract and it needs removal, please refer.’ Some podiatry referrals (but never had one of these).
6. Goes to Data Entry first – if there’s nothing else but a BP / test result ‘your mammogram was clear’ – ‘your pt was referred to the colposcopy clinic because of a borderline smear’.
7. Goes to Scan only – anything that doesn’t need action / sight by a clinician or contain any useful information that could be added to the patient record. DNA’s that have an appointment, letters that basically say, patient came – await investigation results.

Obviously it can happen that several boxes are ticked to indicate a downward cascade, all letters are signed off to indicate relevant person has seen them, they are actioned, sent further on or put in the scanning basket.
Once all post has been filtered then the separate groups are collated, counted and put into relevant folders to go to their respective destinations.
Results have been impressive – overall there is near enough a 60% reduction in the amount of post going to each individual GP and all of the partners have expressed relief at this.


Several issues though are worth considering.

1) Paperwork / letters will always be a part of GP practice. It will always take someone’s time to filter them – even setting up email filters takes a human to do it.  I roughly allocate two hours / per day to complete the task – takes more on heavy days.
2)Needs practice staff with confidence / knowledge / time to do this. I notice there is a slight uptick of the amount of paperwork going to GPs once my mentor GP stopped (ie went back to work) because I want to be sure that the letter wouldn’t be missed.
3)Folibles of individual GPs – the principal GP at smaller site would ‘rather know what’s going on’ than not so proportion of letters he sees doesn’t necessarily equate to what he *should* be seeing.
4) System at present depends on me being present every day to do this as I am the only one that is trained to do this, at present.
5) Possibly more letters could be sent to Nurses at main site – asthma, diabetic reviews etc but their work schedule (at present) does not have the admin time built into it.
6) System creates a time lag in letters being available to Gps but not by much (usually overnight if that) – is this noticeable in practice?
7) Systems always have cracks in it – human nature – one letter with information was missed because it didn’t go through this screening process.
8) Quite frankly some of the information that comes back from secondary or community care needs to be looked at. Is it worth sending a two sided letter which is basically a repeat of the referral letter with ‘await investigations ‘ as the only input from secondary care on? Why oh why don’t secondary / primary care systems not talk to each other – the amount of computerised assessment forms being printed out and mailed …

Filtering seems to work, but as always a project like this will need continual tweaking so suggestions are always welcome. The important part though is that filtering helps the clinician to focus – they know what they have in their baskets need to be looked at and acted upon principally by them. It is up to each practice to decide if the practitioner time gained from being able to focus in this way is worth the cost in the time it will take a member of staff to do the system.

Comments are welcome.

Being the Elephant in the room


Had a really eye opening day last week.

I have two boys who both have what they call ‘complex issues’ that manifest as social, behavioural and emotional issues, hence after a long journey / struggle with mainstream education (think rectangles being made to fit into round holes) are now within the specialist system. I don’t often mention them here as a lot of the stuff is intensely personal and really difficult to blog about. This isn’t really about them but you need to know the background to set the scene. I’ve become involved as one of the many strings to my bow, with a parent / carer forum which engages (mostly constructively 😉 ) with the LA, inching along the co-production route to designing services. In the main as far as I can see, up until now, the staff have been fairly flexible, welcoming and accepting of this new approach to working.

Indeed, co-production is one of the few things that have survived the change of governments. The new Child and Families Bill (expected to be in operation by September 2014) puts working with children and families at the heart of the many reforms in the bill that deal with Special Educational Needs & Disability. Cue the conference on Wednesday, organised by one of the pathfinder authorities in the area (what went on has nothing to do with their organisation I hasten to add!)

All of the local authorities in the area were invited with a set number of places going to each authority. It was open to all who were involved in this area, parents, teachers, health partners, LA staff etc. I’ve seen reports that some authorities didn’t invite parents along at all or restricted them. My LA were good and just invited us.  It was obvious however, that we were most definitely in the minority. 

Cue the presentations. A speaker introduced her talk by rattling through the groups that were there, I looked forward, proudly, to putting my hand up as if to say, ‘I’m a parent, I’m here, I’m involved’. Didn’t happen.   Other professionals came and went, all proudly talking about how the reforms would be putting the family at the heart of it all – meeting their needs and outcomes they specify would be paramount.  Cue the questions – one from health – what if the solution proposed didn’t have a good enough evidence base and something else had a better evidence base, which one do we commission?  (ie who knows best?)The questions about budget / finances (answer from D of E murky as ever) .

Then came lunch.  in the queue I was talking to someone, introduced myself as a parent and she looked a bit agog that they actually allowed parents here and then proceeded to talk about how well its good to have parents here so that they can manage expectations, as other parents might look at the bill and have their expectations raised whereas really a lot of the work is going to be about how to persuade parents that the sky is the limit with regard to meeting the needs of children.  I then went and plonked myself down at a table where a group of (presumed) educationalists proceeded to discuss a common case.  The only thing that they managed to do well was not name either the child or the parents. They did however, proceed to moan about the cost to their budget, the fact that the parents had ‘bent the rules when they didn’t really need to to get the child into the school’ etc etc.  By the time I’d finished my food, I was fuming inside!  I didn’t know whether to be complimented because they just assumed I was a fellow professional and so wouldn’t mind their in house chat or fuming because they assumed that parents wouldn’t be here and so everyone was a professional and be having all these types of chats anyway.

Needless to say, I came away from the conference extremely frustrated and disheartened. The reforms to me, before this, meant a step away from what I currently believe is an adversarial system where a parent has to butt heads with the system and jump through hoops to get (at times) what is the absolute minimum of constructive intervention to a process where each and every family gets what they need – a decent, inclusive, accepting education system, social care delivered according to need and the correct and timely intervention from the health service.  We don’t want anymore than this, why should we be made to feel that this is more than we deserve?

There are lots of areas of good practice in this area – particularly in the NE – but I think the professionals really have to look at us, the parents, yes those demanding, greedy, rule bending, mouthy elephants in the room who are often the only people who are standing up for their families and in particular for those children who have additional needs.  These reforms need and deserve more than the lip service they are getting in various professional quarters.







Everything changes but change itself


 As part of one of the thought processes that has been bubbling through my mind in recent weeks  I found myself at VanishingHighStreet.com late last week. It is a site established by Bill Grimsey , who has had  very long career in all incarnations of the retail sector.   He has very, very recently published a document called The Grimsey Review in response to the 2011 report on the High Street commissioned by the Government from Mary Portas. The document is free to download from the site. The report is independent – neither commissioned or funded by anyone else other than Bill Grimsey and the small team around him. He has also written a book called Sold Out which focuses on the  development of the shopping experience in the UK over the years since the late 1940’s.  On the basis of the Grimsey Review, I bought the book – online and in ebook format (makes the point about how times have changed!).

The book is very frank about how the large retailers, financiers AND consumers have all come together to create the current shopping experience we have today – with all its risks, problems, conveniences and the implications these have for the community and town centres. 

The theme running through the book is that ever since he’s been in retail – five decades there has been accelerating change – mainly due to the creation and application of digital technology. But there have been changes in other ways too, customer service has come and (according to him) gone again, town centres were supplanted by small malls and small out of town centres and now those are being supplanted by the supermall (can’t believe he didn’t mention the Metro Centre which was in being over 20 yrs ago if not more) and the shoptainment complex which doubtless will give way to something else in time. One thing he was sure of though, was that the High Street as it used to be is not coming back and its pointless trying to turn the clock back. This is the stall that he sets out at the beginning of the book and the theme he returns to int he closing chapters. Much of the book is uncomfortable and challenging to read – no punches are pulled in describing the behaviour of financiers, retailers and even the consumer. 

 What he does make clear, however, that he believes that there is no going back to thinking that old solutions to encourage footfall will work- too much has changed for everyone. Indeed, I chuckled early in the book when I found that he’d written almost word for word, certain thoughts that had been recently going through my head.  

He ends the book by calling for more ‘blue sky’  thinking in how we view town centres, high streets and ultimately the future of our communities.  He’s really calling for us to accept that everything changes but change itself.






Thinking outside the box …


There’s a bit of chatter on Twitter today about the results of a Pulse survey showing that more than 50% of Gp’s would charge fees for routine appointments. The article mentions that patient demand is only going to go up and of course there is the lingering issue of OOH of course 

Declaration of interest – I am a GP’s wife and a friend of many Gps. I don’t think many Gps would vote for this charge (which will be doubtless spun as ‘greedy’ GPs wanting to make even more money off the backs of the public) without feeling some sort of desperation about their future workload.

How can GPs work smarter and manage workload?

There are some very good ideas floating around – Patient First, for example- an extension of the ‘traditional’ model of GP practice.

There is always going to be a place for the face-face appointment at Primary Care level especially for those who are acutely ill but surely the time has come to think outside the box instead and look to ways to integrate technology properly into care, especially chronic care?

  • What about thinking about ways to ‘stream’ data from chronic patients eg: blood sugars from diabetics, daily / monthly blood pressures, even peak flows from asthmatics. Constant streaming will mean that clinicians would have access to real time information highlighting problems as they happen. Patients wouldn’t have to come in for routine checks, checking the data wouldn’t be time specific
  • Using wifi pedometers / wifi scales that link to the web that can be accessed remotely by lifestyle trainers to monitor / encourage / set targets for. This approach could potentially have more capacity than any gym program.
  • Better signposting to support groups on and offline
  • Improved Communication between Pharmacists and GPs – if pharmacists begin to see more patients then records need to be shared.

Most of this technology is already here, the vision and the will to use it has to be here too. The NHS should be free at the point of use service but if that principle is to be kept, Primary Care has to have the will to change the model of delivery.

Just my two pence worth!


Digital Gadget wish


Been thinking of this for a while 

Anyone know of any Gadgets / apps that are a syncable calendar  and a whiteboard for writing notes ie like ‘don’t forget your swimming gear’ . I suppose a touchscreen Ipad / tablet / one of the new convertible touch screen tablets would do…


What I’m thinking of something that could go on a kitchen wall so that all the family can see calendars / appointments / working profile / school events of everyone else.

I’ve just switched back to a filofax because there needed to be something universal and easily accessible for the two adults in the family – it would be quite neat to have a screen in the kitchen where you could just walk past and tap it and link into the home network… 

Given the fragmented & turbulent digital world we have at the moment, it might just be out there already…

(ps and some coherent tutoring on how to get all the various calendars to sync would be nice… phone isn’t talking to windows  8,  windows 8 is not talking to google or MS outlook 13, phone isn’t talking to MS outlook either. All being very sulky indeed! 


Wrestling with email


Years ago, I had outlook installed  on the desktop and outlook express and my own domain. I had a fair amount of email but it was all sorted and organised – no mega amounts in in boxes – most everything had its own folder and all was good.

I switched to Gmail a few years back after I gave up my domain (no use for it) and ever since then I’ve struggling to deal with the overwhelming tsunami of mail. I once hailed the use of tags rather than folders for Gmail to be really cool and innovative  and oh its going to be really easy to archive …. Well that was a set of wrong assumptions! 

I don’t help myself because I really do keep 99% emails I receive (just in case *eyes roll*) and being kind of OCD about having everything in order …. well you can imagine what I feel like when I glance at my inbox and see the twitter notifications, the FB stuff, the emails from garages wanting to sell me cars or insurance …

I’m currently dallying with the web version of outlook but the only problem is that it will only d/l stuff from my gmail account post my getting the Microsoft account set up in November.  I am finding it easier to sort stuff into folders and them mark them as read. 

I can imagine that newcomers to the web who are not used to sorting and setting up the rules will be faring even worse than me!

Its easy to overload on email and especially if you are  hoarder like me then that risk is twice or maybe even three times higher… 

So I am still on the lookout for a good mail client and maybe even a new email address but in the meantime, I’ll go back to wrestling with my archiving and yelling King Canute like at the tide to stop! 

The Careless Society – thought provoking read




Recently got a suggestion to read this book from @anniecoops on Twitter. So always interested in reading something new I toddled off to Amazon and bought it. This is the link to its Amazon Page.  Came in the post about ten days ago and since then I’ve been reading it. Finally finished it this morning.

The basic premise of the author is that the move to provided services has led to an erosion of community and thence to a disempowerment of the individual to make positive change in their own lives and those of others. In particular he mentions the institutionalization of the disabled as a case in point. They maybe in the community but are not seen as part of the community due to the provision of services for them that effectively keep them dependent on service agencies for support.  The book, even towards the end, provides few answers to the problem that he identifies in the first chapter.  Although in his defense there is a ‘sequel’ which I have not read yet which details his full response to the problem as he sees it.

The book is soley based in a USA context and was written in the 1990’s.  He steers away from politics, although it appears as though the logical end of his theories would be a smaller state with money being ploughed back to individuals to use in a local context. Although he doesn’t go as far as Thatcher in declaring ‘there is no such thing as society’ (because of course this would completely negate his central point). 

One of the issues I have with the book is that he constantly harks back to a supposed ‘golden age’ of community where everyone helped each other and all was peaceful.  There is no examination about how true to life this ideal was and what implications this all encompassing community had for the development of society. If communities were so tight knit and stable – did this have the effect of preventing change and development?

There are other disturbing issues with the book – particularly in the chapters regarding the criminal justice system, the unremarked upon justification for execution – its a method of dealing with unrepentant criminality is chilling as is description of the holocaust as a ‘sacrifice’. 

He is dismissive of any and all public services, social work, medicine (in particular) , the criminal justice system, grief counselors seem to be targeted for especial treatment .  McKnight compares these services with the glowing all good community.  There is no real investigation of why if community was working so well of the reason and ability of state services to come and take over so easily.  

Hmmm – thought provoking read indeed.