Primary Care - Healthwatch England


Primary Care A review of local Healthwatch reports March 2015

Contents Contents Purpose of this report ................................................................................................. 3 Where the insight comes from ....................................................................................... 4 Overview of issues ..................................................................................................... 5 The structure of the report .......................................................................................... 8 Primary Care in England .............................................................................................. 8 Access ................................................................................................................... 9 Choice ................................................................................................................. 17 Being listened to ..................................................................................................... 19 A safe, dignified and quality service .............................................................................. 23 Information and education ......................................................................................... 26 Conclusions ........................................................................................................... 31 Acknowledgements .................................................................................................. 33

© Healthwatch 2015 You may re-use this information (excluding logos) free of charge in any format or medium, under the terms of the Open Government Licence. To view this licence, visit OGL or email [email protected] Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.

First published March 2015 Skipton House 80 London Road London SE1 6LH 03000 683 000 [email protected]


Purpose of this report

Purpose of this report This report showcases the work that local Healthwatch have carried out to champion their local population’s Primary Care needs, and brings together the key issues the public have raised with them regarding GP practices, dental surgeries, opticians and pharmacies. Local Healthwatch have worked to present the views of consumers to commissioners of Primary Care. They have engaged the public to gain an understanding of the issues they are experiencing through workshops and engagement events, surveys, focus groups, visits to GP practices and dental surgeries. In total, 55 local Healthwatch from all over the country sought the views of more than 11,000 patients and have visited in excess of 550 GP surgeries and other Primary Care premises to ask people about their experiences. By bringing this information together we are able to provide a snapshot of the issues raised to date and a strong articulation of the insight that the local Healthwatch network captures. Whilst this report does not claim to be fully representative of the national situation with regards to Primary Care, it does highlight some important issues and clearly demonstrates how local Healthwatch are listening to the public and in particular promoting the voices and views of those who are seldom heard.


Where the insight comes from

Where the insight comes from Primary Care is a priority for local Healthwatch. According to our 2014 annual survey, almost all local Healthwatch have either already completed work in this area or intend to. (34 per cent of respondents had already completed a piece of work on Primary Care, and 92 per cent have a piece of work in this area in their current work programme). During the last two years, members of the public have contacted local Healthwatch around issues such as access to NHS dentists, practices failing to meet accessibility needs, staff attitude, not being listened to and the increased lack of translation services. Local Healthwatch have led engagement events, conducted surveys and focus groups, talked to patient representative groups, and entered premises to assess the quality of services in their area. They have reported their findings in different ways, such as letters to commissioners, videos of the public talking about their experiences, and publishing research reports. They have achieved different outcomes through sharing them with organisations such as Health and Wellbeing Boards and Health Scrutiny Committees. Local Healthwatch sit on Health and Wellbeing Boards where they actively represent the public and ensure their voice is heard. They feed the results of their work to the Board, to help guide and inform their decisions. Where local Healthwatch find evidence of an issue, it is often passed to the relevant Clinical

Commissioning Group or Local Area team who either respond with how they are going to address the issue, or initiate deeper engagement between local Healthwatch and the public. For example, Healthwatch Halton published a report into access to GP services and out-of-hours provision in November 2014 based on 491 survey responses. Halton Clinical Commissioning Group responded to the report in January 2015 and produced an action plan drawing on its recommendations. If it is not possible to resolve an issue locally, local Healthwatch alerts Healthwatch England, which has the power to raise the matter with NHS England, the Care Quality Commission and the Secretary of State for Health. For example, Healthwatch Enfield has contacted Healthwatch England about inconsistency in charges for GP medical reports and letters and six local Healthwatch (York, Lincolnshire, Bolton, Kirklees, Leicester and Wiltshire) have alerted Healthwatch England to issues they were struggling to address with local commissioners around access to NHS dentists. Local Healthwatch has also raised concerns about the electronic prescription service, the need for photo ID and proof of address to register with a GP practice and GP referrals to other services. For over 50 local Healthwatch their work on Primary Care has resulted in a published report summarising their findings. Healthwatch England reviewed the activity publicised on every local Healthwatch website, reviewed NHS England responses to local Healthwatch reports and contacted those who had been especially active in this area. This document shares a snapshot of the work local Healthwatch has undertaken between April 2013 and December 2014. Additional informal work has not always been recorded. 4

Overview of issues

Overview of issues We have taken the evidence collected from thousands of conversations between local Healthwatch and their communities and analysed them to draw out key themes. The key issues we found were:

1. ACCESS  Physical accessibility Disabled people spoke to Healthwatch about their difficulties accessing services, from physically being unable to enter buildings to inflexible on-the-day booking systems making it difficult to book carer support for appointments. Healthwatch Luton visited all 39 local GP surgeries and found that 28 did not have an induction loop system installed for patients with hearing difficulties, and 26 did not have easy access for wheelchair users.  Translation services Changes to the way translation services are funded have left many Deaf people and those who speak English as a second language struggling to communicate with their doctor. Healthwatch Islington raised serious concerns about the lack of support for women from minority ethnic communities. They explained that victims of domestic violence have been unable to disclose their

situation because the assumption that their families would provide help in translating for them has left them relying on their husbands as the only source of support. Beyond GP services, Healthwatch Kirklees interviewed 410 people with hearing impairments and found that 2 out of 3 experienced difficulties communicating with opticians and dentists.  Registering with a GP or dentist Healthwatch heard from people struggling to register with an NHS dentist, with as few as 1 in 5 surgeries in some areas registering new patients. There were also widespread reports of patients finding themselves being ‘deregistered’ without warning if they hadn’t been for a check-up. Healthwatch Leicester found that just 18 of 58 dentist surgeries were registering, leaving large areas without any provision for new patients. Some GPs have also been turning away patients from transient communities stating that they won’t get paid for treating them under the current GP contract.  Booking an appointment A consistent theme across all the Healthwatch reports was the frustration patients experience booking appointments. This is having a knock on effect on the rest of the system. A Healthwatch England report identified that 1 in 5 patients faced with long waiting times to see their GP are going to A&E instead. The most common issue was with poor telephone systems. Nearly half (47 per cent) of those who responded to a survey by Healthwatch Liverpool said that booking 5

Overview of issues

over the phone wasn’t easy with one resident in Halton reporting having to wait 47 minutes for someone to answer the phone. The Government has set a target for all surgeries to offer online booking by 31 March 2015, but a search by Healthwatch Enfield showed 2 out of 5 local surgeries still don’t have their own website. 2. CHOICE  NHS constitution The NHS constitution gives people the right to request seeing the GP of their choice, and calls on practices to comply where possible. Yet reports suggest patients’ preferences are often not met. For example, Healthwatch Surrey found that a third of patients from across the county were either ‘rarely’ or ‘never’ able to see their own family doctor. Healthwatch Liverpool found that a fifth of patients are not even being given the opportunity to specify the gender of GP they want to see.

3. BEING LISTENED TO  Short appointment slots Healthwatch heard from patients who are unhappy with GPs applying fixed length appointments. Patients reported feeling rushed and struggling to make themselves heard, particularly if they have multiple health problems. Healthwatch Halton found that 6 out of 10 local residents weren’t happy with the

length of appointment available and that doctors were often unwilling to listen to more than one symptom. Healthwatch Oxfordshire spoke with a number of patients with visual impairments who raised concerns about not being granted extra-long appointments to help them go through such details as how to take their medication and what side-effects to expect.  Complaining about care We know from our “Suffering in Silence” report that the complaints system is utterly bewildering for people to navigate. This is made even harder by a lack of information offered by healthcare providers. Healthwatch Newcastle conducted a mystery shopping exercise across 42 practices and found that only half had leaflets at reception explaining how to complain. Even where information is available, patients have to raise their concerns with the practice manager and are often left with no choice but to go back to the same GP in the future. It is not surprising then, that 1 in 4 of those we have spoken to said they were worried about the impact complaining would have on their care. 4. SAFE, DIGNIFIED AND QUALITY CARE  Receptionists’ attitudes The attitude of staff, particularly GP receptionists, often came up with patients reporting that they found them to be nosy, abrupt and often rude. Healthwatch Bradford collected feedback from nearly 600 members of the public 6

Overview of issues

about local surgeries, many of whom complained about poor attitudes of staff. Similarly, focus groups held by Healthwatch Richmond recorded reports from patients of receptionists “screening calls via invasive questions”. 5. INFORMATION AND EDUCATION

late to prevent tooth decay. Even though the parents in question knew the service was free, many were working on the assumption they should only take their children to see the dentist if they were in pain. It is this sort of misunderstanding that is contributing to 26,000 five to nine years olds requiring emergency dental surgery in 2013/2014

 What to do out-of-hours Patients don’t always feel they have enough information to know which healthcare service to visit. In particular, national polling by Healthwatch England revealed that more needs to be done to promote outof-hours services, community pharmacists and walk-in centres to improve consumer experience and reduce pressure on other parts of the system such as A&E. Half of the people Healthwatch Enfield spoke to didn’t know about the out-of-hours options open to them. Similarly, in a spot check of surgery answerphone services, Healthwatch Hampshire found that more than a quarter of the 144 surgeries across the county were still giving out the wrong out-of-hours number over a year after the introduction of the NHS 111 service. 

Lack of clear information Healthwatch identified a need for better information for people to ensure they can make informed decisions about care. In particular, better signposting and wider use of plain English is needed to help ensure patients are accessing care at the right time and that they have the ability to self-care when appropriate. Healthwatch Barking and Dagenham found that children were attending the dentist too


The structure of the report In our review of local Healthwatch reports we looked for common themes in public opinion. We have grouped these to reflect Healthwatch England’s consumer principles1 which describe the minimum all patients and service users should expect from health and social care services.        

Access To choose To be listened to A safe, dignified and quality service To information and education To be involved Essential services Live in a healthy environment

The report focusses on the first five of the eight principles (in bold text above) as the evidence links most strongly to these themes.

Primary Care in England Primary Care is healthcare provided in the community to diagnose and treat health needs and send people on to specialist services. Primary care services include GP practices, dental surgeries, opticians and pharmacies. These services are most people’s first point of contact with the NHS and where 90 per cent of interaction with the NHS takes place. As such, problems with the provision of Primary Care affect a large number of people and have the potential to impact the whole of the NHS. The term Primary Care is confusing to many. It describes services not supplied by hospitals (secondary care), emergency services or providers of mental health or community services. The definition also sometimes includes district nurses, walk-in-centres and out-of-hours GP services, depending on the care they are providing. NHS England is responsible for commissioning GP, dental, pharmacy and optometry services and for carrying out contractual compliance and performance monitoring. It is a jointly agreed objective of the Clinical Commissioning Group and NHS England that local patients should have easy access to safe, high quality and accessible services.




Access 46 per cent of local Healthwatch see access to Primary Care services as a priority to address in their area for 2015. Access was also the most common theme covered in local Healthwatch reports. In this case the term ‘access’ covers two core elements, being able to make an appointment to see a GP and physically being able to get into the building or communicate with practice staff.

Physical Accessibility Some patients struggle to access Primary Care providers Our review of local Healthwatch reports has found that, for some members of the population, accessibility of some primary care services is an issue. This can be because they physically cannot get inside the door (e.g. due to lack of wheelchair access), or because the surgery is not set up to allow for easier communication through hearing loops and easily accessible translation services. Healthwatch Luton investigated the barriers to access at 39 GP surgeries. 28 surgeries in Luton did not have an induction loop system to help people with a hearing impairment in place, 26 did not have easy wheelchair or pram access and 32 surgeries did not let patients know about a translation service2. Healthwatch West Sussex looked at 53 practices and also found 3 less than half had induction loops. Similarly, of 14 dental practices reviewed by Healthwatch Redcar and Cleveland four practices were

unable to provide access for Disabled people and had limited access for those with mobility impairments.4 By law, under the Equality Act 20105, all health services are required to make ‘reasonable adjustments’ to make sure they are accessible to all. This duty requires GPs and dentist practices to anticipate the needs of Disabled people and, where possible, make adjustments to provide the same level service as for nonDisabled patients.

Translation services Patients who require translation services are not receiving an equitable level of care to those who don’t The availability of translation services has also been a key issue tackled by local Healthwatch in 2014, and the issue spans Primary Care services. A survey of 410 people with a hearing impairment by Healthwatch Kirklees found that 60 per cent of people had experienced communications problems with opticians, 59 per cent at the dentist, and 34 per cent with pharmacies. Furthermore, 22 per cent said they had put off making an appointment at the GP surgery because of communications problems. 6 Healthwatch York found that some GP surgeries are refusing requests for British Sign Language (BSL) interpreters and telling patients that it is too expensive. Young mothers who are Deaf told Healthwatch York that they are worried about accessing GP services when their babies are ill. They worry about waiting times if they need an interpreter (2-3 weeks) and can’t get in touch with the GP by text so they have to go to the surgery. 7


Healthwatch Redcar and Cleveland 2014



Healthwatch Luton 2014


Healthwatch Kirklees, February 2014 b


Healthwatch West Sussex, March 2014


Healthwatch York, December 2013



Patients have also told local Healthwatch that the expectation that they will bring a family member with them to interpret is also unfair; it means the family member may have to take time off work, can put undue pressure on children, can lead to misunderstandings and be detrimental to the privacy of the patient.

“Making my first GP appointment after transferring from another area, the receptionist told me I had to book a BSL interpreter myself. They had my records and knew I needed one. But I pushed it back on them. When I checked up the day before, nothing had been booked. So I took a friend. I asked the receptionist if I could see what was written on the computer for my appointment and the screen said ‘Maybe it would be a good idea to book an interpreter’. Maybe? What’s that about? The appointment was terrible. I was embarrassed with my friend in the room. They just weren’t deaf aware.” – Respondent to Healthwatch Kirklees 8 Healthwatch Sunderland have run events with their Polish community, refugee community and asylum seekers (from 11 different countries including, Iran, Togo, Pakistan, Libya, Sudan, Congo), older Bangladeshi women, younger Bangladeshi women and young British people from an Asian background. Access to interpreting services was a concern for all groups involved. Cancelled appointments are one of the most visible results of problems with interpreting; one patient described having her appointment moved four times due to no interpreter being present, meaning that the contracted company had not provided an interpreter on four consecutive occasions. The obvious result of such a situation is delayed

treatment, in turn leading to a possible worse health outcome. 9

What has local Healthwatch been doing to resolve this? Deaf Positives Action visited 13 surgeries in Wokingham Borough on behalf of Healthwatch Wokingham as part of a mystery shopper exercise. They assessed how reception staff approached someone who was wearing a hearing aid, whether the surgery offered an interpreter and if a hearing loop was advertised. Their findings were shared with Wokingham Clinical Commissioning Group, who welcomed the report and accepted that deaf awareness training should be included in the current training package for receptionists.10 Healthwatch Islington collected data on translation services from their local Clinical Commissioning Group, surveyed GP practices, and ran a mystery shopping exercise in 39 GP practices. They then discussed their findings with 16 local voluntary organisations. They discovered five of the GP practices in their area were not offering any kind of interpretation service and 18 sometimes asked patients to bring a friend or family member to interpret. 11 Through their engagement work with local groups and services including the Latin American Women’s Rights Service, Asian Carer’s Support Group, Cypriot Elderly and Disabled Group and Haringey Council Deaf Services, Healthwatch Haringey also found a lack of interpretation and translation support for GP appointments in their area. They found that some individuals paid up to £15 an hour for an interpreter to attend their GP appointments. Healthwatch Haringey shared these findings with the Haringey Clinical Commissioning Group. They discovered that



Healthwatch Kirklees, February 2014 b

Healthwatch Sunderland, May 2014


Healthwatch Wokingham, December 2014


Healthwatch Islington, January 2015


Access one of the key problems was that GP invoices for translation were not being paid and as a result many GPs stopped using the service. Healthwatch Haringey found that there was confusion about who was funding translations and that was why GP’s invoices were not being paid. (In the past, translation services were funded by Primary Care Trusts, but these have been replaced by Clinical Commissioning Groups, who have slightly different responsibilities). Healthwatch Haringey was able to establish that responsibility for the Language Line contract transferred to NHS England and the funding for the service is with them. 12 The findings of Healthwatch York’s research into access to health services by the Deaf community were used as evidence for a BBC programme on the issue13 and were also discussed in the House of Lords in March 2014, along with evidence supplied by other local Healthwatch such as Wakefield, Kirklees, Staffordshire and Stockport. 14 A group of 13 Healthwatch in North and East London have also been successful in obtaining funding for a project which includes training Deaf patients to take part in Healthwatch assessments of services (known as “Enter and View”). Healthwatch Northamptonshire has also been working with Deaf Connect to assess the accessibility of GP practices for people with a hearing impairment through mystery shopping.


“One time I had to use my child – who was 5 at the time. The staff were talking to her …“tell your mum this, tell your mum that …” They were ignoring me. It wasn’t appropriate.” - Respondent to Healthwatch Kirklees

Healthwatch Haringey Annual report, 2013-14 13

“See Hear” Series 34 episode 1




Access Registering with a GP or dentists People have difficulty registering with a provider and/or find that they have been taken off the register without being told. In August 2014, Healthwatch England’s research found that in some areas just 1 in 5 dental surgeries were accepting new NHS patients. A number of local Healthwatch have reported high levels of calls from the public asking for advice on how to find an NHS dentist. In Redcar and Cleveland absence of dental surgeries affects 25 per cent of the Borough’s population, 135,000 residents. 15 Some dentists will take new patients but apply rules to which patients they will take, for example only taking relatives of current patients, and others are not keeping information about whether they are accepting NHS patients up to date on their websites. “I’m a 65 year old pensioner; I called up my dentist for new dentures. I was told that that I was “no longer on our computer”. They advised me to call them every month to check if they were taking NHS patients, but they were only taking on private patients. In the end I had to go private and pay £760 for new dentures and I am on pension credits. Respondent to Healthwatch Kirklees16 Since 2006 dentists no longer have a register, however patients are still being told that they are being taken off the “register” if they fail to attend an appointment, or if they don’t book regular check-ups. Local Healthwatch in Ealing, Kirklees, Bradford and Bolton heard from patients who had been removed by their

dentists from their list of patients for missing an appointment and often struggled to find another NHS dentist. Patient experiences suggest that individual circumstances are not being taken into account in such decisions. For example, Healthwatch Bolton received a horrifying account of a woman who missed a dental appointment due to an incident of domestic violence. She visited her dental practice with relevant police protection documents as evidence of her reasons for missing the appointment. The dental practice told her that this was not a valid reason. 17 Healthwatch Bolton reported this account to their Health and Wellbeing Board.

“I was told I had been sent a slip I had to complete and return to stay on the list. I never received this or any reminder of it either. I simply didn’t get invited for appointments anymore and when I rang I was told I had been “deselected”. I think it’s a very underhand way of being taken off the dentist’s “books” if you’re an NHS patient and don’t earn them much money.”- Respondent to Healthwatch Bradford18

What has local Healthwatch been doing to resolve this? According to the NHS Constitution, “You have the right to choose your GP practice and to be accepted by that practice unless there are reasonable grounds to refuse, in which case you will be informed of those reasons”. 19 GP

17 18


Healthwatch Redcar and Cleveland, August 2014


Healthwatch Kirklees, February 2014a

Healthwatch Bolton, January 2014 Healthwatch Bradford January 2014


NHS Constitution: hment_data/file/170656/NHS_Constitution.pdf


Access practices should therefore register all patients unless they have a good reason not to, and if they do have a good reason they should tell the patient why they are not allowed to register. During the course of their study Healthwatch Liverpool became aware that registering with a General Practitioner was a problem for particular groups of people, e.g. members of the public who might be perceived as unlikely to stay on the list for a substantial amount of time, such as asylum seekers. Healthwatch Liverpool found that GP practices don’t get paid if a patient isn’t registered with a practice for at least 3 months, and depending on when someone registers in a quarter this could be up to nearly 6 months. They surmised that more transient groups in the population may therefore encounter more resistance when trying to register, which is not acceptable. The Social Inclusion Unit made a complaint to NHS England. NHS England acknowledged the finding and responded that they would, with the local Clinical Commissioning Group, monitor the issues through their contract monitoring arrangements. 20 In June 2014, Healthwatch Leicester conducted a survey and found that just 18 of the 58 dentist surgeries across the city were currently accepting new NHS patients, leaving some areas of the city without any provision. When raised with the NHS England Local Area team, they responded that Dentists were available, it would just require more travel to get to them.21 Of course, this raises a host of other questions around transport and access to more remote practices.

A key issue running through local Healthwatch reports was the problem of getting through to a surgery by phone to make an appointment. Of the respondents to Healthwatch Liverpool’s survey 47 per cent of respondents who booked their appointments by telephone said that booking an appointment was not easy. 22 Similarly 42 per cent of respondents to a survey by Healthwatch Warwickshire found contacting the surgery by telephone first thing in the morning to be “difficult”23.

‘Last time I phoned I waited 47 minutes to speak to the receptionist’- Respondent to Healthwatch Halton24 Members of the public reported a variety of issues with the booking systems that GP practices enforce, to the extent that they can be a disincentive to engage with GP practices and a possible barrier to receiving treatment. Analysis of NHS England’s GP patients’ survey by the House of Commons library, found that in 2013 there were 37.4m failed attempts to book an appointment with a GP, affecting about 4.7 million people.25 Healthwatch Hertfordshire surveyed 763 users of five GP practices in their area, 273 (36 %) were unhappy with the last appointment they were given, the majority because of the time or the day. Of those 34 (12%) did not seek treatment as a result. 26

Booking an appointment Some patients find booking an appointment with a GP difficult


Healthwatch Liverpool, March 2014


Healthwatch Warwickshire, June 2013


Healthwatch Halton, November 2014


Analysis by the House of Commons Library published in the

Guardian. 20

Healthwatch Liverpool, March 2014


young-health-family-doctors accessed 22/12/2014



Healthwatch Hertfordshire, 2014


Access It depends on the nature of my visit. If the visit is because my children are ill or because my asthma is exacerbated then I can usually always get an appointment the same day. If it is a routine visit then I usually will need to wait to see a doctor - usually over a week, which I am okay with. I often need to wait about 10 days if I want an appointment with my preferred GP. – Respondent to Healthwatch Oxfordshire27 The telephone booking system is a key problem for some members of the public. Complaints regularly received by local Healthwatch centred on having to phone at a set time, which they found meant that the line was often busy. Many respondents found the rules around booking an appointment to be difficult and restrictive, particularly for shift workers, those who have fairly long journeys to work, and parents doing the school run as they are often unable to phone or queue at the required 28 times. Queuing early in the morning for an appointment was also deemed inconvenient by respondents to a survey run by Healthwatch Surrey, particularly when they were elderly or felt unwell (Healthwatch Surrey found examples of GP practices that do not allow patients to book appointments over the phone, but do allow them to book an appointment in person). 29

“When you phone first thing in the morning (0830am) you are put in a holding queue. After 5 mins if you haven't been answered (which is always the case) you are automatically disconnected. This process can occur 2 or 3 times in a row. When you finally get through about 20 mins after surgery opens there are no appointments left!”- Respondent to Healthwatch Warwickshire30

There are a number of competing explanations for rising problems with booking appointments. For example, the Royal College of GPs (RCGPs) argue that this is caused by the combination of increased life expectancy, rising demand and cuts to funding. 31 They anticipate the situation will get worse in future. Whatever the explanation, it is clear from the evidence gathered by local Healthwatch that appointment booking systems are often failing consumers and solutions must be found so that people can access the care they need. “…Transport is difficult so would be good to have more options such as Saturdays or evening surgeries.”- Respondent to Healthwatch West Sussex32 Extended opening times can help make GP surgeries more accessible. According to the most recent GP Patient Survey33 three quarters of people nationally are happy with the opening hours of their surgery. However, local Healthwatch spoke to some members of the public who would appreciate weekend appointments, especially those that work full time. For example, the most common request to Healthwatch Waltham Forest was for some appointments to be available at the weekend, especially by respondents of working age. Very few respondents wanted additional appointments in the morning (just 9%).34 Saturday, followed by evening slots, were also the preferred options to respondents of surveys by Healthwatch Ealing, Sutton and Oxfordshire.


UnitedKingdom/Local%20Assets/Documents/Research/Centre%20f 27

Healthwatch Oxfordshire, October 2014



Healthwatch Surrey, July 2014


Healthwatch West Sussex, March 2014

Healthwatch Surrey, July 2014


Ipsos MORI, Jan 2015

Healthwatch Warwickshire, June 2013


Healthwatch Waltham Forest, June 2013

29 30


Access Of those patients that advised Healthwatch Sutton that they would want a routine appointment on a Saturday or Sunday, 53 per cent said that they would be happy to travel to a different location locally and see a different doctor. 35 Some consumers are so concerned about perceived work pressures on GPs that it impacts on their expectations and may deter them from making appointments in the first place. For example, one in ten respondents to a survey by Healthwatch Lambeth did not want extended hours, as some respondents were concerned about GPs becoming overworked. 36 Only some practices currently provide access to evening and weekend appointments. For example, 32 per cent of respondents to Healthwatch Liverpool’s study were able to book an appointment in the evening or on a Saturday, but 48 per cent could not. Some GP practices have been slow to make telephone booking more accessible. Until quite recently, many have used premium rate 0844/0845 numbers. In 2011 the Department of Health introduced new rules stating that the cost of calling a GP practice must not exceed local rates. 37 All surgeries should provide a landline number as this is cheaper to call and therefore more accessible for patients. However a number of investigations, including studies run by Healthwatch Warwickshire, Liverpool and Barnsley, have found examples of GP practices using 0844/0845 numbers as recently as 2014.

What has local Healthwatch been doing to resolve this? In February 2014, Healthwatch Barking and Dagenham wrote to their Clinical Commissioning Group to inform them that 9 GP practices were still using numbers which cost more to call than a normal landline. The Clinical Commissioning Group informed the relevant NHS Local Area team, ( the group that holds the contract with the GP practices in its area and is responsible for ensuring that they are meeting their contract terms), and all nine practices changed their numbers.38 Healthwatch Sutton has been exploring public attitudes towards different kinds of appointment. Respondents to a survey run by Healthwatch Sutton were asked to identify which methods they would be happy to use to hold a consultation with a GP if they were not able to have a face to face appointment. 58 per cent of respondents advised that they would be happy to hold a consultation over the phone, 16 per cent by email and 12 per cent 39 via video call (Skype). Healthwatch Devon highlighted the case of a new development of 2,900 homes intended for young families which had no local GP provision. There were no pavements on the roads to the nearest GP practice and the cost of the bus fare was over £5. They championed the cause of a local community development worker trying to speed up planning for a GP practice in the area.40 During the course of their research, Healthwatch Lincolnshire also discovered that some patients were struggling to attend their

38 lt/files/006-14_response_to_healthwatch_re_0844_numbers.pdf 35

Healthwatch Sutton, December 2014


Healthwatch Sutton, December 2014


Healthwatch Lambeth, October 2014


Healthwatch Devon, Winter 2015



Access appointments due to other commitments, such as caring responsibilities. They recommended that GP practices, when trying to reduce the numbers of missed appointments, also ensure that support mechanisms are available and in place for patients with personal barriers to keeping appointments. 41 It is worth noting that text message reminders to alert patients that their appointment is almost due have proved popular in other areas. 695 (72%) of respondents to a survey by Healthwatch Luton thought that text message reminders were/ could be helpful to them, although only 293 (30%) received an appointment reminder text message from their surgery. 42 Healthwatch Lincolnshire has been investigating the impact of missed appointments in their area. The average number of missed appointments at GP practices in Lincolnshire is 184,224, at a cost to the NHS of around £6.6 million. In response to a survey by Healthwatch Lincolnshire, 33 per cent of patients admitted to forgetting to attend an appointment, despite 60 per cent of patients receiving text message reminders. They also found that online booking was open to abuse, with some patients booking multiple appointments but only attending one. A report by Healthwatch Hackney sparked an investigation into GP appointments by the local Health Scrutiny Committee. They found online appointments were offered by almost all GP practices in their area, but that many practices offered only a small number of appointments. Although the GP contract makes no specific provisions about appointments, the committee found that local GPs had many more patients

41 42

each than the amount recommended by the Royal College of GPs. 43 By March 2015, all GP practices should have in place an online booking system and the pressure on telephone services should hopefully reduce.44 Local Healthwatch have found a general lack of awareness and confusion about this plan amongst the public. In July 2014, 36 per cent of patients reported to Healthwatch Surrey that online booking was an option. At the same time, Healthwatch Surrey ran a survey of GP practices. 78 per cent of GP practices told Healthwatch Surrey that they offered online booking, suggesting that awareness amongst the public of systems that are in place is low. 45 An audit by Healthwatch Enfield in September 2014 also found that only 31 out of 49 practices had their own website. This may mean some practices will struggle to meet the March 2015 deadline to offer online appointments.46 Over half of respondents to Healthwatch Waltham Forest’s survey (59%) thought that they would use an online booking service if it was available. 47 This suggests that lack of knowledge may not be because of lack of interest in using such systems.


Hackney Health scrutiny commission, November 2013, 44


Healthwatch Surrey, July 2014

Healthwatch Lincolnshire , November 2014a


Healthwatch Enfield, September 2014

Healthwatch Luton 2014


Healthwatch Waltham Forest June 2013



Choice Lack of choice Some GP practices are not giving patients the option to choose their GP; this has the potential to disrupt continuity of care. Currently, a large number of GPs are due to retire, entry into the profession is low and funding for GP practices is falling. 48 More GP practices are therefore employing locums, temporary GPs, with a 51 per cent jump in the number of locum hours used by surgeries yearon-year. 49 The NHS England January 2015 GP patient survey found that patients value the ability to choose their GP, with 54 per cent having a GP that they preferred to see. However the GP patient survey also found the number that were able to see their preferred GP “always or almost always” was decreasing, from 42 per cent in June 2012 to only 37 per cent in January 2015. 50 The NHS Constitution states that “You have the right to express a preference for using a particular doctor within your GP practice and for the practice to try to comply.51 Members of


intelligence/deloitte-research-uk/deloitte-uk-centre-for-healthsolutions/0a4e45ba2db27310VgnVCM1000001956f00aRCRD.htm 49

the public value being able to choose their GP. 312 respondents to a survey by Healthwatch Luton (32%) only saw a certain doctor at their surgery and for various reasons, 218 (23%) actively avoided at least one doctor at their practice. 52 Some patients are reporting to local Healthwatch that they are not able to see their GP of choice. A third of respondents to a survey by Healthwatch Surrey were ‘rarely’ or ‘never’ able to book an appointment with their preferred GP. 53 Others have reported having so little choice that they could not specify the gender of the GP practitioner when they want to. When asked “if you particularly want to see a male or female doctor is this usually possible?” 20 per cent of respondents to Healthwatch Liverpool’s 54 questionnaire responded that it was not. This may stop patients raising sensitive issues. “I saw my GP and they prescribed me two weeks of anti-depressants and told me to go back in two weeks. There weren’t any appointments and I didn’t want to see another doctor or else I would have had to say everything all over again. I tried to explain this but they wouldn’t listen to me so I ended up with a gap in my anti-depressants” Young person responding to Healthwatch Warwickshire55 However, the main concern around these findings relate to continuity of care. Respondents to research into Primary Care access for people with a sight impairment run by Healthwatch Lambeth particularly raised this as an issue. Many participants felt that having to see a different GP every time they

increasingly-reliant-on-use-of-locum-doctors-surveysuggests/20007598.article#.VKwUcKGnzIU 50

Ipsos Mori, January 2015 02015%20National%20Summary%20Report.pdf 51

NHS Constitution: hment_data/file/170656/NHS_Constitution.pdf 52

Healthwatch Luton, 2014


Healthwatch Surrey , July 2014


Healthwatch Liverpool, March 2014


Healthwatch Warwickshire, November 2013


Choice visit resulted in repeating explanations, actions and poor condition management.56 This view was echoed by respondents to a survey run by Healthwatch Brighton and Hove, especially those with chronic or complex conditions.57 As a result of this lack of continuity, many patients don’t really feel known by their GP. For example, many respondents to Healthwatch Surrey’s survey said that their doctor did not know them, that they were just a list of symptoms on the computer and that this sometimes resulted in them receiving conflicting advice.58

What has local Healthwatch been doing to resolve this? The reduction in the number of GPs has also led to some surgery closures. Where this is the case, local Healthwatch ensure that the public have been properly consulted. During the consultation phase of a GP practice closure in Sunderland, patients did not feel their opinions were being taken into account. Healthwatch Sunderland looked into the process of closing the practice and compared it to the NHS guidelines, they discovered that the consultation was inadequate and the guidelines had not been followed around public engagement.59 As a result of Healthwatch Sunderland’s report, the local NHS England Area Team met with them and agreed to strengthen the process of consultation with key stakeholders such as the local Clinical Commissioning Group, local Healthwatch and the Health and Overview Scrutiny Committee. The local area team have agreed to review the current national guidelines and ensure they meet the requirements in the future.

Healthwatch Reading have also criticised the way the public were informed when five GPs simultaneously resigned from a practice in their area. They called for safeguards to be put in place, particularly to ensure those patients who needed to visit a GP regularly were not affected by any delay in putting new GP services in place after the doctors left.60 Healthwatch Luton has been trying to save a repeat prescription service, a service that many pharmacies offer, allowing people to renew their prescriptions without having to first visit a GP practice. As the result of an audit, and without consulting the public, Luton Clinical Commissioning Group decided to stop their local service. They were concerned prescriptions may be wrongly repeated, which could be potentially unsafe or lead to wasted medication. Healthwatch Luton undertook research which found 96 per cent (194 people) were happy with the service.61 Following the involvement of the Health and Social Care Review Group, Healthwatch Luton worked with pharmacies and the Clinical Commissioning Group to develop a protocol around the repeat prescription ordering service, with the aim of addressing the Clinical Commissioning Group’s concerns. The Health and Social Care Review Group approved of the new arrangement and recommended its use. However, the Clinical Commissioning Group was not satisfied with the new protocol and continues to ban the service. Healthwatch Luton is still championing the views of the public in this area and will represent the public when the issue is discussed further at a local Health and Wellbeing board meeting.


Healthwatch Lambeth, 2014


Healthwatch Brighton and Hove, October 2013



Healthwatch Surrey, July 2014



Healthwatch Sunderland, May 2014



Being listened to

Being listened to Carers’ concerns Carers sometimes need additional support and don’t always feel their voices are heard One group sometimes not listened to is young carers. In a report into the experiences of young carers in Reading, Healthwatch Reading found a worrying lack of knowledge about GPs amongst the young carers they spoke to. None of the young carers who attended a focus group with Healthwatch Reading had had any contact with a GP about their young carer’s role. One child even asked during a small group discussion, “What’s a GP?”62 Healthwatch Liverpool received evidence from a representative from Barnados that young carers don’t feel engaged by GPs and often aren’t asked their views. “Young carers and their disabled parents, when asked about their advice, said the most important thing is to include and support the whole family. GPs may only see the individual patient and therefore critically lose sight of the impact on the whole family”. – Representative from the charity Barnardos, to Healthwatch Liverpool63

What has local Healthwatch been doing to resolve this? Healthwatch Doncaster held a series of events with carers in their region. During the events carers said it was important they were able to choose a GP who fully understood the issues they were facing for themselves and the person they were caring for. They also acknowledged

that carers need support for their physical and mental wellbeing and would benefit greatly from a “listening ear”. Comments received after the events showed that carers who had attended welcomed the opportunity to contribute to the discussions, and felt that they had really been listened to. 64 Local Healthwatch have also been promoting carer friendly pharmacies. Across the country, 44 pharmacies are involved in a pilot in which each pharmacy signed up to the project will actively identify possible carers, explain how the pharmacy can help them, and seek their permission to refer them either to their GP or their local carer’s association. 65

Short appointment slots People who require extra time with their GP are struggling to be heard GPs allow 10 minutes for a consultation, however this only allows time to focus on symptoms, often of just one health problem, and does not allow time for exploring broader issues. Healthwatch Halton found 59 per cent of respondents to their survey were unhappy with the length of time their GP spent with them.66

“GP should listen well, if one has 2 or 3 problems at the same time GP says for every single problem I have to book another appointment” Respondent to Healthwatch Waltham Forest67


Healthwatch Doncaster 2014


friendly-pharmacy 62 63

Healthwatch Reading, July 2014


Healthwatch Halton, November, 2014

Healthwatch Liverpool, March 2014


Healthwatch Waltham Forest ,2013


Being listened to In research conducted by Healthwatch Oxfordshire some respondents with a visual impairment raised that their impairment can mean they need extra time for engagement with their GP, which wasn’t happening. They spoke about not knowing the side effects of the medication they are taking, or not knowing how often to use medication as the instructions are just printed on the packet and they weren’t discussed. 68

to complain about poor care. We found that when considering whether to make a complaint many people worry about speaking out and the potential impact this might have on their care. Add to this the fact that people do not know that they can complain or how to do it and you end up with many people not raising a concern at all. 70 This stops patients from raising the alarm when they are routinely kept waiting for appointments, or when they receive or witness poor care.

Complaining about care

Young people attending a focus group run by Healthwatch Warwickshire were surprised to hear that they are able to make a complaint or raise concerns about their care or the service they receive within the NHS. Healthwatch Warwickshire also surveyed 273 young people, only nine per cent felt they knew how to make a complaint and would be confident to do so. Seven per cent felt that they didn’t know but that they probably wouldn’t want to complain anyway. The reason for this was that they had little confidence in their complaint being taken seriously or any change happening as a result. Additionally, 35 per cent felt that they knew how to go about raising concerns but would not feel confident to use the system. Almost half the young people did not know how to complain but felt that it was something that they would want to do.71

It can be hard to make a complaint about Primary Care Prior to their abolition, Primary Care Trusts had the power to handle all complaints about Primary Care services and there was a clear process. Since April 2013, the process relating to Primary Care complaints has become less clear. This confusion is apparent in providers as well as patients; Healthwatch Lambeth even received a call from a GP practice asking for information on the correct complaints procedures. Of the 14 respondents to a Healthwatch Lambeth survey who had complained about their GP practice, only 4 felt their complaint had been properly resolved by the practice.69 Many of the calls local Healthwatch receive are from people who do not know how and where to go to make a complaint about a service. Complaints provide rich information to healthcare providers and regulators. However, our October 2014 report into the health and social care complaints system, Suffering in Silence, found that patients are often reluctant

“We requested to see the Practice Manager, and were told that complaints should be routed through GP. After submitting written complaint to GP, we had no written communication back from GP or PM.”Respondent to Healthwatch West Sussex72


Healthwatch England, “Suffering in Silence” October 2014 68 69

Oxfordshire, March 2014


Healthwatch Warwickshire, November 2013

Healthwatch Lambeth, October 2014


Healthwatch West Sussex, March 2014


Being listened to Healthwatch England has found that people are not given the information they need to complain and do not have confidence that complaining will change anything, so poor service like this goes unchallenged. This is echoed by local research, Healthwatch Dorset found “When the screen’s not working it’s really difficult. It knocks your confidence. You’re sitting in a crowd of people, watching the receptionist – not taking your eyes off them in case they’re telling you to go in for the appointment. One time I waited 45 minutes. When I went up to them and asked what had happened they said they’d been waving at me, trying to get my attention. But they hadn’t. They’d forgotten about me. I got really upset and went home in frustration. I didn’t complain. It’s not worth it.” -Respondent to Healthwatch Kirklees73

Some patients worry about receiving poor care as a result of making a complaint. For example, a survey respondent told Healthwatch Lambeth that they perceived that they might be “viewed and treated badly by the staff as well as I would be seen as a trouble maker. I might be 'accidentally' given the wrong drugs”.74 Of course this is just one comment amongst many views, but in a recent poll75, Healthwatch England found that 26% of respondents did not complain due to concerns that doing so would impact negatively on their care. Healthwatch Warwickshire found that young people worry that due to their age they wouldn’t be listened to and taken seriously or


that the process would not be confidential and this may affect getting appointments or receiving good care in the future.76 Such responses display a worrying lack of trust amongst some members of the public in the complaints process.

What has local Healthwatch been doing to resolve this? Healthwatch Newcastle visited 42 practices in a “mystery shopping” exercise to assess how the practices let patients know about their complaints process. They found that although most practices had information about their complaints process on their website (93%), only half had leaflets in their surgery (52%). In 20 practices therefore, the mystery shoppers had to ask for information on how to complain. Staff at 14 (70%) provided a copy of the complaints procedure when it was requested; the rest explained verbally how to complain. Of the 42 practices visited, the mystery shoppers felt that only 18 practices (42%) actively 77 encouraged feedback. Healthwatch East Sussex visited 45 GP practices, only 13 practices had a leaflet in their surgery and only one practice produced a booklet specifically aimed at helping people who did not speak English as their first language78. Similarly, Healthwatch Camden sent a mystery shopper into every GP surgery in their area to see the response when they asked to make a complaint. While most front office staff provided the mystery shopper with information on complaints upon request, more than a third had to seek advice on what the practice’s procedure was before answering. Worryingly, several practice managers wrongly told Healthwatch Camden’s mystery shoppers

Healthwatch Kirklees, February 2014b


Healthwatch Warwickshire, November 2013


Healthwatch Lambeth, October 2014


Healthwatch Newcastle, 2014


YouGov survey, August 2014


Healthwatch East Sussex, August 2014


Being listened to to make their complaints directly to NHS England.79 Luton also completed 39 enter and view visits to GP practices over the course of 2013, 32 of the surgeries they visited did not have a comments box, including comments cards and pens, in an area away from reception. 80 Healthwatch Dorset conducted a review of the 101 GP practices and their websites in their area, they found only 13 websites provided details of the local complaints advocacy service.81 Many local Healthwatch also fed into the 2014 Healthwatch England report, “Suffering in Silence”82, which aimed to raise the profile of complaints services available and encourage patients to raise the alarm when they witness or receive poor care.

“What I said wasn’t seen as worth listening to; it was just seen as the utterances of a mad woman. Everything you say is seen through the prism of illness.” Suffering in Silence, October 2014


Healthwatch Camden, 2014


Healthwatch Luton, 2014


Healthwatch Dorset, May 2014


Healthwatch England, “Suffering in Silence” October 2014


A safe, dignified and quality service

A safe, dignified and quality service Receptionists’ attitude Patients do not all receive a compassionate service Nationally, reported satisfaction levels with GP services are high. 92 per cent of respondents to the January 2015 GP patient survey said they had trust and confidence in their GP and 85 per cent are satisfied with the overall service they provide, although this represents a slight drop on previous years’ results. 83 Similarly, most members of the public told local Healthwatch that they are satisfied with the quality of care they receive from their GP. In Luton, 53 per cent of respondents overall rated the doctors at the surgery they were registered with as “Good” and 23 per cent as “Excellent”. Only five per cent described their GP as “Poor” or “Very Poor” and 19 per cent described their GP as “Okay”.84 Patient satisfaction data, however, can be problematic and top-line figures mask a great deal of variation. Expectations differ from person to person and according to the health issue they are experiencing at that time. In response to a survey by Healthwatch Oxfordshire, only 70 per cent of patients who got a same day appointment were happy with the time they had to wait to get that appointment. Conversely, just over 10 per cent of respondents who waited longer than a month

to get an appointment were happy with their waiting time.85 The information received by Local Healthwatch suggest that although overall satisfaction may be high, certain groups are less happy with some aspects of the care they are receiving. For example, local Healthwatch receives a high level of individual complaints around staff attitude. “I would rate my GP service at 6/10. They could sort out my health better. When I first got my cancer, my support worker found the lump under my arm and mum took me to the GP. I could barely see and my legs wouldn’t work, but they thought I was ‘attention seeking.’ Mum insisted that I wasn’t and they got me into hospital.”- Respondent with learning difficulties to Healthwatch Oxfordshire86 Many people spoke to Healthwatch Bradford about encountering unhelpful reception staff at GP surgeries, and others told them that they felt uncomfortable about the lack of privacy when discussing issues at reception.87 510 respondents to a survey by Healthwatch Luton (53%) did not feel that there was enough privacy to talk to reception in confidence.88 People often felt that reception staff were acting as ‘gate-keepers’ and sometimes were perceived as a barrier to getting an appointment. People with disabilities told Healthwatch Bradford that their needs weren’t always taken into account by reception staff when they come to their GP practice, such as guiding visually impaired patients around the building or making sure people with a hearing


Healthwatch Oxfordshire , October 2014


Healthwatch Oxfordshire, March 2014



Healthwatch Bradford, January 2014



Healthwatch Luton, 2014


Ipsos Mori (January 2015) http://gp-survey-

Healthwatch Luton, 2014


A safe, dignified and quality service impairment know when it’s time for their appointment.89 “I once felt I had spiders crawling all over me. I knew it was all in my head but try explaining that to some bossy woman at the desk who hasn’t the first clue what people with mental health issues have to go through without half the patients looking round at you.”Respondent to Healthwatch Bradford90 Comments from patients also suggested that there was wide variation where it came to equality in treatment by GPs and reception staff. For example, mixed reports have come through regarding whether surgeries are willing to refer to a patient by their gender of choice. A positive experience came from a Trans woman attending a Lesbian, Gay, Bisexual and Transgender (LGB & T) network meeting in Liverpool, who had her new name recorded on the touchscreen at her GP surgery before her gender recognition certificate had come through91. Healthwatch Liverpool heard a number of positive experiences in terms of practices being diversity aware. “I would like to say that as a gay man I find Greenbank Surgery very friendly. I have been with others that frankly need to be more LGB & T aware and friendly” –Respondent to Healthwatch Liverpool92 However reports collected by Healthwatch Bradford suggest this is not always the case. 93 Healthwatch Liverpool has also heard that


some lesbian women are being told they don’t need smear tests.94

The young Black and Minority Ethnic (BME) people who took part in an engagement exercise run by Healthwatch Sunderland also felt that they were not treated seriously when they raised a health related concern, or their needs were not taken into account when they were accessing services. 95 Patients taking part in focus groups in Richmond spoke about receptionists sometimes being seen to be “screening calls via invasive questions” and were generally felt to be unhelpful by many in the focus groups. However, Healthwatch Richmond felt perceived lack of flexibility in the appointment system and the seeming unavailability of doctors, coincided with negative feelings towards receptionists.96 The way GP practices are organised isn’t always helpful. During a focus group run by Healthwatch Liverpool with patients diagnosed with a mental health condition, participants mentioned that glass partitions at reception desks meant having to speak louder, and receptionists at times were not mindful and would shout.97 Respondents also felt GP practice staff simply lacked knowledge about complex, emotional problems. In a piece of research run by Healthwatch Bradford, nearly half of comments from people who identified themselves as having mental health needs said that GPs should get better training on current mental health medication and treatment.98 This was echoed by attendees to a focus group run by

Healthwatch Bradford, January 2014


Healthwatch Liverpool, March 2014


Healthwatch Bradford, January 2014


Healthwatch Sunderland, May 2014


Healthwatch Liverpool, March 2014


Healthwatch Richmond, March 2014

Healthwatch Liverpool, March 2014


Healthwatch Liverpool, March 2014

Healthwatch Bradford, January 2014


Healthwatch Bradford, January 2014

92 93


A safe, dignified and quality service Healthwatch Sheffield; several people said that they didn’t think their GP had a good understanding of their mental health condition.99 “GP completely disinterested in my mental health conditions. They up my medication rather than offer therapy. Referred me to a service which is unable to help.”-Respondent to Healthwatch Cornwall, Sept 2014100 Healthwatch Oxfordshire also ran 11 focus groups with 106 people with learning difficulties. They found there are still areas within GP provision which are lacking for those with Learning Disabilities, predominantly in relation to preventative measures such as annual health checks. Just over half those taking part were satisfied with the level of GP services but a similar quantity felt that health service staff, particularly those working in general healthcare, had little or no understanding of Learning Disabilities.101

What has local Healthwatch been doing to resolve this? Local Healthwatch are seeking out seldom heard groups who may feel they are not treated fairly, for example, a discussion between Healthwatch Bradford and a leader from the Roma community indicated that language and cultural barriers are a particular issue. They were told that GP practice staff did not always make enough effort to overcome language barriers or take the time to communicate effectively, and that people from the Roma community felt there was prejudice against them. 102 Healthwatch Kent has been speaking to parents and carers who had to get a referral from a GP for a child to a Mental Health service. In an


Healthwatch Sheffield, September 2014


Healthwatch Cornwall, September 2014

investigation into Children’s and Adolescent Mental Health services (CAMHS) in Kent, Healthwatch Kent found that parents and carers found a lack of awareness about the needs of children and young people in this area amongst GPs. They found this resulted in delays in access to services. They highlighted the impact these delays can have on the mental health of the young people involved. In their report, Healthwatch Kent recommended that NHS England should confirm how they will respond to the need for improved awareness from GPs about mental health issues in children and adolescents to ensure a more consistent service and quicker referrals. In its response, NHS West Kent Clinical Commissioning Group confirmed that it is working with other Clinical Commissioning Groups and the County Council to further develop the Common Assessment Framework (CAF) referral process. This includes information being shared with GPs both verbally and through publications about how to refer and also information and support on raising awareness about children’s mental health. NHS West Kent Clinical Commissioning Group is also collecting referral data from the local Foundation Trust and assessing the quality and number of referrals from GP practices.103 In evidence supplied to Parliament, GPs told MPs they currently feel ill-equipped and lacking in confidence in dealing with mental health issues in children and young people, and that their current training does not prepare them adequately for this.104 Healthwatch England has joined a national taskforce to tackle the issues children and young people who need mental health services are experiencing to improve the provision of CAMHS services and will be supported by local Healthwatch in supplying evidence for that team.


Healthwatch Kent, August 2014


Parliament, Children’s and Adolescents Mental Health and

CAMHS (October


Healthwatch Oxfordshire, March 2014



Healthwatch Bradford, January 2014



Information and education

Information and education What to do out-of-hours Patients don’t always know the best service to visit and this can lead to pressures on other services like A&E All GP practices are covered by an out-of-hours GP service at evenings and weekends, which will provide an appointment if there is an urgent need. Half of the respondents to Healthwatch Ealing’s questionnaire were not aware of the out-of-hours service operating in 105 their area. This may be partly because the availability of the services is not well advertised. In July 2014, almost a year after NHS 111 was nationally implemented as the number to call for out-of-hours GP services, Healthwatch Hampshire reviewed the out of opening hours telephone messages at 144 GP surgeries and found 27 per cent gave the old number for their out-of-hours GP services rather than “111”. 106 Some patients told local Healthwatch that they were confused about the best out-of-hours options for them. For example, Healthwatch Manchester spoke to 100 people in waiting rooms at the local A&E and walk-in-centre. 37 per cent of respondents said that they were not aware of other services they could go to besides A&E which weren't in the hospital (such as GP services). 40 per cent of the respondents in the A&E waiting room did not think their problem was an emergency and almost half of the 37 respondents who they spoke to at the walk-in centre had initially presented at A&E

when they arrived.107 This suggests that more needs to be done to promote awareness of minor ailment treatment centres so that consumers can easily identify the best course of action for them. Of 136 users of a walk-incentre surveyed by Healthwatch Barking and Dagenham, 65 (47%) were there because they had not been able to get an appointment with their GP. 108

What has local Healthwatch been doing to resolve this? Members of the public who cannot get an appointment with their GP put strain on other services. In response to a Healthwatch England national poll, 1 in 4 respondents said it is likely they would resort to using A&E in the future if they were unable to get a GP appointment in a reasonable timeframe. 109 Healthwatch Reading spoke to more than 40 members of the Polish community in their area. They found that upon arriving to the UK, 21 per cent did not register with a GP. Most of the respondents had been in the UK for more than three years, however, 12 per cent were still not registered with a GP. The reasons they gave for not being registered were mostly around a lack of understanding about the need to register with a GP, consequentially around half had used the local walk-in-centre at least once. 110 Some respondents mistakenly believed that if they developed a serious health problem they could take themselves directly to the local hospital, rather than seek a GP referral first. They were also unaware that GPs


Healthwatch Manchester, August 2014


Healthwatch Barking and Dagenham, May 2013



Healthwatch Ealing, April 2014



Healthwatch Hampshire, July 2014


Healthwatch Reading, August 2014


Information and education offered many preventative services and managed many conditions in the community instead of hospital. As a result of their findings, Reading’s two Clinical Commissioning Groups are launching a Polish-language mobile phone app called Mój lokalny (Reading region) to ensure people arriving from Poland access the most appropriate services.111

Lack of clear information The public needs better information to make the right choices about their own care. More needs to be done to promote awareness of community pharmacies and walk-in centres to improve consumer experience. Healthwatch Suffolk uncovered confusion around the role of pharmacists and the range of services they offer. Of the 607 respondents who answered the question, just under half of respondents to a Healthwatch Suffolk survey (49%) thought that pharmacists were qualified to offer medical advice, although almost a third of respondents (29%) reported that they did not think pharmacists were qualified to offer medical advice. Nearly a quarter of respondents reported that they did not 112 know. Healthwatch Hackney also found some members of the public are confused about whether opticians are shops, or part of the health service.113 “I had no idea that pharmacies provide services such as blood testing service, vascular risk assessment, sugar testing, BMI so they must advertise more. It would be fantastic if all pharmacies offered these services.”



In response to a survey run by Healthwatch Dudley115 to explore the awareness of the range of pharmacy services, the highest instances of people indicating they did not know about a pharmacy service were for HIV testing (19%), needle exchange and methadone supply (16%), stroke services (16%), Chlamydia screening (14%), alcohol advice (13%), healthy eating and living advice (11%), immunisation and vaccination jabs (11%). Healthwatch Waltham Forest ran an event to discuss the future of pharmacy services with close to 50 members of the public. There were a number of comments made about the special relationship that many patients have with their pharmacist, with people pointing out that they see their pharmacist more often than their GP and therefore they may be better placed to undertake certain vital conversations. Participants agreed with statements that community pharmacy could be a first port of call for minor ailments and be utilised better for the management of stable long-term conditions.116

“[The] pharmacist … is absolutely brilliant I always go to her first before doctors”Respondent to Healthwatch Dudley117 A focus group run by Healthwatch Dudley found that most participants liked the consistency of contact they had with a particular pharmacist and they valued the convenience of the pharmacy to get medicines and help and advice on health matters and treatments. In addition, it was felt that there could be an enhanced

launched-response-healthwatch-report/ July 2014 112

Respondent to Healthwatch Waltham Forest114

Healthwatch Suffolk 2014



Healthwatch Waltham Forest, April 2014


Healthwatch Dudley, November 2014


Healthwatch Waltham Forest, April 2014


Healthwatch Dudley, November 2014


Information and education role for pharmacists providing more in-depth advice and help on health and wellbeing matters. For instance, a participant in Dudley’s focus group said, ‘[The] pharmacist needs to be the first point of contact for minor ailments’.118 The majority of people responding to Healthwatch Dudley’s survey of 786 people (89%) indicated that a minor ailments scheme, where people can get medication for conditions such as coughs and colds, a sore throat and insect bites without the need to see a doctor, would be useful, with 44 per cent using such a service. Respondents to a survey by Healthwatch Brighton and Hove were both aware of (91%) and used (71%) their pharmacy’s minor ailments service. 119 However, there seems to be variation across the country, with only 8 per cent of respondents to a survey by Healthwatch Lincolnshire, saying that they use their local pharmacy for help with minor ailments and only 4 per cent going to the pharmacy for health advice. 120

GPs and dentists are well placed to provide information to the public to help them selfcare and reduce their need to access Primary and Secondary Care services, however local Healthwatch have found that services are not always providing this additional information. Members of the public that local Healthwatch spoke to were often confused about which services to access. Confusion about how to selfcare, combined with confusion about which service to access, is resulting in some patients attending emergency services with preventable problems. Members of the public who spoke to local Healthwatch about the quality of Primary Care

were generally happy with the service they received and mostly felt listened to and properly involved in decision making around their care. For example, both adults and children have told local Healthwatch Barking and Dagenham and Liverpool that their dentist is good at explaining treatment options and keeping them informed about what treatment they are receiving and why. 121 Local Healthwatch in many areas found dentists are not engaging with the public or providing information about their services. Healthwatch Barking and Dagenham found that children were attending the dentist too late to prevent tooth decay and conducted some investigative research to find out why. They spoke to 157 local children and young people and found that a large proportion had not attended the dentist in the past year, because they thought they only needed to go if they were experiencing pain. The majority knew that NHS dental treatment was free for under 18’s; but were not aware of the importance of six monthly check ups for children and young people. 122 The impact of children not seeing a dentist until their teeth hurt is that they are not seeking treatment until they need emergency surgery. According to NHS figures, nearly 26,000 five- to nine-year-olds had to be treated in hospital for rotting teeth in the year beginning April 2013123, it’s the most common reason for this age group attending hospital.124


Healthwatch Barking and Dagenham, November 2013,

Healthwatch Waltham Forest, April 2014 122

Healthwatch Barking and Dagenham, November 2013



Healthwatch Dudley, November 2014



Healthwatch Brighton and Hove, October 2013



Healthwatch Lincolnshire, November 2014 b



Information and education This is an easily preventable issue which could in part be fixed by providing better information about when it is appropriate to visit a dentist. Local Healthwatch have also found a lack of public engagement from GP practices with the public. In Rochdale, when GP services extended their opening hours Healthwatch Rochdale did a piece of work examining the proportion of the 161 survey respondents that knew about the changes, and how they knew. They found just under half were aware of the extension to GP opening hours in their area, of those a third had heard about the changes through community radio, a third had read about the changes in local media and only 4 per cent had found out about the change from communication by their GP practice.125 The needs of the patient are also not always taken into account in the way that information is provided. For example, deaf people often receive standard letters from their health providers in formal English which they may struggle to understand, showing a lack of recognition that English is not always a first language for people who communicate using British Sign Language. 77 per cent of respondents to a survey by Healthwatch Leicester of Deaf and hard of hearing people in their region did not understand NHS information from leaflets, websites and papers, often because of the formal language which is harder for those who have British Sign Language as a first language to understand.126 “Sometimes they write something down for me – but my English isn’t good and it’s unclear to me what they mean. They know I’m Deaf – but I don’t think they understand that I don’t read

125 126

Healthwatch Rochdale, November 2014 Healthwatch Leicester, November 2014

English the same as hearing people.” Respondent to Healthwatch Kirklees127 Of 79 respondents to a survey by Healthwatch Lambeth of people who are blind or had a visual impairment, 49 people stated that when their GP surgery provides them with information, such as appointment letters or information about their health, it is not in a format they can use easily use, such as large print or Braille. Furthermore, 30 out of 63 respondents also stated when an optician provided information about their visual impairment it was not in a format that they could easily use.128

What has local Healthwatch been doing to resolve this? The impact of Primary Care providers failing to engage the public properly about their services is that it can leave the public confused; this sometimes leads to patients accessing services too late, or using the wrong service. Local Healthwatch provide an information and signposting service to help guide the public to the right support for them. There are many examples of local Healthwatch providing health information to help the community; Healthwatch Central Bedfordshire has been conducting targeted research with young people in their area around access to GP services and produced a short video of young people talking about their experiences of Primary Care. They are now doing the same with the elderly population in their area. 129 Healthwatch Leicester invited the local smoking cessation service to host an event with their local deaf community; after they fed back they wanted more information about leading


Healthwatch Kirklees, February 2014b


Healthwatch Lambeth, 2014




Information and education healthier lives.130 Healthwatch Peterborough is working with HMP Peterborough to run health information and awareness sessions for female prisoners over 50. 131 Many consumers who spoke to local Healthwatch were open to the idea of getting some care from sources other than GPs. Members of the public taking part in community outreach visits run by Healthwatch Merton indicated that they would be happy to see a nurse practitioner for services that do not relate to being ill, such as blood pressure checks, vaccinations, weight checks, blood tests, feet checks, smear tests, and other health checks.132

dentists splitting treatments that patients felt could have been carried out in one appointment, forcing the patient to pay for two separate procedures). Healthwatch England conducted some national research, raised the findings from both the national and local work with the Chief Dental Officer, (the government’s most senior advisor for dentistry in England), and also put the sixteen local Healthwatch134 who had conducted work in this area in touch with Which Magazine, so that they could feed into their national investigation into confusing and misleading costs for dental procedures.135

Healthwatch Hackney participated in a group developing a Vision Strategy for Hackney. The strategy was based on a literature review, a local survey of service users, and feedback at a consultation event. Healthwatch Hackney supported two members of the working group, both of whom are also service users, to take some of their recommendations to Hackney's Health and Wellbeing Board. Amongst others, their recommendations included; focusing on education and prevention, as they found many people think opticians are shops rather than part of the health service, bringing the visual impairment register up to date, (the group estimates 2,700 Hackney residents are missing from the register), and providing information in accessible formats.133

“Young woman who had recently found out she was pregnant went to her GP for advice about abortion - she was offered a referral appointment but wanted information about the process, and about some counselling support but this was not offered, she was told she would be told about the process at the clinic but wanted this information in advance to help her ensure she had made the right decision. She felt the doctor didn’t understand this and didn’t really have time to talk to her.” Healthwatch Cornwall 2014

Healthwatch Bradford and District raised concerns with Healthwatch England about the clarity of information on charges for dental treatment (for example they had heard of


leicestershire-helps-deaf-community-stop-smoking 131




Healthwatch Merton, September 2014

Barnet, Shropshire, North Yorkshire, Brighton and Hove, Dorset,


Healthwatch Hackney,

Rutland, Kent, Devon, Northumberland, Bradford, Haringey and

Healthwatch Warwickshire, Wiltshire, Hampshire, Islington,

Bury. 135



Conclusions By listening hard to people’s experiences we can see that there are a number of key areas that require improvement which go beyond the frequently reported issues around the need for longer opening hours. Some of these issues are relatively straight forward to fix. For example, ensuring everyone has access to clear information. We already know NHS England is looking to introduce a Plain English information standard which Primary Care services will be able to use to ensure they can provide every single patient with the clear and concise information they need to navigate the health and care system. The challenge will be in making sure this is adopted all across the country. Similarly, the issues around staff attitude are already being addressed, with one particular pilot programme being run by a CCG in Bradford around improving customer services following a report done by the local Healthwatch. If successful, this sort of programme should be rolled out nationwide as part of continual development for NHS staff. However other issues are less well recognised, in particular those around accessibility and communication with patients who have various disabilities. By law, under the Equality Act 2010, all health services are required to make ‘reasonable adjustments’ to make sure they are accessible to all. This duty requires GPs and dentist practices to anticipate the needs of patients with disabilities and, where possible, make adjustments to provide the same level service as for non-disabled patients.

Whilst the evidence collected by local Healthwatch is by no means a comprehensive study of whether or not practices are meeting this obligation, Healthwatch reports show clear problems right across the country with access ramps, availability of induction loops, provision of BSL translation services etc. Whatever the reasons for this, it should be considered a matter of priority by everyone; from individual practice managers and commissioners, right to the heart of Whitehall. It is clear from the research that there is value in listening to people’s direct experiences as well as considering official statistics. For example, there is clearly an issue with access to NHS dentists in some areas but because official figures only track the number of appointments and not the numbers of those not registered with a dentist this issue is slipping under the radar. The same applies to promises around patient choice, with the work of local Healthwatch clearly questioning the top level findings of the GP Patient Survey. More research is needed to establish to what extent people’s rights around seeing their GP of choice or ability to book longer appointments are actually being respected on the ground. Finally, poor feedback mechanisms create barriers to patients raising their concerns and complaints. In our ‘Suffering in Silence’ report we have set out a comprehensive series of recommendations to restore patient confidence in the complaints system and ensure people know that if they do speak up, their concerns will both be listened to and acted on.


What next? Whilst the findings of local Healthwatch are not representative of the full national picture they are significant, particularly because we are hearing from many people whose views are seldom heard elsewhere in the system. Having collected this wealth of evidence, local Healthwatch are now working with their local Clinical Commissioning Groups to address a number of issues on behalf of patients. Nationally, Healthwatch England will be taking up these findings with NHS England and the Department of Health to ensure that the experiences and views of patients are put at the heart of reviewing the GP contract, the dentist contract and the ongoing development of primary care services at a national level. Over the next year we will be taking our conversations forward with the public to find out more about the sorts or radical changes they want to see in the way Primary Care services are delivered and will use this to inform the debate around the implementation of NHS England’s 5 Year Forward View.



Evidence: Review of 240 enquiries

Acknowledgements Healthwatch England would like to thank all of the local Healthwatch who have conducted research and investigations into Primary Care for sharing their findings with us and responding to requests for further information. Unfortunately, we could not include all work by local Healthwatch that has touched on Primary Care in this report, so please do not consider this an exhaustive list of what has been done in this area. Healthwatch Barking and Dagenham “A response from the public- Barking & Dagenham Clinical Commissioning Group (CCG) Consultation – Proposals for Urgent Care Services and the Broad Street ‘Walk-in’ Service (May 2013)

Healthwatch Bradford “Invisible at the deskexperiences and views of people using Primary Care services in Bradford and District” (January 2014) invisible-desk-healthwatch-publishes-report-gpservices-0 Evidence: Qualitative data from 30 outreach events Healthwatch Brighton and Hove “Urgent Health Care services” (October 2013) k/content/what-weve-done Evidence: 179 survey response Healthwatch Camden “How do I have my say? Finding information about making a complaint at Camden GP surgeries: A mystery shopping project” (2014)

http://www.healthwatchbarkinganddagenham. _public_final_.pdf efault/files/130114_complaints_information_re port_final__1.pdf

Evidence: Public consultation and 200 survey responses

Evidence: Visits to 39 GP surgeries

Healthwatch Barking and Dagenham “Dental patient experience project for children, young people and parental views” (November 2013)

Healthwatch Cornwall “Report on Primary Care Services, GP Surgery/Health Centre from March 2014 to September 2014” (September 2014)

http://www.healthwatchbarkinganddagenham. ildren_young_people.pdf

Evidence: 157 responses Healthwatch Bolton “Accessing NHS Dentistry in Bolton” (January 2014)

Healthwatch Doncaster “Event Report- Are you a Carer? What are your needs?” (July 2014) efault/files/final_version_accessing_nhs_dent istry_in_bolton.pdf s/default/files/08-0714_carers_needs_event_report.pdf

Evidence: Analysis of 343 feedback comments


Acknowledgements Evidence: Engagement event with 27 carers, past carers and professionals who support carers

Healthwatch East Sussex “Mystery shopping: Making a complaint in your GP surgery” (August 2014)

Healthwatch Dorset “Something to complain about?” (May 2014) s/reports Evidence: Mystery shopper visits to 101 GP practices and their websites Healthwatch Dudley “Dudley Pharmaceutical needs assessment” (November 2014) Evidence: 827 survey responses and one focus group Healthwatch Ealing “Access to GP Services Report” (March 2014) ault/files/access_to_gp_services_report__march_2014.pdf Evidence: 169 patient survey responses

Evidence: Mystery shopping visits to 45 GP practices Healthwatch Halton “GP Access and Out-ofHours Provision” (November 2014) Evidence: 491 survey responses Healthwatch Hampshire “A survey of the outof-hours telephone messages of GP practices in Hampshire” (July 2014) /default/files/hw_hampshire_out_of_hours_rep ort_july_2014.pdf Evidence: Called 144 GP practices

Healthwatch Ealing “NHS Dental services event report” (April 2014)

Healthwatch Hertfordshire “Accessing GP services- Stort valley and villages locality” (2014) ault/files/tell_healthwatch_ealing_about_nhs_ dental_services_event_report_-_april_2014.pdf p-access-report/

Evidence: Engagement event attended by 40 people Healthwatch Enfield, “GP Audit Report” (September 2014) efault/files/gp_audit_report_september_2014_ final_with_amendments.pdf Evidence: review of 49 GP practices

Evidence: 763 survey responses and focus groups Healthwatch Islington, “Mystery shopping interpretation services” (January 2015) ces/reports Evidence: Survey of GP practices, Mystery Shopping, consultation with voluntary sector organisations 34

Acknowledgements Healthwatch Kent “Children and Adolescent Mental Health service report” (August 2014)

Evidence: Consultation event with 68 residents, 101 survey responses ult/files/healthwatch_kent_camhs_report_final _0.pdf

Healthwatch Leicester “ Deaf Community speaks up on local Health services” November 2014

Evidence: Focus Group af_Community_Speaks_Up_On_Local_Health_Se rvices_Healthwatch-Leicester_Nov-2014.pdf

Healthwatch Kirklees “Why can’t I find an NHS Dentist in Kirklees?” (February 2014a) ces/access-to-dentists-in-kirklees-february2014.pdf Evidence: Investigative report using web survey and engagement care Healthwatch Kirklees “Welcome to my world Issues affecting people in Kirklees who are Deaf and hard of hearing as they interact with Health Services- Full Report” (February 2014b) resources/welcome-to-my-world-issuesaffecting-deaf-and-hard-of-hearing-people-inkirklees-as-they-interact-with-health-services002-full-report-final.pdf Evidence: 372 survey responses, focus group and drop in session attendees. Healthwatch Lambeth “GP survey report” (October 2014)

Evidence: 53 members of the Deaf community Healthwatch Lincolnshire “Report on the Impact of Patient ‘Did Not Attend’ Appointments at GP surgeries in Lincolnshire (November 2014 A) es/default/files/report_on_the_impact_of_pati ent_dna_-_final.pdf Evidence: 38 GP practice responses, 428 patient responses Healthwatch Lincolnshire “Resident’s views of their local pharmacy service” (November 2014 B) es/default/files/hwl_pharmacy_report__final.pdf Evidence: 115 survey responses

Evidence: 114 survey responses

Healthwatch Liverpool “improving Access to GP services” (March 2014) default/files/final_healthwatch_lambeth_gp_su rvey_report_format_0.pdf default/files/final_version_gp_access_report_p df.pdf

Healthwatch Lambeth and Thomas Pocklington Trust “Lambeth Vision Strategy Evidence Base – Supporting Document” 2014

Evidence: 753 patient survey responses, 34 GP survey responses, several focus groups default/files/lambeth_vision_strategy_evidenc e_base__thomas_pocklington_trust_and_health watch_lambeth_0.pdf

Healthwatch Liverpool “Access to dental services report” (December 2014) default/files/access_to_dental_services_report _final_dec_14.pdf 35

Acknowledgements Evidence: 62 questionnaire responses

Evidence: 828 survey responses

Healthwatch Luton “A review of GP services in Luton” (2014)

Healthwatch Oxfordshire and my life choice “Every Voice counts” March 2014 ault/files/healthwatch_luton_gp_services_revie w_report_0.pdf s/default/files/mlmc__every_voice_counts_final.pdf

Evidence: 962 patient survey responses, 39 GP practice visits

Evidence: Discussions with 106 respondents

Healthwatch Manchester “Report from the waiting rooms” (August 2014) es/default/files/hwm_report_from_the_waitin g_rooms_0.pdf Evidence: 100 patient responses in A&E and walk in centre waiting rooms Healthwatch Merton “Strategies for improving GP services in Merton” (September 2014) WM%20GP%20Report%20with%20summary%20Se pt%2014.pdf Evidence: Qualitative data from seven community outreach visits and two workshops with 114 members of the public

Healthwatch Reading “How the recent migrant Polish community are accessing healthcare services, with a focus on primary and urgent care services” (August 2014) Evidence: Qualitative data from 34 interviews and a focus group with 9 participants Healthwatch Reading “Findings from a focus group of young carers into the health and social care services they use” (July 2014) Evidence: Qualitative data from a focus group with 13 carers aged 7-19

Healthwatch Newcastle “Compliments, comments and complaints- Encouraging feedback from your patients” (2014)

Healthwatch Redcar and Cleveland “Dental Health Care Access for the Disabled & Infirm” (August 2014) lt/files/uploads/GP_Report_Amendedv1.pdf

Evidence: 42 visits to GP practices Healthwatch Oxfordshire and the Patients Association “Survey to determine patient views about accessing their GP services” (October 2014) s/default/files/oxfordshire_healthwatch_gp_su rvey_final_october_2014.pdf

Evidence: Survey of dental surgeries Healthwatch Richmond “GP Project Report” (March 2014) default/files/richmond-uponthames_full_general_practice_report.pdf 36

Acknowledgements Evidence: Qualitative data from 105 respondents and a further 10 focus groups

Evidence: Surveys of 65 practices and 1,111 patients

Healthwatch Rochdale “GP extended services report” (November 2014)

Healthwatch Sutton “GP Access Report” (December 2014) /default/files/gp_extended_services_report.pd f access_report_final2/1

Evidence: 161 survey responses Healthwatch Sheffield “Mental Health in Sheffield: A Snapshot” (September 2014) default/files/mental_health_in_sheffield__report_for_hwbb_sept_2014_-_final.pdf Evidence: Qualitative data from an engagement event and a live web chat Healthwatch Suffolk “Engagement Report: Public Perceptions and Experiences of GP Surgeries in Haverhill” (2014) fault/files/engagement_report_gp_haverhill_fi nal_0.pdf Evidence: 627 survey responses Healthwatch Sunderland “BME people and access to health and wellbeing services in Sunderland: A report from BME engagement events” (May 2014) /default/files/uploads/BME_people_and_access _to_health_and_wellbeing_services_in_Sunderl and.pdf Evidence: 5 engagement events with 49 participants Healthwatch Surrey “Getting an appointment with your GP: Experiences of the people in Surrey” (July 2014)

Evidence: Survey of 454 responses Healthwatch Waltham Forest “Accessing GP services in Waltham Forest” (2013) sites/default/files/healthwatch_waltham_fores t_-_gp_report_0.pdf Evidence: Survey of 395 respondents. Healthwatch Waltham Forest “The future of pharmacy services” (April 2014) sites/default/files/pharmacy_final_report.pdf Evidence: Patient engagement event Healthwatch Warwickshire “Patient Access to GP Services Survey Analysis and Report” (June 2013) tes/default/files/uploads/Healthwatwch_Warw ickshire_GP_Suvey_Report_Final.pdf Evidence: 312 patient responses and 20 GP practice responses Healthwatch Warwickshire “Young People’s GP experience survey” (November 2013) tes/default/files/uploads/Yp_gp_report_final.p df Evidence: 323 survey responses Healthwatch West Sussex “GP report- a survey of GP practices across West Sussex” (March 2014)


Acknowledgements s/default/files/gp_surgeries_1.pdf Evidence: 155 patient survey responses, 54 GP practice visits Healthwatch Wokingham Borough, “Are you hearing us?” (December 2014) ources/are-you-hearing-us Evidence: Mystery shopping visits to 13 GP practices Healthwatch York “Access to health and social care services for Deaf people” (Dec 2013) Evidence: Qualitative data from an engagement event



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