sturry surgery and canterbury health · pdf filenbsurvey, to enable the collection of views...

Sturry Surgery

And

Canterbury Health Centre

Canterbury Health Centre

26 Old Dover Road

Canterbury

Kent

CT1 3JH

T: 01227 452444

Sturry Surgery

53 Island Road

Canterbury

Kent

CT2 0EF

T: 01227 710372

Practice Manager: Mr Jeremy Lawrence

Local Patient Participation Report March 2012

Sturry Surgery and Canterbury HC Local Patient Participation Report 2012 | 2

Executive Summary The following report outlines requirements for a Local Patient Participation Report to satisfy the PP-DES 2011 – 2012 requirements as directed by the; THE NATIONAL HEALTH SERVICE ACT 2006 The Primary Medical Services (Directed Enhanced Services) (England) (Amendment) Directions 2011 Insertion of new direction 12A - “Patient Participation Scheme”.

Sturry Surgery Canterbury Health Centre

Practice Manager: Mr Jeremy Lawrence

Number of full time doctors(FTE) 8.75

Number of patients 14772

Patient Participation Direct Enhanced Service Methodology

The practice engaged with NETbuilder to provide their comprehensive managed survey solution, NBSurvey, to enable the collection of views from patients in multiple locations across various demographic groups. This enabled us to canvass our patients opinions via an input channel most suited to them, from paper surveys to in-practice touch screen kiosks / laptops, through to virtual online surveys. The practice has both a face-to-face and a virtual Patient Reference Group. This means that patients are invited and encouraged to give their feedback via surveys on various aspects of the practice in a number of ways. The current number of PRG Members is 19 and recruitment is on-going

Results Summary

Item Total

Number of Surveys 4

Number of Responses 387

Number of Input Channels 4

Summary Outcomes & Action Plan

Telephone access at busy times and the booking of appointments more than 48hrs in advance were identified as the key areas to address. The practice is to look at current capacity and facilities, and identify additional measures that could be taken to improve telephone access. Ways of promoting the advance booking of appointments are to be implemented to raise patient awareness of the facility. Experience and thoughts regarding the PP DES

The Practice has been running a Patient Reference Group since 2007 and it has been a very useful way of receiving feedback from patients, but attracting people to the group has been difficult and the members did not fully represent the demographics of the Practice. The DES has guided the


development of the group so that there is now both a face-to-face and a virtual PRG which has more members and so can better reflect the practice population. The virtual group has been quite slow to develop and the level of interest in becoming a member has been lower than hoped to this point. This may be due in part to a reluctance to commit or a lack of awareness of the potential benefits of providing feedback, but it may also be due to a low awareness of the existence of the group. The ways of advertising the group have been developed over the last few months and it is hoped that membership will grow further over the next year. The results of the surveys so far have closely reflected the results of previous local and national practice surveys, particularly with regards to patient access and this promotes confidence in the findings. There had been a perceived risk at the beginning of the process that a greater proportion of patients with extreme views may be attracted to take part which would skew overall results, but this has proved to be unfounded. Overall, once the membership of the virtual group has developed further it will be a more effective way of receiving feedback from patients than was previously available.


CONTENTS

Executive Summary 2

Patient Participation Direct Enhanced Service Methodology 2

Results Summary 2

Summary Outcomes & Action Plan 2

Experience and thoughts regarding the PP DES 2

About The Practice 6

The Doctors 6

Associate Doctors 6

The Practice Staff 6

Practice Nurses 6

Senior Practice Nurse 6

District Nurses 7

Healthcare Assistants 7

Health Visitors 7

Opening Hours 7

Telephone Consultations 8

Home Visits 8

When the Surgery is closed 8

Local Survey Methodology 9

The NBSurvey Methodology 9

Input Channel Evaluation Criteria 12

Patient Reference Group 14

PRG Membership 14

Member Profiles 14

PRG Recruitment & Representation 14

PRG Agreement of Priorities 15

Results, Outcomes& Findings 17

Summary Information: 17

Survey results by Input Channel: 17


Summary of Demographics Survey: 17

Representation of Registered Patients 17

Survey Results 19

Discussions & Action Plans 21

Discussions 21

Action Plans 21


About The Practice

Our aim is to provide patients with a high standard of health care by making appropriate and innovative use of NHS resources in partnership with other Health Care providers, and in partnership with patients. Our team includes Doctors, Practice Nurses, District Nurses, Health Visitors, Health Care Assistants, Midwives, Counsellors, Receptionists and Support Staff. Other professionals regularly work within this Practice. The Practice is part of the Eastern and Coastal Kent Primary Care Trust. We are a training Practice for Medical students and Doctors specialising in General Practice.

The Doctors

Dr Paul Molony MA MB BS (London 1982) DA DCH DOcc Med Dr Kim Stillman MB BCh (Liverpool 1982) CLTHE (London 2003) Dr Jane Lilley MB BS (London 1984) DCH MRCGP DOcc Med Dr Sue Greaves MB BS (London 1989) DCH DRCOG MRCGP Dr Ian Sutherland MB ChB (Aberdeen 1988) MRCGP

Associate Doctors

Dr Alison Firth Dr Peter Toon Dr Rob Jolliffe Dr Eddy Rossini Dr M Palanisamy

The Practice Staff

Practice Nurses

Louise Peckham Wendy Siddle Lorraine Hamilton-Box Nicky Antoniazzi

Senior Practice Nurse

Jo Walker

Our practice nurses specialise in preventative medicine and the management of chronic diseases

such as diabetes and asthma. Appointments can be made for immunisations, cervical smears,

blood pressure checks, blood tests, foreign travel, asthma, vaccinations and advice.


District Nurses

The district nurses are employed by the Community Trust but visit the surgery daily and liaise

closely with all staff to ensure continuity of care.

Healthcare Assistants

Claire Wain Sheila Williams Our healthcare assistants support the nursing team by providing phlebotomy clinics as well as

monitoring blood pressure and taking ECGs. They also provide smoking cessation clinics and

administrative support in the chronic disease management of our patients.

Health Visitors

Health Visitors are available for advice on such things as baby and child care, child health and development, minor ailments, family nutrition, family dynamics, coping with disabilities, welfare benefits and local services and facilities. They also run support groups.

Opening Hours

Canterbury Health Centre Sturry Surgery

08:30 to 20:00 Monday 08:30 to 18:30 Monday

08:30 to 18:30 Tuesday 08:30 to 20:00 Tuesday

08:30 to 18:30 Wednesday 07:00 to 18:30 Wednesday

08:30 to 20:00 Thursday 08:30 to 18:30 Thursday

08:30 to 18:30 Friday 08:30 to 18:30 Friday

The Canterbury Health Centre offers extended hours appointments on Mondays and Thursdays

until 20:00. The Sturry Surgery also offers extended hours appointments on Tuesdays until 20:00

and opens earlier on Wednesdays at 07:00.These extended surgery times are intended for pre-

booked routine appointments as the surgery is not open for telephone calls, prescription enquiries

or registration at this time. The South East Health out-of-hours service will operate for

emergencies at these times.

Our aim is to provide the majority of consultations on the same day that a patient calls where this

is needed. This may be a face to face consultation in the surgery, or if more appropriate, a

telephone consultation. These enable the doctors and nurses to help the patient with some

problems or queries without having to attend the surgery. Appointments may also be booked up

to one month in advance to enable follow-up appointments and appointments for non-urgent

conditions to be made more easily.


Telephone Consultations

Patients are able to book a telephone appointment with a doctor who will call them back at an

allotted time. This is often more convenient for patients when booking an appointment for issues

such as discussing test results or queries with medications.

Home Visits

If someone is too ill to attend the surgery a home visit by a doctor or a district nurse can be

arranged by calling the surgery.

When the Surgery is closed

South East Health Ltd has been commissioned by the Eastern and Coastal Kent Primary Care

Trusts to provide this care on their behalf.

If urgent medical attention is needed outside normal GP surgery hours, patients will be able to

access South East Health Ltd by dialling the surgery after which they will automatically be put

through to South East Health Ltd.


Local Survey Methodology The practice engaged with NETbuilder to provide their comprehensive managed survey solution, NBSurvey, to enable the collection of views from patients in multiple locations across various demographic groups. This enabled us to canvass our patients’ opinions via an input channel most suited to them, from physical paper and in-practice touch screen kiosks / laptops, through to virtual online surveys. Findings from previous studies carried out by NETbuilder exposed that multiple short surveys with a maximum of 8-10 questions each are more effective than one long survey running continually throughout the survey period. Each survey was customised to the investigational design and measures, for example measuring the patient’s feedback on a doctor’s appointment using a short survey (Seeing a Doctor). Additionally, this encourages patients to give feedback for the areas relevant and important to them.

The NBSurvey Methodology


Step Description Surgery Comments / Experiences

Continual Development of Patient Reference Group (PRG)

The PRG is a representative group of patients from the practice. They are responsible for providing feedback to surveys and collaborating with the practice to analyse the results and agree realistic change opportunities.

Although we had an initial drive to recruit as many people as possible, this is an on-going process so that any of our patients, new or current, have the opportunity to contribute. The inclusion of a sign-up form on the website as well as at both surgeries, along with promotion of the PPG is designed to make signing up to the group as easy as possible.

Determine Priority Areas

Key areas include but are not limited to the following:

Access

Overall Satisfaction

Seeing a Doctor

See a Nurse

The Reception

The Surgery Environment

Demographics

Specialised Clinics (e.g. Flu, Vasectomy)

The PRG and other patients complete the Patient Priorities Surveys to priorities the areas (above) to determine the order in which key areas are addressed by the practice. Patients are also given the opportunity to provide comments regarding other areas they would like to see addressed.

A good response to the survey gave us three areas of priority that patients wished to look at. These were:

Satisfaction with doctors/nurses

Access

Overall satisfaction

Design & Build Surveys

The practice work closely with NETbuilder to design and build the surveys. Each survey is designed to measure the patient’s view of the identified key areas. Each survey contained between 8-10 questions. Patients are able to choose to complete the surveys they believe are relevant to them and ignore those that are not.

The practice collaborated with the PRG to agree the areas to concentrate on in each survey.

Decide on Input Channels and

The practice worked closely with NETbuilder to agree which input

We used the Input Channel Evaluation Criteria to help us decide


Publish Surveys channels are suitable for the surgery and patients. Input channels available are:

Surgery Kiosk

Web Portals

Laptop

Paper

Face to Face Each survey can be used on (published to) one or more of the input channels listed above.

which channels to use for Sturry Surgery and Canterbury Health Centre:

In-surgery Kiosk: to capture patients from all demographics visiting the surgery

Paper: available in the surgery as an alternative to the kiosk.

PRG Web Portal: specific portal to for PRG Members

Advertise Feedback Channels

Inform patients of the available input channels and current surveys, in order to create a greater number of participation responses. Types of promoting include but is not limited to:

Encouragement slip given by the doctor

Posters

Leaflets

News Letters

Encouragement from all Practice Staff & PRG

Surgery Website

Notice Board

Information is displayed in the waiting areas at both sites, both above the input kiosks and on the patient information displays. Reception staff encourage patients to complete the surveys and paper copies of surveys are available for those who are not comfortable with using the touch screens We also have a Patient Participation section on our website.

Capture Patient Experience

Patients complete surveys using the available input channels as listed above.

There was an initial reluctance to use the touch screen kiosks, possibly because patients were unfamiliar with them. This is improving but we had a greater response to the paper surveys which were then manually entered into the portal. It is hoped that more patients will use the kiosks as they become familiar with them.

Produce & Distribute Reports

Results in the form of reports are produced for each individual survey and distributed via the Practice Website, Practice Meetings, Surgery Notice Board, PRG consultations.

Reports have been discussed at the face-to-face PPG meetings and at practice meetings. They have also been published on the practice website and on the patient information displays in the waiting areas at both surgeries.

Collaborate with PRG to Analyse

The Practice Manager will discuss & analyse the survey results with the

The results of the surveys were discussed at a staff meeting as well as


Input Channel Evaluation Criteria

Input Channels should be thoroughly evaluated for their suitability for use by patient belonging to a practice. The following table describes the advantages and disadvantages of each input channel currently supported for practices.

Input

Channel

Advantages Disadvantages

Paper Surveys

Suitable for a large percentage of

patients across most services

Known and trusted media for many

patients

Production, deployment and

collection of surveys required

Data input required

Public Web Surveys

Instant feedback

Fast deployment of survey

Easily changeable

Limited to patients with internet

access

Limited to patients with the ability

to use technology

Open to people who are not

patients with the Practice

Email Surveys

Instant feedback


Easily changeable

Limited to patients with internet

access


Results Practice Doctors and then discuss with the PRG for further analysis.

at a PPG meeting. The overall results were thought to be positive but two areas that could be improved were the telephone system and raising the awareness of advance bookings. There were still a surprising number of patients who seemed to be unaware that advance bookings were possible, and difficulty in getting through on the telephone at busy times was identified a number of times.

Agree Action Plan An agreed action plan between the PRG & Surgery will be created according to the outcome of the analysis from the results.

Details are provided in the section Discussions & Action Plans below.

Implement Change Practice must obtain the agreement of its local PCT to its proposals for any significant change, e.g. change of opening hours. Approved changes can then be implemented.

Details are provided in the section Discussions & Action Plans below.


Excellent for tracking feedback for

specific treatments (e.g. specialised

clinics)

to use technology

Limited to patients with email

accounts

Limited to patients who have

provided Trust with email addresses

Phone Surveys

Instant feedback


Easily changeable

Excellent for tracking feedback for

specific treatments

Limited to patients with telephone

access


to use a telephone

Additional cost to practice

Touch Screen Kiosks

Immediately and conveniently

accessible before and after

appointments

Instant feedback


Easily changeable


and willingness to use a touchscreen

kiosk

Requires suitable physical location

Touch Screen Tablets / Laptops

Instant feedback


Easily changeable


accessible before and after

appointments

Portable

Fashionable


and willingness to use a touchscreen

tablet

Requires overnight charging

Standard Desktop

Instant feedback


Easily changeable


accessible following treatment


and willingness to use a desktop PC

Requires suitable physical location

Requires protection from being

damaged, lost or stolen

Face to Face interviews

Instant feedback (proving tablet

used to input response)


Easily changeable


accessible following treatment

Patients able to converse with a

person, puts at ease

Rapport building

Canvasser must be independent

Additional resource required

Patients may be reluctant to give

honest answers to canvassers


Patient Reference Group

PRG Membership

Member Profiles

Members of the Patient Reference Group (PRG) are recruited from patients registered at Sturry Surgery and Canterbury Health Centre. The Practice has a ‘virtual’ Patient Reference Group. This means that patients are invited and encouraged to give their feedback on various aspects of the practice by using the PRG Web Portal that is sent to them on a regular basis by the Practice Manager. We communicate with the PRG members once a quarter and contact them via email. The group gives feedback by email as well as on the website and the kiosks in the Sturry Surgery and Canterbury Health Centre. In addition to this, the Practice has a smaller group of 8 patients who meet once per quarter. This allows face-to-face discussions which the Practice has found to be very beneficial.

PRG Recruitment & Representation

In order to ensure that members of the group are fully representative of our registered patients, the Practice uses the following means to recruit:

The practice website

Sign-up slips handed to all patients when attending an appointment

Sign-up slips given to all new patient when registering The current number of PRG Members is 19 and recruitment is on-going using all the methods described above. We will continue to promote the PRG to increase the numbers to ensure we have a greater representation of patients within the group. Note: Feedback is not solely reliant on the PRG, surveys are also completed by other Patients from the Practice via the surgery kiosk and web portals etc.

PRG Agreement of Priorities

Following the outcome of the Patient priorities survey completed on the kiosks at both sites we referred to the Patient Reference Group for agreement of priorities. All means of communication as described earlier in this report were used to gain feedback from the Patients. The Patient Priorities Survey asked which of the following were considered a priority area to look at; Access (getting an appointment), Overall Satisfaction, Seeing a Doctor, Seeing a Nurse, The Reception and The Surgery Environment. The results:


The Results show that Patient prioritised the areas as follows: 1. Seeing a Doctor (80.00 %) 2. Access (68.00 %) 3. Seeing a Nurse (68.00 %) 4. Overall Satisfaction (65.33 %) 5. The Reception (42.67 %) 6. The Surgery Environment (42.67 %)

Additional comments regarding areas provided by the PRG were:

Where possible these will be incorporated into the next round of Surveys to understand the full opinion of the Practice Patients.

Results, Outcomes& Findings

Summary Information:

Item Total

Number of Surveys 4

Number of Responses 387

Number of Input Channels 4

Survey results by Input Channel:

Input Channels

Survey Kiosk Canterbury

Kiosk Sturry

Paper Canterbury

Paper Sturry

PRG Portal

Website Total

Doctor 75 13 0 0 0 0 88

Patient Priorities 48 23 4 0 0 0 75

Seeing a Doc/Nurse 2 15 0 0 80 1 98

Surgery 0 27 0 51 47 1 126

Total 125 78 4 51 127 2 387

Summary of Demographics Survey:

Our Practice took the strategic decision not to solely rely on our Patient Reference Group for feedback to our surveys and wanted to capture the views of as many of our patients as possible. To support this decision we invested in a touchscreen kiosk and web portal technology. The intention was to encourage patients visiting the practice to provide us with “in the moment” feedback about the service they had just received. The web portals enable us to reach-out to patients who are unable to visit the surgery. In addition, all surveys can be requested in paper format. We believe that this strategy will provide the practice with feedback from a representative demographic of our patient population. Representation of Registered Patients

Canterbury Health Centre & Sturry Surgery does not currently have a PRG which is a fully representative group of its registered patients, but it is reasonably diverse and it is hoped that representation from under-represented groups will increase over the coming months. The following table shows the demographic of the practice population compared to that of the PRG:

Demographic % Practice

% PRG

SEX

Male 46.5 47.4

Female 53.5 52.6

AGE

Under 16 15.3 0

17-24 21.2 0

25-34 15 21


Demographic % Practice

% PRG

35-44 10.6 10.5

45-54 9.6 10.5

55-64 7.6 21

65-74 5.8 26.3

75-84 3.2 5.3

Over 84 1.7 5.3

EMPLOYMENT

Employed 47.4

Unemployed 10.5

Retired 42.1

Student 19.8 0

ETHNICITY

White British 51.3 89.5

White Irish 1.9 5.2

White Other 17.1 5.2

White & Black Caribbean 0.4 5.2

White & Black African 0.3 0

White & Asian 0.4 0

Other mixed 0.6 0

Indian 1.6 0

Pakistani 0.6 0

Bangladeshi 0.2 0

Other Asian 3.6 0

Black Caribbean 0.4 0

Black African 1.6 0

Black Other 0.6 0

Chinese 0.9 0

Any Other 2.4 0

Not Stated 16.1 0

PARENT OF AN UNDER 18YR OLD 5.4 21

CARER 0.3 10.5

DISABILITY 0.6 10.5

There is missing representation from the following groups:

Patients under 24 years old

Students

Ethnic minorities The following steps are being taken to increase representation:

Sign-up forms are being given to all new patients registering with the Practice. Availability of sign-up forms on the Practice website is anticipated to appeal more to younger patients and we are looking at introducing an electronic form that can be submitted directly from the website.


A link to the Practice website has been added to the Canterbury Christ Church University intranet to encourage students to register and give access to the PPG sign-up form.

Once we reach a membership of 50 patients we will become selective in those who are accepted so that they better represent our demographic. This should help to balance representation from ethnic minorities.

Survey Results

Detailed reports for each survey can be found on Canterbury Health Centre & Sturry Surgery Website http://www.sturrysurgery.co.uk/ All results were discussed with the PRG and relevant practice staff; the key outcomes for each survey are highlighted below. Please note that the reports found on the website display the latest feedback captured and therefore may contain more results than are summarised in this report.

Seeing a Doctor

The Doctors were rated as excellent in the following areas:

. Displaying care and concern - 75.00%

. Giving Patients enough time – 73.86%

. Listening – 82.95%

. Putting patients at ease – 76.14 %

. Taking problems seriously – 78.41%

When asked how thoroughly the doctors asked about symptoms and how they were feeling

96.59% of patients said ‘quite’ well or ‘very ‘well’

79.55% of patients said that the doctor fully involved them on decision concerning their care

When asked how well the doctor explained problems or treatment the patients said the doctor

did this ‘fairly’ well or ‘very’ well 92.10% of the time (when applicable)

When asked if the doctor explained the test results to the patient they said that he did explain them 84.61% (when applicable)

95.29% of patients said that they had confidence in the doctor they saw

Seeing a Doctor or Nurse

The doctors were rated as ‘satisfactory’ or ‘good’ in the following areas (when applicable):

. Asking about symptoms – 100%

. Explaining test and treatments – 100%

. Giving enough time – 100%

. Involving patients in decisions – 100%

. Listening – 100%

http://www.sturrysurgery.co.uk/


. Taking problems seriously – 100%

. Treating patients with care and concern – 100%

95.00% of patients said that they had confidence in the doctor they saw

98.75% of patients said they would be happy to see the doctor again

When seeing a doctor, patients gave their reasons for having a consultation as:

. On-going problem 46.25%

. One off problem - 26.25%

. Asking for advice – 10.00%

. Routine check-up – 10.00%

. Prescription – 6.25%

. Other – 1.25%

The nurses were rated as ‘satisfactory’ or ‘good’ in the following areas (when applicable):

. Asking about symptoms – 100%

. Explaining test and treatments – 100%

. Giving enough time – 100%

. Involving patients in decisions – 94.44%

. Listening – 100%

. Taking problems seriously – 100%

. Treating patients with care and concern – 100.00%

100.00% of patients said that they had confidence in the nurse they saw

100.00% of patients said they would be happy to see the nurse again

The Surgery

88.98% of patient normally book appointments to see a doctor or nurse by phone

77.34% of patient prefer to book appointments by phone

81.60% or more of patients that have tried to contact the surgery by phone rated the service as good or excellent in the following areas; getting test results; getting through; speaking to a doctor; speaking to a nurse

93.75% of patients were able to get an appointment within the same or two working days

75.49% of patients were able to book an appointment for more than two working days in

advance

Patients rated the reception environment as ‘good’ or ‘excellent’ in the following areas:

. The helpfulness of reception staff – 96.06%

. The way patients were treated by reception staff – 97.66%

89.84% of patients waited less than 5 minutes to speak to a receptionist

Patients rated the surgery environment as ‘good’ or ‘excellent’ in the following areas:

. Cleanliness of waiting area – 99.22%

. Comfort in the waiting area – 98.44%

. Level of information displayed – 98.43%


Discussions & Action Plans

Discussions

The results of the surveys were reviewed by the Practice Manager and discussed at a Partners meeting and a PPG meeting. The initial reluctance of patients to use the touchscreen kiosks was noted, and that the electronic format of the survey made the formatting of the paper versions rather bulky. Having previously run paper-only versions of patient satisfaction surveys the practice considered the current approach of having touchscreen, web based and paper input options an improvement which allowed participation from a wider section of the practice population. Overall satisfaction was considered to be good, particularly satisfaction with the doctors and nurses but telephone access and ability to book appointments in advance were identified as problem areas. It was surprising that 24.5% of patients said that they were unable to book an appointment more than 48hrs in advance, as appointments have been bookable up to 4 weeks in advance for several years now. As well as including this area in the action plan it was decided to survey this area again later in the year with greater breakdown on reasons why advance bookings had not been possible. Another area identified potentially for future surveys was the overrunning of appointments leading to other appointments running late. This had been identified by comments made on the survey forms. The action plan below shows how the two proposals for change will be implemented. The introduction of call queuing is included in the action plan, but when the practice undertook a survey 2 years ago with a view to introducing it the majority of patients did not want it. Therefore a further discussion will be had with the PRG if implementation proves to be feasible.

Action Plans

Area for Improvement

Recommendations Actions Practice Lead

Date for Completion/

Review

Comments

Better telephone access to the surgery. All lines can be busy at peak times.

Review current telephone system, identify options for improving and implement where appropriate.

Review number of lines and assess for capacity.

Review numbers of staff manning phones at bust periods.

Monitor numbers of calls.

Practice Manager

31/03/12 6 lines per site. Reviewed with supplier and considered adequate. 3 staff per site answering phones. To see if additional staff can assist at busy periods.

Consider call queuing Contact telecoms supplier for costs

Practice Manager

30/04/12


Area for Improvement

Recommendations Actions Practice Lead

Date for Completion/

Review

Comments

to install.

Review costs/feasibility with Partners & PPG

Consider online appointment booking

See clinical system manager for current options.

Review product with Partners & PPG

Practice Manager

30/04/12

Raise awareness of advance bookings facility. A significant number of patients appear to be unaware that appointments can be booked in advance.

Identify different ways of promoting the advance bookings service

Display appointment bookings information at reception desks.

Display appointment information on patient information screens

Consider adding appointment information to recorded message when calling the surgery

Review information on website and in practice booklet, update as necessary.

Practice Manager

12/03/12 12/03/12 30/04/12 31/03/12

Discuss with PPG whether this will make length of message too long.

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