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3 GPs - 'child-unfriendly practice' jibe hits nerve

Yours is one of two practices in the town which consists of the ‘old town’ and a large, fairly new estate, popular with families. Comparisons with local statistics confirm your suspicions that you have a relative preponderance of middle-aged and elderly patients, and fewer children and young healthy adults than you might expect.

Yours is one of two practices in the town which consists of the ‘old town' and a large, fairly new estate, popular with families. Comparisons with local statistics confirm your suspicions that you have a relative preponderance of middle-aged and elderly patients, and fewer children and young healthy adults than you might expect.

This is having workload and financial implications as it impacts on your consultations, prescribing, QOF targets and referral levels.

When you speak to the health visitor you are shocked to discover that the practice is generally regarded as less child-friendly than your competitors.

Dr Robin Fox

‘Investment now may pay dividends later'

There's lots of anecdotal evidence that the practice has a problem. Our lack of insight into this is as concerning as the issue itself and will need addressing. I suspect the change management needed will point to some of these problems.

Reputations are made over years and destroyed in minutes. Is this situation a legacy of now retired health professionals? How much change do we need to enable a more child-friendly practice to develop?

At morning coffee I would raise this with the doctors to see whether others think we have a problem and, if so, whether it is worth addressing.

Wasting time investigating a problem no one else wants to remedy is fruitless. If we agree to look into things further, I would speak to our patient participation group and canvas a selected group of young mum patients and ask their opinion.

I would propose a brainstorming session at the next primary healthcare meeting and ask the practice manger to email all practice and attached staff asking them to think about this ahead of the meeting. Additionally I would try to speak to them in person. Brightening up the surgery or buying appropriately hygienic toys for the waiting area is easy to do.

Offering local antenatal classes use of our meeting room or providing help to local school contraception initiatives may help.

Altering clinic times to ensure timely access to the midwife, health visitors, doctors, baby and vaccination clinics, should be possible. Skill deficiencies can be addressed by training or investing in new services that we currently do not offer. This may well be financially and professionally advantageous in the longer term even if it means a degree of investment now.

We should do a simple SWOT analysis before plunging the whole practice into wholesale changes. Staff attitudes, often buried deep, can be more difficult to change. With luck unfriendly reception staff can be trained (some drug companies have access to such a service for practices), rotated to non client care tasks and, if necessary, 'line managed'.

Often the most difficult problems lie with the attitudes of attached staff or, most unfortunate of all, a problem within the partners themselves. While we make changes for the longer term, we also need to review current problems.

Missing QOF targets may be remediable by investing more protected time in someone taking charge of this. This needs to be someone motivated and who has the authority to make change happen.

The financial benefits could help fund other changes we need to make. Making changes to prescribing may ease the drug budget. The PCT prescribing advisers are usually very keen to help.

Dr Robin Fox is a GP in Bicester, Oxfordshire

2 Dr Patricia Cahill

‘We may be out of touch; the doctors too cranky and the receptionists too dragon-like'

A family practice being told they are family unfriendly is pretty devastating. But I would try to keep calm in the face of this revelation as it may have been difficult for the health visitor to tell me. I don't want to get defensive and upset her.

I would ask her to explain further as she might be able to cast light on why we are not viewed as family friendly. If we are the 'old town' practice it may be that it is merely a geographical issue, especially if the other practice is purpose-built as part of the new estate. However, if we're the practice closest to the estate then things are serious.

Various factors could be involved. It may be our list was closed for a while and it was difficult to for new patients to register. This might have even been because we were so popular we had filled up to capacity.

Or patients who came as young families were so happy they have grown old with the practice. QOF is supposed to be a measure of quality of care but it is also connected with our livelihood.

The points are going to be easier to get, prescription and referral audits more golden, if the patients are young and generally fit in the first place. The problem may be that we're out of touch. Most of us like to think we are doing a good job.

We need to consider if we want to change. I could bring the matter up at the next practice wide meeting. Try to flush out the problems. A bit of self-reflection may be helpful. The doctors could ask out loud if they are too cranky and then the reception staff might wonder if they are too dragon like.

Should the waiting room have some toys? We could try having dedicated children's clinics. We could consult the patient as well as other colleagues to see what they think. We could also try not to worry about it too much - do our best and hope things come full circle.

Dr Patricia Cahill is a salaried GP in Ipswich

3 Dr Steve Jones

‘Changing the reputation of a practice takes time'

I would ask myself two questions. Firstly, is the health visitor right, and secondly, if she is right, do I want to do something about it?

I would canvas opinions from families that are patients and tap into the coffee morning gossip. As one of two practices in the town there is little competition for patients, and the fact that the other practice is on the estate means that young families will naturally gravitate there.

This would be a good time to assess whether my practice is being efficient with managing my middle aged and elderly patients. Although our patients would create a high workload I would hope to be efficient in chronic disease management to maximise the QOF score which takes into account disease prevalence.

I would make sure my nurses were doing a lot of the work of checking blood pressures, managing asthma and checking cholesterols. I need to check recall systems are in place and that the clinical and admin staff have regular meetings.

I would make use of the PCT prescribing advisor, and do regular referral audits to ensure the practice is efficient. If all this is in place I would then have more energy and willingness to consider attracting younger families to the surgery.

I would involve the health visitors in the process. It would be good to make the baby clinic fun. As well as doing immunisations and baby checks there would be an opportunity to have a short talk from the GPs on say asthma in children, the febrile child or meningitis. Having a question and answer session would break down barriers between the families and the GPs.

It would be good to have a social element of having tea or coffee available and a chance for parents to chat together. I would also encourage the practice midwife to start practice antenatal classes so that friendships can start at an early stage.

I would look at the toys in the surgery and see if I am catering for children of all ages. A few old books in a box is not good enough so I would buy a little play house for kids or a plastic slide (after careful health and safety consideration of course).

To really appeal to working parents I would consider a few early appointments say starting morning surgery at 7.30 am once a week. This would promote a sense of the practice meeting the needs of busy young families. I would also look at internet appointments and e mail advice.

Changing the reputation of a practice takes time, but the best way to do this is to be friendly to all patients and deliver a high standard of care, The practice needs all members to work towards this goal so I would promote a practice where the staff are looked after well by the doctors, are supported and trained to a high standard.

Dr Steve Brown is a GP trainer in Beaconsfield, Buckinghamshire

Learning checklist

Change management

• The first involves the whole practice, not just medical staff, deciding whether they want to change

• The cycle of change used in motivational interviewing (such as for smoking cessation) can be used for organisations as well as individuals; pre-contemplation, contemplation, determination/deciding to change, action & maintenance – developed by US psychologists, Prochaska & Di Clemente in the 1980s

• Reviewing and updating the practice development plan would be a good place to start

• SWOT analysis; strengths, weaknesses, opportunities and threats, is a good way of assessing the status quo

• Force field analysis can be useful way to assess where the practice is currently and factors that might help or hinder change

• Change fatigue is a problem within the NHS at present due to recent multiple widespread reorganisations so get all key stakeholders on board

• More on change management can be found at

Staff training

• The attitude of reception staff is vital in establishing good first impressions of the practice to prospective patients

• 360 degree appraisal, even including patient perspectives, can be a good way of getting feedback on individual clinical and non-clinical staff provided care is taken to feed it back constructively

• Maslow's hierarchy of needs says most staff work better if their basic needs are met – do you value your reception staff? Do you have regular in-house appraisals? Are you interested in their professional development?

• AMSPAR, the Association of Medical Secretaries, Practice Managers, Administrators and Receptionists, was established in 1964 to create and promote appropriate qualifications, initially for medical secretaries and subsequently for medical receptionists, administrators and practice managers. It offers a range of training opportunities – see

• The AMSPAR Receptionist Programme is a short course for those already working in general practice and covers:

1 Ethics, confidentiality and the role of the receptionist

2 Communication skills, patient care and discrimination awareness

3 First aid, health and safety and legal aspects

4 Preventive medicine, control of drugs, repeat prescriptions and medical audit in general practice

5 Medical terminology

6 Stress management, motivation and delegation

Making a practice child friendly

• Recent GMC guidance, 0-18 years: Guidance for all Doctors, emphasises communication, capacity to consent, parental responsibility, access to medical matters & confidentiality as well as child protection

• It is worth referring to the government white paper Every Child Matters which sets out their priorities for work with children & young people & may even open up funding opportunities for the practice

• What about access? Have you altered the practice, as far as possible, to comply with the Disability Discrimination Act or is it still inaccessible to wheelchair users, and therefore mums with pushchairs?

• Reviewing the toys available on a regular basis is important – do they remain fit for purpose? What about infection control issues?

• Close working with attached staff – health visitors & midwives - is crucial for ensuring the practice remains focussed – are they on site? If not, how do you contact them? Are they invited to your PHCT meetings? What about any relevant CPD sessions?

Dr Mandy Fry is a GP VTS course organiser in Oxford and a GP in Cirencester

Waiting room

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