Dilemma: Recruiting an extra partner to deal with demand
Your patient feedback questionnaire shows dissatisfaction with waiting times and access. You realise that one FTE doctor per 2,000 patients is not enough. Should you recruit a new partner?
‘Walk through’ your systems to find the hold-ups
This survey result does not point to the answer, it leads to more questions. First, the partners should look at just what their patients were dissatisfied about: perhaps the practice needs to change its telephone answering or appointment arrangements. They also need to ‘walk through’ their systems to see where the holdups are. More people may not be the answer.
But for a modern practice providing the full range of GP services, 2,000 is a big list per WTE. They are likely to need more clinical staff, although if three of the five partners are worried about the loss of income it may be that the practice is not earning as well as it should be, which means they need a thorough external review before doing anything.
This should identify who they need to recruit. If patients cannot get appointments for blood tests, they need a health care assistant, which may free up the practice nurses to undertake more of the work the GPs are doing. If the problem is demand for GP appointments, could some GP work be done by a specialist practice nurse or nurse practitioner?
If the only solution really is more GP sessions it may be easier in the current climate to find a salaried GP, perhaps with a view to partnership, or they may be fortunate enough to recruit a retained doctor.
As it is currently a seller’s market for GPs in much of the country, the job offer should be as flexible as possible to attract good candidates.
Dr Harry Yoxall is a GP in Taunton and medical secretary of Somerset LMC
Seek a no-cost option such as working more efficiently or generating some income
Only one partner wishes to exchange increased patient satisfaction for a drop in income. Assuming equal voting rights, and no resignation, a no cost option will need to be found. I see four potential solutions: to work longer hours, to work more efficiently, to find the revenue for employing a new doctor by shedding some existing costs and/or income generation schemes or to reconfigure the practice.
Extending hours is never a popular option. Most full-time GPs work a four-or four and a half-day week. Historically this provided recovery time for the out of hours workload which most of us have now shed. In this context is this a still a necessity or an expensive luxury?
We all feel we are as efficient as possible. However an audit of GP working practices, to include patient recalls, referrals and investigation rates will always reveal differences. This exercise can lead to a discussion about changing working practices which may free up extra appointments.
Does the practice have any staff hours it can shed? This is worth looking at. Can the practice earn more in order to afford the new doctor? Are they generating as much as they can from list-based activities including QOF and enhanced services? If so, then diversification to generate the cost of a new partner is worth considering. Many innovations can generate extra income, including providing or hosting community services, AQP contracts or others.
Finally and most radically they could consider merging or federating with adjacent practices. If this delivered economies of scale or more income through improved QOF and LES performance, the new doctor could become affordable.
Dr John Ribchester is a GP in Whitstable and Canterbury and Coastal CCG’s GP commissioning lead
Take a close look at how the practice is operating and consider all the alternatives before acting on patient feedback
Before you decide to take on extra doctor sessions, take a close look at how the practice is currently operating. By making a number of small changes the practice may be able to minimise the number of extra sessions needing to be worked by another doctor.
If there are specific periods when access is difficult, changing surgery hours might make a difference. Make sure your patients know when they should see a nurse rather than a doctor. Look at creating capacity by diverting clinical work away from doctors to nurses and HCAs.
Consider whether there is a role for telephone triage. Audit the number of patients seen by all the partners. If there are wide variations some partners may need training to work more efficiently. If doctors are getting bogged down in administration, take these tasks away from them so creating more patient-facing capacity. If the partners are counting eight sessions as full time work, this may be an unaffordable luxury for the three who do not want to reduce their income.
If this practice employed a salaried GP for three sessions the patient/doctor ratio would come down to a more manageable 1,828 per FTE. If the practice takes no action and patients leave, this will be costly. Losing 688 unhappy patients may reduce the list size to the same patient/doctor ratio but will cost 2 to 2.5 times the salary of a salaried doctor working three sessions a week.
Ask your accountant to calculate after-tax figures to understand the real effect on drawings. If a partner is paying effectively 60% tax, the net cost of extra help may be rather less than you think.
Liz Densley is a director at Honey Barrett Ltd and Secretary of the Association of Independent Specialist Medical Accountants