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At the heart of general practice since 1960

GMC is arrogant to charge GPs over Shipman

Dr Peter Stott describes how his practice has dovetailed several clinics together to ease workload

So, you've developed your skill mix. You've got your doctors, your nurse practitioners, your nurses and your health care assistants. You have your special clinics and your routine surgeries. What should you do next? Do you want to be more efficient? Do you want to become truly multidisciplinary?

Do you want to be in better control of

your workload?

There is a lot to be said for getting patients to consult at times that suit the practice. Undoubtedly you need opportunistic clinics on the days of greatest demand ­ Mondays, Tuesdays and Fridays ­ but you could channel routine work like diabetic clinics, hypertension checks and asthma checks to Wednesdays and Thursdays. When Mrs Smith wakes up on a Monday and realises she needs her thyroid function checking, the system should direct her to come midweek, not that day. Better still, it should have recalled her during the summer, when the workload was least.

Summer to Christmas are times when you can make positive steps to bring people in for routine checks for the quality and outcomes framework. Proactive recall requires active management. The new contract makes it inevitable that we will see many patients for several checks and wish to do as much as possible in a one-stop visit.

Key contract areas

The new contract has created three clinical areas in which regular review is key:

Group 1 Metabolic clinics

·Diabetes ·Hypertension ·CHD and heart failure ·Stroke and TIA

Group 2 Respiratory clinics

·Asthma ·COPD

Group 3 Others: ·Hypothyroid ·Epilepsy ·Mental health ·Cancer

Groups 1 and 2 can earn a potential 473 points out of a clinical total of 550 (ie 86 percent). They necessitate year-round clinics. Group 3 is a mixed bag that requires a limited amount of work, best done at times of year when the workload is least.

Metabolic clinic

The metabolic clinics use the full skill mix. At Tadworth, four members of staff have dedicated time for one afternoon a week ­ two health care assistants, one nurse and a doctor. A dietitian and podiatrist also attend one afternoon a month. Patients do not see everyone every time.

Most clinics run on a weekly basis except for the stroke/TIA clinic, which because of fewer numbers is only held once a month. The GP reviews all cases, but does not see them all.

If we use the analogy of the hospital outpatients clinic, the health care assistant and the nurse are the junior staff working alongside the consultant and with whom they can discuss problems. The dietitian and podiatrist see selected cases.

Other issues

The metabolic syndrome and its ramifications underlies most of the problems we see, whether they have presented with heart disease, diabetes or stroke. So the blood tests needed are more or less common to all (see table). The clinical co-ordinator has a simple job to write out the blood test forms and arrange the pre-clinic fasting bloods.

Range of tasks

If the clinic is to work efficiently, everyone must know what they have to do. All their roles are defined by a protocol. The health care assistants support the clinic co-ordinator, assist the venesectionist, ensure the data is complete on the computer template the day before the clinic and carry out a range of tasks in the clinic itself like weighing, BP, urinalysis, neuropathy testing and lifestyle counselling.

The nurses modify treatment according to the clinic protocols and discuss issues related to compliance and medicines management. Where problems are found or when the nurses feel out of their depth, the doctor is involved.

When we began these clinics, patients were booked at 20-minute intervals. As we became more efficient this became 15 and is now 10 minutes. Staff communicate directly and by computer to speed patient flow through the clinic. As they leave, patients are given their next appointment or told when they will be recalled.

Respiratory clinics

This pattern is repeated in the respiratory clinics, but the GP is much more peripheral since both the asthma and COPD clinic are more protocol-driven and are run almost entirely by the health care assistants, nurses and nurse practitioners. But there is always a GP available for severe cases and to review referrals.

Once again, the range of clinic tests needed are very similar. Spirometry and peak flow testing can be performed by the health care assistant before the patient sees the nurse. This means training is integrated, staff are used to their full potential and that clinical care is most cost-efficient.

Other clinics

We run metabolic and respiratory clinics all the year round but have not yet developed a

co-ordinated approach. This year, we have decided to tackle them individually with intensive periods of work during the summer.

Conclusion

The co-ordinated clinic as described is an ideal. From time to time, as staff leave and new staff have to be trained, we fall back into old patterns of working. Nevertheless, we can see definite advantages to this system.

Peter Stott is a GP in

Tadworth, Surrey

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