How a modern practice can preserve continuity of care
Dr Clare Gerada and Dr Frances Dudley explain how their practice group embraces flexible working but still provides continuous care.
General practice is changing yet again. This time the trend is inexorably towards a supermarket model of primary care, with 24-hour opening and polyclinics high on the Government agenda. The risk is that traditional values of general practice, such as continuity of care, provided by a doctor the patient knows, will end up being sacrificed to the twin alters of access and convenience.
The challenge for the next generation of GPs will be to try to maintain these traditions while responding to increasing commercialisation. Practices need to bring in the new (better access, imaginative use of IT, better use of skill mix) while retaining the values of the old (personalised, longitudinal care delivered by experts). Our group practice – the Hurley Group in south and east London – takes a range of approaches to meeting this challenge.
Striking a balance between pre-booked and on-the-day appointments
Like many practices, we have grappled with how to offer choice, continuity and access.
In the days of all pre-booked appointments, we had to deal with DNA rates of up to 25%. During the early 2000s, we moved to all appointments being booked on the day, but found this was not ideal for patients who needed to plan their diaries. We now have settled on 25% of appointments booked ahead and 75% booked on the day.
Retaining a quarter of pre-bookable appointments allows patients to see the doctor of their choice, on the day that suits them, while allowing sufficient access for those who need to be seen on the day or find it difficult to plan ahead. But we continually review the availability of different types of appointment, to ensure the level of capacity matches demand.
We do not demand that patients ring the surgery before they are seen by a clinician. We feel patients themselves should choose whether they see a doctor or a nurse.
Flexible working patterns for staff
The loss of traditional partnerships, increasing mobility of GPs and the feminisation of general practice (requiring more flexible employment arrangements) means that ensuring continuity of care becomes even more challenging.
Most practices now have to balance demands for flexible working against the needs of continuity. Extended hours provide increasing opportunities for flexible working, fitting working hours according to family or other needs. In our practices these range from 7am to 8pm, 365 days a year. But availability of doctors needs to be planned, so that patients can see the GP of their choice if necessary.
Our approach is:
• to request a GP's availability a month ahead
• to request annual leave requirements three months ahead
• to have a full-time appointment manager
• to have core activities that we expect all staff to attend (for example, clinical meetings, protected learning events).
All-day telephone advice
Our practice provides all-day telephone advice, which both improves access and reduces the number of patients who need to attend the surgery. This in turn relieves pressure on appointments and makes it easier for a patient to see their doctor of choice. The telephone advice service helps triage patients to the most appropriate access point, and is provided by a GP supported by a physician assistant.
Innovative ways of communicating with patients, such as text or email consultations, allow GPs to provide continuous and personal care.
Our policy for email consultations is that:
• they are carried out by prior agreement between a specific GP and patient only
• the patient needs to be aware that email may not be seen for days (or ever, if it lands in the spam queue) and therefore can assume receipt only once a reply has been received
• email is not for urgent issues
• though all efforts are made to ensure confidentiality, personal or identifiable information should not be included in an email
• an email consultation does not replace face-to-face or telephone contact, but can be a useful adjunct to care
• where a third party is the nature of the email consultation (for example, relatives of elderly patients) pre-consent is required from that patient.
Creating a stable workforce
Quintessential to continuity of care is a stable workforce. This means providing the GPs of tomorrow with:
• opportunities for leadership
• opportunities for career progression
• support such as ‘buddying', daily hand-overs or a group email clinical forum
• attractive working conditions, including income, study leave and remuneration based on profits
• the ability to effect change.
The Hurley Group is headed by five senior partners and three operational managers and includes seven practices in some of the most deprived areas of London (Tower Hamlets, Lambeth and Peckham). In the past, these areas have struggled to attract high-quality GPs, leaving large areas of the boroughs with poor access.
The group currently employs about 30 salaried GPs and is implementing a method of career progression and support, including a new path to leadership for those that want it. Individuals can take on leadership roles in each practice and gain autonomy and remuneration.
Each practice has its own leadership team, headed by a local medical director – a GP appointed for their leadership skills. Where appropriate, this role is a stepping stone to practice partnership, with a guaranteed income floor and a profit share.
We hope this model addresses the current lack of partnerships, provides a supported route to independence – and allows the group to maintain continuity of care with a modern staffing structure.
Dr Clare Gerada is vice-chair of the RCGP. She and Dr Frances Dudley are both partners at the Hurley Group
Modern surgery signage Guest editor