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How we put skill mix change into practice

Three GPs explain how their practices are benefiting from the use of innovative staffing models

Three GPs explain how their practices are benefiting from the use of innovative staffing models

Turning GPs into their own receptionists

Dr Amit Bhargava is a GP in Crawley, West Sussex, and NHS Alliance South-East PBC lead

Ever since I have been a GP there has always been a problem with appointments. Our receptionists had running battles with patients and the waiting room was always heaving with tetchy patients. So we took a radical step – now we GPs do the receptionists' job, taking direct phone calls from patients, carrying out immediate telephone consultations and booking in our own appointments on the computer.

We got the idea from a local surgery that had done the same thing, under the theory that the most qualified person should be triaging patients, not the least. The practice manager and senior partner came and told us about their system, and we implemented our version within a month. Since then we have changed our phones, tweaked the system many times and would now never go back to receptionists making our appointments again.

We have a 5,700-patient practice with three GPs. Two GPs take calls from 8.30-9am and the third until 11.30. I have a headset and say: ‘Good morning, Dr Bhargava, how can I help you?' We also have an afternoon telephone surgery to call patients back.

Some 30-40% of patients who call have telephone assessments and do not need a face-to-face consultation. Patients who do book can make appointments up to six weeks ahead after a chat with us, but most are seen that day – usually by their own GP or by the GP with the appropriate expertise.

There are certain ground rules that we have set and evolved – if there is a language issue we see the patient face-to-face, and also if the patient calls twice for the same problem. As we are a small practice with long-serving GPs, the clinical advice we give to our patients is based on continuity of care. We have found keeping the rules simple and under regular review works.

The patients are happier, although they complained initially about having to justify their appointment request to a GP. But now they are used to it. We like it because we have more control and can ensure the right people see the right GP. The receptionists are still busy keeping up to date with ever-increasing admin tasks. The only downside is the clinical risk of phone consultations, but we err on the side of caution.

I would recommend GPs become their own receptionists if they use a good phone system. Patients tend to make good judgment calls about themselves, and going with their instincts as well as our common sense has kept us out of trouble and in control.

Employing a patient liaison officer to improve access scores

Dr Stan Shepherd is a GP in Bethnal Green, east London

A MORI poll put our practice bottom of our PCT for 48-hour access, with only 56% satisfied versus the trust's average of 80%. We are otherwise a high-performing practice – the same poll put patient satisfaction with the GPs above PCT and national average. If the 44% of unsatisfied respondents could not get an appointment in 48 hours we should have had 560 breaches of 48-hour access in the six months prior to the survey – which was not the case. So the problem is patient perception.

We and the PCT were unhappy. Hence the patient liaison officer, a full-time role funded by the PCT for one year and then by us. Our 11,500 patients are 50% white British, 30% Bengali and 20% rest of the world. We were lucky to recruit Linda Begum Ali, who speaks English and Bengali. Here's what she said after two months.

‘At every surgery I attend in the waiting room and select 30 patients to complete a two-question questionnaire, asking:

• Have you tried to get an appointment with any doctor about any matter on the same day or on the next two days the surgery was open?

• Were you able to get an appointment with any doctor on the same day or on the next two days the surgery was open?

‘When I started we had 17% answering no to question two. Now it's 7% or less. The most common reason for a no to question two was that patients did not get the appointment with their doctor. The fact they could have seen any GP did not count. Once I explain what 48-hour access means, most feel differently. But some people still make a next-day appointment with their preferred doctor, and answer no anyway!

‘I have just finished my first newsletter to patients. In it I have set out exactly what 48-hour access means. I hope we can help patients understand the Government target and see we are meeting it.'

Linda has made a significant difference in a very short time. She is full-time but if funds were limited the role could easily be shared between receptionists. Linda's role will now extend to measuring and improving patient satisfaction in other areas as, like it or not, we may be increasingly judged on patient perceptions.

Can you afford to leave patient perceptions to chance? Look at your own patient survey scores and see whether you could benefit from more direct liaison with your customers. We wouldn't be without a patient liaison officer now.

Using the new breed of physician assistant

Dr Nav Chana is a GP in Mitcham, Surrey, and National Association of Primary Care vice-chair

The physician assistant role is built on 40 years of experience in the US and in essence is a healthcare professional trained to a medical model. A physician assistant is neither doctor nor nurse, but a new species of professional who works in partnership with a doctor to deliver healthcare. They tend to start as a biomedical sciences graduate or similar and, like a GP, they will usually remain a physician assistant through their career, with professional development coming through developing clinical expertise. They are paid according to the Agenda for Change pay scale around bands 7-8 depending upon experience.

Physician assistants are trained to:

• formulate a differential diagnosis based on history and physical examination

• develop and deliver treatment and management plans, including medications, on behalf of the supervising doctor

• perform diagnostic and therapeutic procedures

• request and interpret diagnostic tests.

In our Surrey practice, we employ two physician assistants and a core aspect of their work is to help us address on-the-day demand. They assess patients presenting with a variety of problems and, after discussion with a supervising GP, manage that patient and follow up if need be.

They should be available to ease the workload of GPs. For example, in the recent swine flu pandemic, ours managed most of the inquiries, home visits and so on.

I find physician assistants very useful if a complex patient needs a full clinical assessment, perhaps in an acute situation. The assistant does the assessment and discusses their findings with a supervising doctor, and together a decision is made.

The role works for our practice. We have not employed physician assistants to replace any GPs or nurses, but to add to our workforce so we can respond more flexibly to demand. We have had assistants for more than three years. Once we overcame initial patient confusion about the role, satisfaction with our GPs has been as high if not higher than before. Our staff have adapted easily as we are a long-established training practice, so territorial issues have not arisen.

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