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Independents' Day

Planning staffing at your practice

GP Dr Simon Atkins and practice manager Paul Williams give their advice for cost-effective and safe staffing at your surgery.

The practice is a business – at the moment its main area of growth and funding is list size, although being able to gain a high QOF score, take optimum benefit from enhanced services and maximise the opportunities from private income will also be beneficial. To make a success of these various elements, you need the right staff with the right skills.

We are a training practice in Bristol with eight GPs (both full- and part-time) plus a registrar and nursing team. Our list size is in the region of 12,600, and we scored 99% on the QOF scores we declared on 1 April. We are also one of the few GP practices in the country to hold the Customer Service Excellence award.

GPs have been faced with several nationwide staffing issues: pay freezes or minimal pay increases, pension reform reducing the net pay for many of our staff, revalidation workload and preparation for Care Quality Commission registration. But there are also opportunities coming.

Practices may now have the opportunity to make money under the any qualified provider (AQP) banner. By diversifying in this way, practices may make themselves less vulnerable to threats in their other income streams. Not all practices will wish to go down the AQP route, but all practices should consider what might happen in their marketplace.

CCGs are required to demonstrate engagement with their local GP practices to drive their agenda, and this key part of the reforms will inevitably require a time commitment from practices.

Partner time is also likely to be diverted away from core business to providing services under AQP. Assessing your staff resources and planning ahead for this can get you on the front foot.

Staff skills analysis

When considering what staff skills your practice needs to have, it is important that you are clear on what its objectives are. Most practices will probably have some form of business plan, but is it reviewed regularly and has full consideration been given to the impact of the current reforms on general practice?

A business plan should be a working document and be reviewed at least annually, especially if something significant happens to the practice team – for example, a change in the partnership. Each business plan will be different, but all are likely to include financial projections, a staffing strategy and premises needs, all tailored towards the achievement of the practice objectives.

Once you are clear on what your objectives are, you can begin to focus in your plan on the staffing that will be needed to achieve them.

The first step is to identify what key skills are needed to achieve the practice objectives. For example, an objective around growing income or increasing list size is likely to require communication or marketing as a key skill.

When you have identified the skills you require in the future, you can then perform a skills analysis of your existing team. Comparing the required skills with the current skills in you team can highlight any skill gaps and bring focus to the process. You must then decide on your strategy to plug these gaps.

In our practice, we recognised there were an increasing number of patients being diagnosed with diabetes and provided staff with specialist training in the condition.

Our lead nurse completed a diploma, which took six months and cost around £650, and afterwards developed her skills in intensive diabetes management. Patients can now avoid the waiting list for the community nursing team and receive better care at point of origin.

Whatever the strategy you adopt, a cost-benefit analysis should be carried out to ensure the investment of time and money can be justified.

Cost-benefit analyses map the estimated financial projections of different options. The first step is to look at the costs of each option, which include things like training expenses and any locum or other staff backfill.

There may also be an opportunity cost to consider in terms of time, even if no direct cost is incurred. Once costs have been identified, these can then be assessed against the benefits being sought, be they financial or otherwise.

To demonstrate this in a simple way, we recognised in January that we were at risk of not achieving as much in the QOF as we felt we were capable of. So we decided to look at employing a locum doctor for two sessions a week for six weeks to free up GP time to focus solely on the QOF.

At a cost of about £200 per session, our total costs were around £2,400 – but our assessment identified the potential to generate an additional £10,000-12,000 of QOF revenue. The benefits could significantly outweigh the costs, so it was an easy decision to proceed.

GPs also need to be looking at whether any of the workload in their existing team can be delegated to free up time at a higher level within the practice. You could, for example, use a nurse for minor illness work to free up GP time.

A key factor here can be maintaining staff awareness of the potential opportunities in the evolving world of general practice. While change may be feared by some, it can be a great motivator for others.

Training and development

You should conduct a full analysis not only of the skills currently available to you, but also those that could potentially become available thorough training and development.

Ideally, each member of the practice team should have a personal development plan (PDP). This earns QOF points for clinical staff, but it is just as important for everybody else. The PDP should primarily be focused on the needs of the staff member, but the needs of the practice should be linked in as well.

As the political landscape starts to take shape, it is an important time to review plans.

Although some individuals may be keen to move into new areas, their enthusiasm will sometimes have to be tempered by the need to adhere to regulations.

Our practice team is already becoming more multi-skilled, with one of our nurses looking to obtain a prescribing qualification and advancing to become a nurse practitioner.

Likewise, some of our salaried GPs will have ambitions to become a partner and have a lot to offer in supporting the business strategy of the practice.

The practice used to employ a salaried GP who wanted to increase his chances of joining a partnership – he took on our private services agreement with the local boarding school, and in return we invited him to partners' meetings to give him an impression of what our business needs

and concerns were. This resulted in him gaining a partnership at another practice a year later.

Administrative staff can often be overlooked in a skills survey. In our practice, both a receptionist and a secretary came forward wishing to move into phlebotomy alongside their existing roles, and it was not a difficult task to achieve this.

They initially attended a three-hour course outlining the basics of the role, and then advanced under practice supervision from our lead nurse until she was satisfied they were competent enough to carry out the phlebotomy role. Both individuals have been motivated by the changed responsibilities and patient care has been enhanced.

The lead nurse also manages a healthcare assistant, formerly a receptionist at the practice. The healthcare assistant studies through distance learning on a Work-Based Plus course, and works part-time as both a phlebotomist and a receptionist.

In time she'll do ECGs, take blood pressures and pulses, and then move into ear irrigation, wound care and flu immunisation. The skill flexibility she offers means the practice has better triage skills overall and can delegate lower-skilled clinical tasks to an enthusiastic learner.

Recruitment

Once you have exhausted the possibilities of training and development, you must then decide on how to plug any remaining skills gaps. Can some of them be left empty and the practice objectives still be met?

This is where the assessment of cost against expected benefits comes in, and can result in a revision of your original plans. For example, a review may reveal that hiring a new salaried GP would not be cost-effective – but additional nursing support for the existing GP team could create the additional GP capacity at lower cost.

Cashflow can be a concern if you find yourself recruiting for a service which will be funded by a contract you don't yet have. In these situations, we might look to save recruitment costs by hiring someone with whom we already had an established relationship.

You may know locums, trainees or former colleagues of existing staff members who would make good candidates. Local clinical networks such as clinical forums, locum chambers and practice nurse forums are good places to look for candidates and recommendations.

It may not be just in clinical areas that a practice will need to recruit. When looking to enhance admin teams, GPs often feel that our ideal candidate should have some health service experience, but if you compile a detailed job description and person specification you are likely to discover that more general and easily transferable skills are the more prominent.

An obvious example of this is in reception, where we have recruited from the retail, financial services and hospitality sectors as these staff have become practiced at dealing with customers.

Additional medical knowledge can then form part of the training and development programme for each team member.

Dr Simon Atkins is a partner and Paul Williams a practice manager at Fishponds Family Practice in Bristol

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