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Use your clinical staff to best advantage

The most efficient and highest earning practices use their clinical staff to very best advantage. Rachel Stark shows how

The most efficient and highest earning practices use their clinical staff to very best advantage. Rachel Stark shows how

Delivering primary care is becoming ever more onerous. The QOF will have increased your workload, patient demand is increasing all the time, and your practice team may already be struggling. With a revised QOF imminent and practice-based-commissioning on the horizon, the practice needs to ensure it has the right level of clinical staff to deliver services effectively.

Skills in primary care have continued to develop, and many practices now have a more diverse team that not only includes GPs, practice nurses and receptionists but also prescribing nurse practitioners, health care assistants and many attached professionals allied to health, such as physiotherapists and pharmacists.

Practices need to evaluate their clinical team against their current and likely demand so that an effective plan for recruitment and skill mix can be developed. The first step is to establish the workload of the practice, by clinician and type of work. This can be a laborious exercise but is invaluable for making sure the foundation of your skill-mix plan is solid. It is often best done by reviewing past workload rather than asking clinicians to capture data while they are consulting (although this does rely on accurate recording of the consultation).

It will mean choosing a period that gives a reasonably typical snapshot of the practice workload ­ for example a single week in a given month. Where a practice has not done this exercise before and so has little current knowledge of or feel for its workload, it would be sensible to choose a longer period to measure. The next step is to look at each clinician and each appointment for that period and classify what the appointment was for. For tasks like taking blood or doing a medication review, this is reasonably simple. But for some consultations a judgment will have to be made ­ and this will depend on what you want to get from the analysis. For example, if you want to transfer some of the GPs' work to a nurse practitioner or practice nurse, your classification would reflect this.

For instance you could classify all appointments in terms of musculoskeletal, heart problems, breathing problems, etc ,with a subdivision in each for those for which another clinician would have been competent to deal with the problem. When the analysis is complete it is important to check with the clinicians to ensure that the data analysis seems reasonable and accurate.The final analysis should be a comprehensive yet suitable list from which the current workload can be seen and from which transfers of work can be identified.

Often the practice can immediately see where there aren't enough staff to cope with current demand for certain appointments.For example, where the practice has a health care assistant but an F level practice nurse is still taking bloods, it may indicate that more health care assistant time is needed. The next opportunity lies in transferring certain work to other practitioners. For example:

  • many practices have been running a nurse-led minor illness clinic for some time and this has proved very effective. Your analysis may show there is demand now to increase this service to transfer the workload from the GP.
  • B12 injections, minor dressings and assistance in minor operations could be done by a health care assistant instead of the practice nurse.
  • complete management of certain chronic diseases, such as diabetes or hypertension, could be undertaken by a nurse practitioner (or practice nurse). For example, where a nurse practitioner has a special interest in diabetes, the impact they can have on poorly controlled patients can be dramatic.
  • screening new patients ­ blood pressure and urine ­ could be done by trained 'clinical receptionists'.
  • low back pain is usually a significant problem in general practice and a direct access physiotherapist can be effective in managing these patients.
  • most pharmacists now provide a minor ailments service, and where good relationships exist between the practice and pharmacy this can be a valuable service for patients.
  • patients may still be booking appointments for certain administrative tasks that can be dealt with over the phone. Educating patients can reduce this workload.·
  • if the practice is experiencing high levels of DNAs, ways to reduce this should be explored. Perhaps you could use text-messaging reminders, or introduce a more formal policy for warning patients who persistently DNA.

Once transfers of work have been identified, the practice needs to discuss them, whether to implement them and how. This will frequently require costing. Often a stumbling block is the extra initial investment. The practice must take a long-term view. Efficient practices generate more income. For example, staff being used well could enable the practice to increase its list size. An efficient practice that provides a manageable yet satisfying workload for its team is also an attractive employer.

Remember to consider at this stage any future changes that might affect the team. Are any team members about to retire? Are demands on the team suddenly likely to increase (maybe a new housing estate is going to be built). Is the practice intending to introduce new services? Now is the ideal time to try to accommodate these changes and ensure the practice has the resources to cope.

Skill-mix is a very personal thing, and no two practices are the same. Practice teams develop over a long period of time and each has certain idiosyncrasies and performance patterns that encourage or hinder change. All practices should bear this in mind. Any plan developing from the analysis I have described should consider not just matching the levels of skill required to the right level of clinician but should also think about where clinicians have special interests. Job satisfaction is important.

Variety is one of the things that attract people to primary care and there is a risk with skill-mix that this variety can be eroded. Therefore the practice plan needs to strike a balance between providing satisfying and challenging job roles with a cost-effective staffing structure that uses the right clinician for each task. Finally, what applies to clinical staff applies to all staff. Everyone should be doing the right job. It's good news for them ­ and good news for the practice.

Rachel Stark is the practice manager of New East Quay Medical Centre, Bridgwater, Somerset

Getting the best from your staff

  • Establish practice workload and who does what
  • Study findings carefullyDiscuss how re-allocation of work can be implemented
  • Remember to consider future changes that might affect team (ie, a retirement)
  • Remember to tailor things to suit your own practice· Re-allocate work as required

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