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How we freed up 35 GP appointments a day by reviewing nurses' workload

Reallocating work to nurses, setting times for routine tasks and closing chronic disease clinics allowed Sheinaz Stansfield’s practice to offer eight more GP sessions per week

We found that patients and receptionists in our 15,200-patient practice were irate and unhappy each morning because all appointments were taken by 8.30am. A review of our appointment system showed that, with almost 12 full-time-equivalent GPs, we had the capacity to deliver 9.5 appointments per patient per year - double the national average - so we were confused about what was going wrong. But a further audit demonstrated that despite our capacity, we were managing to offer only 5.4 appointments per patient per year.

Using the EMIS system we did a review of acute appointments and found that a third of the work the doctors were doing should have been done by a nurse. The nurses were also blocking appointments inappropriately: 22% of appointments were reserved for hypothetical scenarios rather than planned consultations. Almost half of the nurse appointments were wasted.

What we did

We used a discovery tool from the CCG to work out how we could improve access to acute appointments. GPs thinking of a similar restructure should contact their CCG to find similar tools.

We found that our nurse team (three AfC Band 6 nurses and two Band 4 healthcare assistants) had no access to clinical supervision and were reactive in most of their interventions. They were trained to deliver QOF processes rather than quality outcomes for patients. There was variation in the time taken to undertake clinical tasks and clinical recording.

After observing and measuring the nurses’ tasks, the appointment system was changed to enable 10- and 15-minute bookings. The time allocated to carry out clinical tasks was reduced - for example, smears were allotted 15 rather than 20 minutes (observation had indicated that the majority of smears were completed and recorded in 12 minutes). We also started phoning patients rather than sending them letters, as we found they preferred this method of contact. This resulted in an immediate increase in uptake of smears, childhood immunisations and other screening activities.

Chronic disease clinics were stopped as they caused bottlenecks and reduced access. In addition, the clinic times were not always suitable for patients. We now ring patients and make an appointment that is convenient for them, either at home or in the surgery.

Challenges

Our nurses were initially very resistant to the redesign. Two members of staff left the practice because they were unhappy with the changes, but we worked hard to ensure they were implemented in a way that would keep everyone else on board. For instance, we involved the nurses in decision-making as much as possible by introducing nurse meetings and clinical supervision from the senior nurse every six weeks. Monthly meetings were also set up for the practice team, and we stressed that the changes would affect all staff members, not just nurses.

To get the best results, we found it was also essential to focus on the needs of our practice population rather than the individual members of staff, and to involve patients in the redesign by recruiting volunteers.

Results

Within 10 weeks of starting this work our nurses became more effective, efficient and productive, which saved 35 GP appointments a day. This coincided with the CCG putting out service-level agreements for nursing homes and we now had freed up enough time for GPs to take up the service, resulting in an additional £70,000 funding for the practice.

We put that money into employing two new GPs to cater for our expanding practice population. We’ve also employed a frailty nurse, which has reduced A&E attendances by 54% and reduced home visits by 81% for housebound people with long-term complex needs.

Sheinaz Stansfield is practice manager of Oxford Terrace Medical Group in Gateshead, Tyne & Wear.

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Readers' comments (17)

  • I hope some of the savings were used to reward the "senior nurse" if she's paid the same Band 6 as the other nurses no wonder you lost staff.

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  • The senior nurse is an advanced nurse practitioner trained and remunerated appropriately. Our whole team receive clinical supervision and actively involved in leadership and decision making. there is a structured process for support and education. The team are stimulated motivated and thriving. All the savings were ploughed back into front line services that supported transformation of our whole team

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  • So you alienated almost half your nurse 'team' so much that they left....and you haven't explained in any way the link between your pretty basic reallocation of time for nurse activity and the GP appointments you managed 'free up'.

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  • In changing the contact method for chasing smears to phone, and in reducing the time slot, what did you do to ensure *informed* consent was gained?

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  • well done. i would be interested to know what the tool was that you used via the ccg. keep up the good work.

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  • 35 GP appointment- about 2 session of GP partner work....sooo not all that impressed

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  • You phrase it so nicely. It must have been great for the nurses morale!

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  • 12WTE for 15,200 patients
    What were your GPs doing not able to provide enough appointments, that's an individual list of less than 1300 patients.
    I'd get to have lunch with those numbers and see my kids.
    No wonder there's shortages elsewhere

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  • Whilst agreeing that QoF clinics generally limit patient choice (and therefore agree that this is a poor use of time) spirometry clinics are useful because of the need for calibration etc. Smear timings are about right PROVIDED everything is totally straightforward and in terms of consent, LARC advice etc. that "extra" five minutes is certainly useful in terms of QoF... but I have only raised our cytology rates by 17% in 12 months! I certainly do like the flexible appointment times, however - provided your nursing staff say how long is needed, and not non-clinical staff. However your tone is very disparaging of your nurses and I'm not surprised if your staff are leaving. There is something important about helping your staff to feel valued as well. GP time is not the only time that is important in a Practice - nor are nurses mere production line operatives.
    A Practice Nurse (with a Ph.D!)

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  • Anonymous above 4.36pm.

    I have read this before and your description "disparaging" hits the nail on the head as well as nurses being mere production operatives.
    In the practice where I work it is constantly made clear to me that GPs and receptionists time is more precious than nurse time but I am fortunate in not having anyone dictate how long I need for a patient. That said, I tend to need 15 minutes for most things and I had my own way not having set clinics for the reasons given. I have worked in some practices where one feels totally isolated from being a member of a team, not even being included in the coffee round!
    I think there are some fantastic practices but many of the bad ones are hidden and just have a high nurse turnover, treating them as disposable if they do not tow the subservient line.
    Congratulations Dr Practice Nurse.
    I wonder if you are one not allowed to display your "Dr" lest it confuses the patients.

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