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At the heart of general practice since 1960

How we survived losing 37 GP sessions a week

Practice manager Katie Slack

Two years ago, three of our five partners and three of our four salaried GPs retired. This left our 9,000 patients in the care of four GPs and we could offer only 26 sessions a week, 14 of these being partner hours. Despite extensive advertising, we had no applicants to replace them. Staff morale hit an all-time low, which exacerbated the problem of attracting new GPs. After a Christmas break during which the remaining partners came close to leaving, we decided to meet the needs of our patients with different clinical skills.

What we did

Abandoning our hopes of hiring GPs, we opted to recruit advanced nurse practitioners instead. While our reputation as a struggling practice put potential GPs off, it didn’t seem to have the same effect on nurses who were keen to make the switch to primary care. The partners worked with the nurses on out of hours services and knew that several of them were looking for a job with more sociable hours, such as in the practice. The four we now employ can prescribe, refer and see patients with almost any condition. In fact they have their own specialist areas - one has an interest in musculoskeletal problems and another in complex ear care.

We recruited a practice pharmacist who is our prescribing lead, does all medication reviews, and helped move us to electronic prescribing. She can prescribe, does home visits and deals with many of the acute prescription queries.

An additional practice nurse, previously a community matron, was hired specifically to manage our housebound elderly with multiple chronic conditions to reduce unplanned admissions. She also does the ward rounds for our nursing homes.

We now have a full-time community psychiatric nurse to take the pressure off our GPs who were finding their caseload increasingly taken over with mental health problems. She deals with everything from mild depression to psychosis and is working to obtain a prescribing qualification.

Our administration team has grown with more ‘specialists’ able to take charge of prescriptions, letter triage, and QOF, reducing the GPs burden and further freeing up their time.

Challenges

Some of our new recruits have needed more support than others, such as extra supervision for one nurse who had not previously had much experience in general practice, but we view this as an investment in the future.

Our appointment system, which saw patients calling up on the day and going though phone triage with the practice nurse, had not worked for years; there were a lot of queues and appointments disappeared very quickly. Now we have new staff, we’ve implemented a system of next day and fortnight ahead pre-bookable appointments alongside a same-day system for patients needing to be seen urgently. Queues and frustration have dissipated as a result.

It has been hard work to pull through this period: staff have accepted no pay rises across the board and the partners have worked every spare moment.

Results

We may have lost 37 GP sessions, but now offer 42 sessions a week filled by a range of skilled staff supporting our remaining two partners and single salaried GP. Only 19 of the sessions we currently offer are with GPs but patients have been content with the new system. After all, the new appointment system makes it easier to see a GP if you really need to, because these sessions are no longer clogged up with patients who could be treated by someone else. Patients also like being directed to an advanced nurse practitioner who has expertise in a certain problem they’re suffering, such as problems with their ears. We also made sure patients were aware of our staffing problems by putting up newspaper articles about the recruitment crisis in the surgery. We’ve also got an area both in the waiting room and on our practice website that explains the new appointment system and what the Advanced Nurse Practitioners can help with.

Having fewer GPs hasn’t put an extra strain on those remaining as the nurses work independently and can prescribe and refer. The only patients the nurses don’t see as a rule are children under one years old and those with mental health issues. We’ve found that the patients are happy to see the nurses and can always book in advance to see the doctor. 

We’ve saved around £50,000 in staffing costs per year. However, the locum bill eats into this and it will disappear when we hire a new salaried GP. Still, the service we offer is far more proactive –we have a pharmacist on site and a nurse who manages complex elderly care. Our prescribing costs fell by about £30,000 last year due to having the pharmacist on site doing medicine reviews. Also, our QOF score the best it’s ever been. We are offering the same number of appointments as we did when we had nine GPs.

Our GPs are freed up to practise ‘proper medicine’, dealing with the patients they really need to see and we are planning to assign a nurse practitioner to home visits to free them up even further.

While the practice isn’t perfect we’re proud to have not only survived but to have improved what we offer our patients.

Future

We still need one more full-time GP, although this isn’t as urgent as it once was. Unfortunately our previous problems have continued to hamper GP recruitment in an environment where there are too few GPs to go around.

Katie Slack is practice manager at Blue Dyke Surgery in Chesterfield

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Readers' comments (20)

  • Yes. Looks like you don't need any GPs at all. What a total waste all those years of training.

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  • Well done you! Really interesting.

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  • I thought the whole point of having nurse practitioners when the role was created, was to help GPs by seeing less complex medical problems and freeing the GPs from the coughs and colds and chest infections and similar. So the system sounds great. I would add though, having worked at a surgery that relied heavily on nurse practitioners, to increase the consultation time to 15min. I used to run stupidly late as I did not have the "simple" pill checks, ear aches etc to help me catch up. When seeing complex patients, dealing with multiple problems, you can get really drained if you continue seeing the same number of patients in 10 min slots. Well done for saving the practice, just don't burn yourselves and the salaried doctors out

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  • Some experienced practice nurses could do a lot more, in fact are striving to do it. I only GPs and some managers did proper appraisal and find out what their staff are capable of.
    Nurses, but the time they have been in a career for 15 years, also may have done more training than some GPs, especially in some specialist areas.
    It isn't a competition, it's a different route to gain not only knowledge, but the skills and motivation to apply it.

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  • You had 63 sessions per week for 9000 patients? 10 patients a session? Did all the doctors leave because you were only paying minimum wage?!!

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  • No we certainly not. What a shame that you appear to have missed the whole point of this article. We wanted to share our experiences to give people hope!!!

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  • It would be useful to clarify the maths as the headline says you lost 37 sessions a week. That's more than our total sessions for a practice of > 9000 patients.

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  • the article does not give hope. it suggests that nurse practitioners are being used as replacements for GPs when their role was to supplement GPs. It is not fair on the nurse practitioners really.

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  • Could I just clarify that 2 years ago we had 11,000 patients but this has now dropped to 10,400 (across 2 sites) and at that time we had 53 sessions - 8 sessions covered 1700 patients and 45 for the remaining 9,300. Our access was considered poor by our demanding population.
    The article was written to let people know that alternate models work - we didn't want to replace the GPs but we have a duty of care to our patients and had to find a workable solution to the GP crisis.

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  • Vinci Ho

    Well done , Katie .
    It is called improvising and hence surviving . Nothing is called absolutely right or wrong when you have a crisis. Put yourself in the same shoes , either do something or pack it in . We should not be judgemental .....

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