Seven ways to manage rapid practice list growth

The benefits of increasing your list size are many: more income and more profit, economies of scale in administrative and managerial functions, greater opportunities for service development (for example in clinical specialisms that require a critical mass of patients to be viable), more opportunities for staff career progression, and greater standing as power and influence shifts from PCTs to clinical commissioning groups.

But expanding your list rapidly is hard work and not for the faint hearted. Regular recruitment decisions have to be made that represent serious financial investment in the business. It can sometimes feel like half the working week is spent sifting through job applications, the other half in constant change management and revision of your business strategy.

Our practice was originally located in a run-down area of London's Docklands. It was closed after its list shrank to 800 or so patients, but after a campaign by local residents in 2002 the PCT opened it again. The practice moved into purpose-built premises in December 2007 and is now located in the Barkantine Centre with a pharmacy, a café, a dentistry suite (special needs and teaching), the community mental health team, health visitors and a birth centre.

In September 2010 the Barkantine was commissioned as an APMS practice. Now located next door to Canary Wharf, an area of extensive urban regeneration and fast population growth, the practice anticipates a net immigration of 40,000 patients to its catchment area over the next decade. The Barkantine's patient list has been growing steadily at a rate of 2,000 to 2,500 annually since it moved into its new premises, and we currently have just under 18,000 patients on its books.

While list growth at this rate tends to happen only in urban areas, any practice can face a period of rapid expansion – in fact, many will seek to attract large numbers of patients quickly if they are running a specific campaign. Here are seven suggestions to help you maximise the financial benefits of a new patient population, and avoid costly mistakes regarding staff, premises and service quality.

Significant list growth will not be for everyone and the business case must look closely at whether the additional income will result in additional profit. Certainly for many inner-city practices, the capitated income under GMS may not be high enough to warrant expanding the list. Premises
may simply not be big enough. And once
a practice has embarked on a plan for rapid list expansion, it has to be ready to manage that growth proactively to ensure that neither its quality of care nor its organisational stability is compromised.

The key thing before embarking on
a project like this is to make sure everyone has come on side and is engaged with the challenges ahead.

It is important to understand what factors will help or hinder list growth. Visibility and accessibility are obvious factors. A practice on a main road in a large purpose-built premises, served by several bus routes, has a clear advantage over a practice set
back from a quiet side-street. A practice
that encourages additional footfall by co-locating with a pharmacy or
a dentist, or accommodating community-based activities like expert patient or parenting classes, yoga or weight management, can advertise itself in a subtle but effective way.

Receptionists should be trained in customer service skills – eye contact and a smile being the basics. Use technology such as automatic telephone and online appointment booking systems to create better access and reduce the demand on staff, ultimately saving money. The staffing rota should be rearranged to cope with peak times for call volume. Keep the practice website up to date: these days it may be the first point of contact for a new resident wondering where to register. Develop and invest in your patient forum and e-forum, and listen to what patients are saying in the forum or on NHS Choices for signs that things are going wrong. Don't forget to market the changes that you make so patients know you're responsive.

Clinical staffing at the Barkantine is reviewed every quarter and recruitment options are considered. Standard benchmarks combined with local experience are used – for example, we have an access plan of 80 appointments per week per 1,000 patients to maintain 48-hour access, which drops to 65 over the summer. We aim for list growth to be a smooth process with additional clinicians joining the team just before they are needed. One of the challenges we face is attracting clinicians, particularly GPs, to ourshift-based working pattern. We are open 8am to 8pm every day – not something that appeals to everyone. But we know that short-term staffing by locums is not a good solution and patients prefer the continuity offered by permanent staff. 

Bigger lists will also require more capacity in some administrative functions, for example secretarial services and summarising notes. It is important to understand these functions and to know, for example, the average time taken to summarise a set of notes, or how many referral letters per 1,000 patients are written, and to review capacity.

Practice workforce planning is essential but consider also the effects on attached services such as health visitors or midwives, whose caseloads will grow. Keep them aware of the rate of growth and provide them with more information if you can. CCGs will, we hope, give us the influence to do more than just manage need – in Tower Hamlets, local practices have successfully supported the business case for the creation of five new health visitor posts.

It is one thing to ensure you are recruiting the staff to see all your new patients, but have you got enough consulting rooms to accommodate them? Consider how to make the best use of clinical space. Combining extended hours with a four-hour shift system means a room can be used three times a day (8am till midday, midday till 4pm, 4pm till 8pm) compared with the typical twice-a-day usage, creating an instant 50% increase in room space.

In the longer term, think strategically: new residential developments, changes at neighbouring practices and options for premises growth are the key areas to keep an eye on. We have recently taken on a second site with five consulting rooms. At the current rate of list growth of 15-17%, this will be fully utilised in less than three years.

More patients mean more income and more profit for the partners, but what is in it for the staff, apart from more work? It is essential to continue consulting with staff through any period of change, which rapid list expansion most certainly is. Communicate your plans for recruiting more staff to cope with the increasing activity so that your existing staff are reassured about workload issues. As your workforce grows, consider how to integrate new workers with old hands. Opportunities for internal promotion are positive in terms of individuals' career progression. Make sure recruitment processes are open and transparent to avoid disappointing unsuccessful internal candidates.

A large practice that is growing rapidly risks becoming impersonal and losing the human touch. Involve staff in quality improvement or patient education programmes, and take fresh approaches to interaction with patients. Barkantine's Summer Baby competition, sponsored by
a local telecommunications company and the on-site pharmacy, invited parents to send in photos of their babies. Staff organising the competition have enjoyed tackling new issues such as the ethics of commercial sponsorship and found it was an easy way for staff to show extra care for young patients, for example making sure immunisations are up to date. 

A rapidly growing list requires a close eye to be kept on prevalence recording, the QOF and assimilating medical records and other data gathered by other practices (and in the case of the Barkantine, overseas healthcare professionals). Reconciling childhood immunisations or cytology schedules from, say, Eastern Europe, with our own UK schedules is a challenge and time has to be invested to ensure targets are still
met. Make sure you have the capacity to deal with bigger volumes  of data by making accurate estimates of the administrative burden that, say, 1,000 new patients will create.

Ensure that commissioning and prescribing budgets attached to the practice are updated to reflect the bigger patient list as well, otherwise you risk missing out on the financial benefits of list growth. Commissioning budgets are mainly just indicative at the moment – but they will become more of an issue soon.