Dr Richard More, clinical lead for the Productive General Practice programme, introduces three case studies that show how practices can cut costs and free up GP time
General practice is the route that the vast majority of patients take into the NHS, with more than 8,000 individual practices delivering hundreds of thousands of consultations a day in England alone.
It has never been busier, with the estimated total number of consultations rising from 217.3 million in 1995 to 300.4 million in 2008.
We are dealing with more complex patients, more frequently. This rising demand on practices, coupled with constrained funding, means there is a pressing need for greater productivity – so there has never been a greater need to examine what we GPs do.
The NHS needs to achieve even higher quality and safer care at lower cost amid rising expectations from the public. It therefore makes sense for practices to use the new year as an opportunity to examine everything they currently do, challenge current ways of working and ensure that every process is as efficient and reliable as possible.
Here, GPs in England and Scotland talk about how they improved efficiency at their practices.
Standardising practice procedures and putting a GP in reception
Dr Knut Schroeder, Bristol
Initially we thought we were quite a well-organised practice, as we'd previously won the RCGP quality practice award. However, there were ongoing problems with access and getting work done in time, with less and less time available.
There seemed to be longer hours and the pay didn't match – it felt like we were rushing, and the on-calls were getting busier and patients more frustrated.
We had brought in a management consultant to try and help us address some of these issues, through full team meetings. But the day job is busy enough and there wasn't the creative time to allocate to addressing the problems.
We first decided to organise the consulting rooms better. All the rooms are now standardised and more user-friendly. We then introduced a set of clear, plastic drawers to sit on the desk in the clinical rooms, which we filled with essential equipment anyone might need but that was always going missing – such as a peak-flow meter, specimen bottles and ear pieces for thermometers. Because the drawers are clear, visiting locums can see how and where things are stored.
We have also developed the duties for replenishing these items and formalised it to be a part of the role of a healthcare assistant in our practice, which came about as part of an exercise to reduce waste.
Logistically, we are also trying out a few changes – for example, daily patient management.
There is now a GP in the back part of reception, immediately available for answering receptionist or patient telephone queries, to issue sick notes and sign prescriptions – but they are not visible by patients from the front of reception in the interest of patient confidentiality.
Reorganising the resource available has reduced the multiple steps involved in these elements and they no longer ‘go into the workflow' of the practice.
Drawing up a calendar for managerial tasks
Dr Paul Cook, Bolsover, Derbyshire
Historically, management is something that has been squeezed in between patients or between clinics.
But our management tasks are increasingly more complex, so finding an extra 10 minutes here or there is no longer sufficient. Instead, we have to value management time more highly and look for ways to group those 10-minute slots into longer periods, allowing us to keep on top of the more involved tasks.
We decided to restructure planned reviews to better organise predictable work, giving us a larger capacity to deal with the unpredictable.
A large percentage of the patients we see are those who ‘walk through the door', and we are quite good at that aspect of general practice. We are, as a practice, less good at scheduling routine work to match capacity.
So we have begun changing the way we work on chronic diseases, to schedule routine work at times when the system is under less pressure. This restructuring across our annual calendar was something we had not done before.
We are scheduling chronic disease reviews when we have less staff on leave and during periods of the year when we know there will be less work. We're working to identify when we have more GPs in, and rather than just adding more appointments to the system, we're trying to be smarter with the appointments available.
We are working towards streamlining services to provide one longer appointment for patients with multiple conditions – a ‘one-stop-shop' approach.
The aim with this initiative is to reduce costs within the practice and give the patient more freedom and ownership over the management of their conditions.
It also means we have been able to create some head room for the changes the health bill will bring and for other future workload.
For example, QOF deadlines at the end of March meant we were always chasing around to complete work at the busiest time of the year (January to March).
We're now looking at completing more of this work before Christmas and avoiding sending for patients in the busiest months.
Through team discussions, we examined the annual distribution of patients who require regular check-ups and decided to trial avoiding COPD assessments during the January to March period – not just because it's the busiest time of the year, but also because seeing this category of patient at this time of the year can give an inaccurate perception of the severity of the patient's condition.
We are becoming increasing able to provide better access and better targeting, and are making sure the right people see the right professional – for example, patients seeing a nurse rather than a doctor if necessary – but this is a continued process of improvement.
Revamping the practice's prescribing systems
GP Dr Bill Taylor, receptionist Jenna Clayton and practice manager Fiona Dalziel, Aberdeen
We held a clinical meeting to address the inefficient aspects of the current prescribing system and decided that any, even small, improvements we could make would release time.
Actions were drawn up to work through changes to the prescription system. These included meeting with the nursing home and residential home that the practice serves to see if we could improve the request system, looking at the information provided to patients about their prescriptions and reviewing the protocol on hospital discharge letters.
Prescriptions come into the surgery in several ways – by phone and asking someone to do it on the patient's behalf, by post, handing it in over the reception counter, and on the prescription telephone line (a dedicated telephone line patients can call and leave a message).
We found patients didn't understand the repeat prescription system, and that this caused confusion and further work for the practice.
For example, patients didn't know the name of their medication, or they waited until they had run out before asking for a repeat prescription, which meant it became ‘urgent' – placing pressure on the staff involved.
To assess the current system, we calculated the number of prescriptions that come into the practice and also looked at the number of GP interruptions for prescriptions.
When the results of this exercise were presented to staff, the high level of interruptions wasn't a surprise – but it was a shock to see quite how many prescriptions we receive in a day.
We then reviewed the results in a workshop where representatives of all the different staff groups were present.
Having the system mapped out illustratively in front of us was a great aid for discussing which challenges we wanted to address and ways we could make changes.
Through analysis we have found that most patients were happy with the service, so our work has focused on making the system more efficient for us.
We are trying to better understand prescriptions from patients' point of view and encourage them to suggest how to improve the system, and are trialling a patient information sheet.
We also decided to meet with the pharmacists – located in the same building as our practice – to review the prescriptions system with them. This was beneficial because it opened up channels of communication.
We now have a better understanding of each other's point of view, how each party contributes to the system, and the practice has a better understanding of the problems for the pharmacists we work with.
Dr Richard More is a GP at Hendford Lodge Medical Centre, Yeovil, and the GP clinical lead for the Productive General Practice programme
These practices all took part in modules through the Productive General Practice programme. Productive General Practice, developed by NHS Institute in partnership with NHS Scotland, is an organisation-wide change programme that supports general practices in realising internal efficiencies and streamlining processes to ‘release time' so that GPs, practice nurses and other clinicians can spend more time seeing patients. The programme is structured into self-directed modules, which are implemented from the bottom up. It is flexible in order to enable the practice to achieve scaled improvement to suit their level of aspiration and resource. The greatest impact comes from implementing all of the modules. For further details about the programme, visit www.institute.nhs.uk/productivegeneralpractice
