Brookside Group Practice is an innovative three-site teaching practice in Berkshire, with a patient population of 27,000 and approximately 130 employees. Like many practices we have experienced increasing pressure on all our appointments over recent years, with workload becoming unmanageable. In particular, our system for same-day urgent appointments – GP telephone triage to determine if an appointment is required – led to GPs spending a significant amount of time on the telephone and was not an efficient use of resources, resulting in poor patient and staff experience.
What we did
We reviewed our processes and looked at alternative models of urgent care, before introducing a new model for same-day urgent appointments that eliminates the GP telephone triage; instead patients requiring a same-day appointment are asked to attend an urgent clinic at the practice. The first phase of the clinic was introduced in February 2017, with full roll-out in July 2017.
The new urgent clinic is run by a multidisciplinary team (GPs, junior doctors, prescribing nurses, practice nurses, paramedics) with support and overview from a supervising GP. The make-up of the clinic varies each day depending on staff rotas, but the average number of clinicians in clinic (including the supervising GP) is six. The supervising GP does not see patients unless requested, enabling them to get on with other tasks.
We also introduced an enhanced website in July 2017 providing patients with much greater flexibility in how they can interact with the practice. For example, patients can now book an asthma or blood pressure review, register a carer, ask the GP a question, track a referral or put in a prescription query via the practice website.
An audit undertaken in December 2017 in conjunction with the Oxford Academic Health Science Network showed that 74% of patients were seen by non-GP staff in the first five months of introducing the new urgent clinic, and nearly half (47%) were seen and treated without the involvement of the supervising GP.
The main reason for input from the supervising GP was prescriptions (51%), followed by the complexity of the presenting complaint (44%). Of patients deemed ‘complex’ and requiring input from the supervising GP, 41% were aged 16 years or younger and just under 40% presented with respiratory illness and fever.
Overall, an extra 1,650 patients have been seen following the introduction of the new urgent care model – more than 100 additional patients per month.
The clinics vary in terms of patient complexity and the demands on the supervising GP, making it difficult to quantify the amount of GP time released directly by the new model. However the audit did demonstrate that the supervising GP is able to undertake other tasks during the clinic – reviewing results, letters and case notes; writing referrals; reviewing electronic prescriptions; and making telephone calls.
We have also seen a reduction in waiting times for routine GP appointments, to an average of one week, as a result of the urgent clinic.
The staffing complement within the clinic varies each day, meaning the cost of running the clinic is similarly variable. However, analysis has shown it is at least cost neutral compared with normal practice.
The enhanced website has made a significant impact too. A survey undertaken in April 2018 indicated that over 2,000 telephone calls, over 1,100 visits in person and nearly 300 appointments had been avoided.
The urgent clinic was introduced in two phases, with the first phase delivered by nursing staff and one GP, but with no dedicated supervising GP. This limited the number of patients being booked in to the clinic initially, as requests for GP input would be directed to a GP who already had their own list of patients.
Also, nursing staff initially had very stringent criteria determining the type of complaint they could deal with. In phase two we were able to relax the criteria through training delivered by the partners and external speakers; the GP supervisor also trained nursing and other clinical staff in the roles on the job. This supervision need gradually tails off as experience and confidence builds. For example, training has been delivered in managing acute MSK conditions, and staff are now confident to manage such conditions, which largely need conservative management, with the supervision of the GP at hand for more complex cases.
A further drawback in the first phase was that patients were not given an allocated appointment time, so they had to wait to be seen. This resulted in some patients declining to use the clinic as they did not want to ‘sit and wait’. This feedback was incorporated into the second phase and patients are now given a 30-minute slot in which to attend. This has helped spread attendance more evenly throughout the clinic and prevent lengthy waits for patients.
To further improve our services for patients and to increase the efficiency of the practice, we are keen to explore the use of point of care testing and have this month introduced point of care tests for CRP, FBC, U&E and lactate within the urgent care clinic.
The audit results helped identify areas where additional training could allow more patients to be managed without input from the supervising GP. For example, increasing the prescribing rights and enhancing the paediatric competencies of non-GP staff.
We also want to integrate mental health care into the same-day clinic and have started to work with our local Improving Access to Psychological Therapies programme on this.
We hope the ongoing work to further improve efficiency with urgent appointments will in future allow us to introduce longer consultations in our routine GP appointments schedule where needed, increasing from our current average of 12 to 15 minute appointments.
Dr Amit Sharma is a GP partner at Brookside Group Practice