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.
