BSc(Hons)/RGN MBA PGCMedEd
Limes Medical Centre, Epping
Debbie worked in neonatal intensive care and gynaecology at the Royal Hampshire County Hospital before moving to the USA to work as a medical/surgical nurse. While in the USA, she moved into the management of an international healthcare company, becoming Vice President of Operations, overseeing a staff of 250 healthcare professionals. After completing an MBA, Debbie moved back to the UK to work as a managing director of a healthcare facilities management company before moving into primary care nine years ago. Debbie is also involved in consultancy, teaching and training in primary care
Access and demand management have always been key issues at our practice, which cares for 16,000 patients in leafy, suburban Epping, Essex. So when we decided to embark on a new way of looking at access and the flow of patients through the practice we were understandably a little nervous.
Media attention on GP patient access targets during the 2005 general election campaign galvanised our thoughts that we needed to make significant changes at the practice. We decided that tinkering with systems was no longer possible and that an overall review of how our patients access the services we offer was needed.
How could we ensure that we could offer the right service to the right patient at the right time? And how, in the midst of all of this, could we keep our staff motivated and satisfied with their roles? Above all, though, we wanted to make sure that a new access system would facilitate patients who need to be seen quickly, and who may have previously suffered in silence when treatment was immediately necessary.
After an extensive period of review and consultation, during which we gathered a huge amount of research data and information from access models used elsewhere, we developed what we felt would be the tenets of a robust access pathway that was safe, appropriate and met all the various primary care trust and Department of Health guidelines. We called this new pathway our algorithm. The details of how we went about this process can be found here.
The system involves three clear pathways:
All pathways evolved with a focus on the co-ordinating role of our receptionists and healthcare assistants (HCAs).
For the first few weeks of our new system, we committed to hands-on support in all areas so that no one felt alone in this brave new world! I guess we shouldn't sound surprised, but we were astonished when – after week one, two, three … – the system seemed to be holding up to the test of being operational.
For many months we kept saying that it was early days, but slowly we began to feel that perhaps this was really going to work for our patients and possibly achieve its objectives.
Eighteen months after its conception, we had our first operational anniversary. This was the culmination of several "mini-reviews" and amendments on a quarterly basis. This is when we thought about entering the MiP "Practice of the Year" award.
The clinical partner leading on the project and I felt that our access project was worthy of almost "testing out in the marketplace" to see if we had come up with ideas that could perhaps benefit other practices. We were actually very surprised to be shortlisted for an interview with the awards judges and, in true Limes style, took a multidisciplinary team along. This is because the project has encompassed all areas of the practice and changed the way in which we work. For once, we all really wanted to be able to express our enthusiasm for a "system change" that has been so positive for staff and patients alike.
Greater skill mix
So what have we found to be the main benefits of working in a more structured and perhaps even more formalised way?
First, our acute and chronic care pathways are now clearly identified. We have protocols that allow our team to understand the chronic disease management (CDM) pathway and enable our HCAs to take a much more active role in CDM. This has increased not only our capacity but also job satisfaction for the HCAs. Their roles have further widened the boundaries of skill mix and enabled even greater integration with the
Using skills and expertise to the full has always been important to the practice, not only for team motivation but also to ensure that we utilise our most expensive resource: staff. The new system has enabled us to look again at the roles of the nurse practitioners, the prescription clerk, the HCAs and the receptionists.
Benefits to patients
Second, patients are happy that they can book follow-up appointments with their clinician up to six weeks in advance, giving them excellent continuity of care. We had tried hard to achieve this before but never quite made it. Both the clinicians and patients have told us that they benefit from the ability to follow up consistently, without having to worry about the lack of appointments.
For clinicians, it does mean that routine surgeries can be quite intense and are not now punctuated with a cold or sore throat, or an inappropriately booked appointment allowing a few minutes' respite. It can be that all patients have significant issues to follow up and, although we did worry about this, the benefits of continuity appear to outweigh any concerns we had.
Third, the duplication of appointments – for example around medication reviews – has been reduced. Our receptionist can now offer the patient who needs a medication review a call back from an HCA. At this point of contact, the HCA is able to ensure that all tests appropriate for the medication review are carried out prior to the patient being seen. Feedback from patients has been very positive about this; especially from busy patients that like to keep appointments to a minimum.
A satisfying boost
Another key benefit, of equal importance, is that staff satisfaction levels are up – as qualified in our recent Investors in People report and staff appraisals. Instead of feeling unable to offer the patient a high level of service by always having to explain why there are no appointments, the receptionists have a greater understanding of appropriate flow throughout the practice and are able to end each telephone or face-to-face interaction with a patient in a positive way, by being able to say: "Yes, we can help – and this is how we can help you best!"
The number of patients complaining about the system verbally and in writing has reduced, and positive feedback has increased. A year on, patients seem to see the real benefits of all staff at the practice being involved in their care, both clinical and nonclinical, obviously at an appropriate time and in an appropriate way.
So what has the "Practice of the Year" award done for us? Well, it's given us a real boost, knowing that the hard work we put into the changes in our system has not only been positive for us but is also of interest to others.
I recently spoke at a healthcare management conference to a small group of practice managers, and the response to what we have done was quite astounding. We undertook our access project to help our patients and staff, but it seems that, just as we have been fortunate enough to learn from other practices, we now have something that can help others in a small way.
The MiP Practice of the Year Award was sponsored by Wesleyan Medical Sickness.
To find out how to enter the Management in Practice Awards 2009, click here.