Mb ChB MRCGP DRCOG DFFP
Fiona is a fulltime GP working in a practice just outside Edinburgh. Her interests include women's and children's health and acupuncture treatment for pain. Outside work, she enjoys running and keeping fit, as well as hill walking and having a glass of red wine by a real fire
Juggling the multiple demands of modern-day general practice can be a fulltime job in itself, even without the medical management of patients. Trying to coordinate the fluctuating demands of day-to-day clinical care, with chronic disease management, training, audit, IT, financial management, employment law, Agenda for Change and the ubiquitous chase for Quality and Outcomes Framework (QOF) points can be a challenge in any practice.
Try that in a practice with five partners, one of whom is a trainer, another of whom is a GP with a special interest and another who is routinely out of the practice three days a week at the local LHCC. Add in a part-time registrar, a retainer and four part-time GP assistants and you soon have a real headache when coordinating medical staff and ensuring that the practice is covered at all times.
Not only does cover for clinical care need to be consistent and flexible enough to cope with the individual emergencies and mishaps that happen every day, but we, as a practice, had to find a way to coordinate room allocation, annual leave, training and study days in an equitable, fair and flexible way.
Needless to say, the responsibility for coordinating leave and the GP rota fell to the newly appointed junior partner. To my dismay, I found the old manual rota system was fiddly and took hours of otherwise precious time. On average, a three-month rota had taken the previous partner 10 to 12 hours of checking and adjusting to ensure that all the little quirks and idiosyncrasies of our particular practice were being catered for.
For example, it was hard to remember that one partner couldn't do "on call" on a particular day because of the school run and also cater for the fact that half-days on a Friday were sought after and should be shared equally. Allowances also had to be made to cover the varying clinical and nonclinical demands of each individual doctor. I had to keep in mind differing priorities for all the various chronic disease clinics, tutorial times, visits and audit times while trying to juggle shifts around annual leave, part-time working hours and absences from the practice.
I was trying to calculate the rota manually and kept needing to check and recheck to avoid omissions. A single mistake could mean a clinic time that wasn't covered or a huge shortage of appointment times. Imagine arriving one morning to realise there is no on-call doctor and the rest of the staff are fully booked all day; very difficult to cover for and potentially extremely stressful for the whole practice team.
Over the years our practice had grown and evolved, and it was apparent the old rota system couldn't cope with the new face of "new contract" clinical care. Luckily, all the partners were in agreement that the allocation of annual leave and the rota allocation of duties should be fair. Not for us the "first come first served" mentality, necessitating a race for annual leave requests during school holidays. Neither did we want one person to be unfairly lumbered with too many Friday afternoons on call, nor with the busiest on-call days.
We were united in wanting a fair allocation of more enjoyable aspects of practice care, such as Friday afternoons off and teaching medical students and our registrar. Clinicians would be allocated time set aside for their own areas of chronic disease management and audit, but the timing for these sessions would suit the practice. Finally, we were keen to ensure that there was always a partner available on the premises in the afternoon to support our clinical and nonclinical staff in the day-to-day running of the practice.
We therefore developed a series of "rota rules" (or to give them their more appropriate political name, "guidelines"). These aimed to ensure the practice could function seamlessly with an agreed minimum amount of staff each day, regardless of the ebb and flow of annual leave and outside commitments. We tried to do this as a practice team, and involved reception staff, the nursing team and, of course, the practice manager. We even tried to incorporate feedback from patient questionnaires and ensure that we had addressed the political demands of 24-hour access.
I asked my husband, a computer software developer/ programmer and the managing director of his own HR software company, to find us a rota system that could cope with variable hours and duties that we could use in our practice. I assumed that there must be a more efficient way of planning the GP rota than by doing it by hand. After all, the challenges posed by creating our rota are hardly unique to doctors in general practice. Surely there were computer programmes that could manage the coordination of staff that we could use, or at least adapt?
Unfortunately, after much researching and detective work, we realised that there was nothing available that suited our needs or that we could adapt and change with the evolving demands of our general practice. Luckily, after a bit of wifely persuasion, my husband agreed to write a programme for us.
A new rota system
Writing a programme from scratch that can deal with the rather eccentric demands of a group of disparate individuals can be difficult and time-consuming, and we soon realised why it appeared not to have been attempted before. A period of testing and retesting, and of staff changes in the practice due to maternity leave and a new GP assistant, then followed.
Eventually a computer system that could be flexible, fair and easily adjusted with future practice changes evolved. It was so easy to use that even I could input annual leave and adjust the working times of each clinician. It also let me know with specific alerts whether the practice was understaffed on any particular day or if any of the preagreed guidelines were not being met. It could be adjusted and edited according to last-minute changes and also let me see graphically when inputting leave that we would be short-staffed on any particular day. It would also print out individual rotas for each doctor.
After discussion with our practice manager, the software was further developed to include annual leave allowances, so that this data only had to be entered once. The system automatically prints out a leave allowance form that can be signed by the practice manager.
Using a computer system to plan the rota for the clinical staff now took minutes, and I could add on or edit individual changes as they became apparent, even at the last minute. A task that was a laborious chore to perform by hand now became much easier when the donkey work was performed by a computer programme. It meant that, as a clinician, I could concentrate on what was more important – patient care.
Word-of-mouth recommendations then meant that the computer system has been adapted and is being used in different practices. It is now generic and can be used by any-sized practice with any particular set of individual circumstances.
In retrospect, using a computerised rota system, instead of trying to do the same job by hand, seems as obvious as using a computer programme to run searches on individual Read codes or contract points, or to generate routine prescriptions.
Now the major challenge left for the practice is trying to get the 11 doctors to agree when they are taking leave and getting them to send their forms back on time. Unfortunately I don't think any computer programme can round up staff like a sheepdog.