It is now approaching 20 years since I was appointed practice manager at Carradale Surgery, writes Gail McIntosh (pictured), a small single-handed dispensing practice in Argyll on the west coast of Scotland. Our practice population of around 700 is spread out along a 30-mile stretch of coastline on the Kintyre peninsula, served in the most part by a winding single-track road.
The practice also has responsibility for care of its patients admitted to the community hospital in Campbeltown – our nearest town, which is 15 miles away. Originally, the practice covered its own out-of-hours care, but due to difficulties in recruiting an associate or locums to permit the GP to have time off, it finally "opted out" in 2006.
When I started, I had no previous management experience and no knowledge of healthcare. I believe I was offered the job as, having previously been a computer programmer and IT tutor, I knew how to work the newly acquired practice computer and its DOS operating system. I was initially employed six hours a week to type the GP's letters, file correspondence, collate prescriptions, and maintain the patient register in Gpass.
Back then, the surgery was a small wooden building, comprising a consulting room, a small dispensary and a waiting room just large enough for two rows of four chairs. To begin with, I was essentially the only other practice employee, although the district nurse did assist at some surgeries. I therefore soon learned to turn my hand to a variety of things, from helping the GP take out stitches to sorting problems with the plumbing.
Initially, five "open surgery" hours ran during the week. Patients attended the GP personally to obtain repeat medication, and management of chronic disease was achieved opportunistically. Scripts and labels were handwritten, and dispensing was a time-consuming task of counting pills into bottles.
Over time, and following the introduction of two "new GMS contracts", the job and I have developed together. I first completed a Dispensing Doctors' Assistants Course, which allowed me to assist with the dispensing side of the practice, and then, as the scope of my job expanded, I went on to gain qualifications in management.
New building, retained values
In 1998, the practice moved into a new purpose-built surgery with a treatment room and community nurse's room, in addition to a GP consulting room, dispensary, office/reception area and a waiting room three times the size of the old one. My job is now almost full-time and the practice also employs two part-time receptionists/admin staff and a practice nurse.
Our team, which works together very closely, also includes the community nurse, palliative care nurses and other attached staff from Campbeltown Community Hospital. We run weekly physiotherapy sessions, monthly baby clinics with the health visitor, antenatal sessions with the midwife and regular clinics with the podiatrist and diabetic liaison nurse.
Although we still have "open surgery" consultation slots each day, we also offer appointments throughout the week with both the GP and the practice nurse, including extended hours appointments. Our patients appreciate the flexibility this permits and knowing they will be seen on the day they want. In addition, the team ethos and small number of patients still permit us to offer very personalised care and treat our patients holistically with regard to care and chronic disease management.
This has also helped us achieve Practice Accreditation in 2003, and in 2007 we became the first single-handed practice in Scotland to achieve the Royal College of GPs' Quality Practice Award. Working towards these achievements has helped us to plan, develop and manage change together. These change management skills proved beneficial last year, during the upheaval of our clinical system change (from Gpass to Vision) and when arranging physical alterations to the building to improve accessibility and confidentiality at reception.
Changing face of patient demographics
Over the years, the scope of the services we provide and the workload at the practice has escalated. The number of prescription items dispensed each month has more than doubled, and the volume of lab tests has increased 250% in the last decade.
While our patient numbers have reduced slightly, the demographics of the population have changed considerably. The traditional sources of employment in the area are disappearing. This has led to many younger people moving away, and property being bought by those seeking to retire in a quiet location. This has resulted in the practice having a high incidence of patients aged over 65 (33% as opposed to the Scottish average of 15%), and a correspondingly high incidence across chronic disease.
Despite this and losing out in economies of scale (we still have to have the same policies in place as a large practice), we continue to score highly in the Quality and Outcomes Framework (QOF) through good teamwork and harnessing the benefits of information technology.
As services and staffing levels have increased, so have my areas of responsibility. As well as management of information and activities, I now handle strategic management, human resource management, financial management and health and safety. I am also responsible for recall of patients, clinical audit, summarising records, and monitoring QOF achievement. I am still involved with collating prescriptions at month end and with dispensing, drug ordering and stock control, and each week do reception duties to cover breaks and staff absence.
Being "hands on" means I keep in touch with everything that is going on, although I have learnt to ensure I am never the only person able to carry out any aspect of my job, so that in my absence, foreseen or not, someone else can take over.
Although by no means as remote a practice as many in Scotland, the rural location of the practice does have implications. Recruitment and retention of clinical staff is an issue, as is accessing training. The dispensing and management qualifications I have gained were all conducted by distance learning; other members of staff have had to travel long distances to further their professional development.
The limited public transport infrastructure makes it difficult for our patients to access healthcare without use of a car. Collaboration with the Red Cross has meant a minibus being available for patients to attend the surgery each week to see the doctor or nurse, pick up their medication or to attend other specific clinics.
The remoteness of our location brings other problems, especially in bad weather, but so far we have always managed "business as usual". The single-track road is not on the council's gritting schedule, making it difficult for the GP to get to outlying hamlets in snowy conditions. This year it got so bad he had to abandon his car six miles away and walk back, forcing him to hire another car in Campbeltown for three days until the road reopened and he could retrieve his own vehicle.
Dealing with such drawbacks can be challenging. As our bloods normally go out by Royal Mail, recent disruptions to the postal service meant finding an alternative route to another lab. Power cuts inevitably happen every year, both scheduled and unscheduled. Two winters ago, heavy snowfall meant loss of mains power to the village for three days. The power outage also caused over-chlorination of the water supply at the local treatment plant, rendering the mains water unusable. We coped, but this experience left us reluctant to go paperless.
Spice of working life
Although Carradale Surgery has changed considerably in the last 20 years, many aspects of my job remain the same: the diversity of what I may need to do in a day, the aim of providing high-quality, patient-centred care, and the ongoing need for practice, team and personal development. I still never know what may lie ahead when I start work each day – from ensuring medication reaches a snowbound patient to advising a helicopter pilot of a suitable landing place to pick up a patient with a suspected MI; from changing a lightbulb or unblocking a drain to gritting the surgery car park masquerading as an ice rink.
Carradale has also long been a holiday destination. While not as busy now as in its heyday, we still experience an influx of visitors in holiday periods. Along with the inevitable forgotten medication, this brings a range of extra work – tick bites and jellyfish stings are regular problems. We even encounter snakebites, and one unfortunate visitor had a nasty bite from a seal. But it is this variety, and the recognition from patients when we go that extra mile, that make my role as practice manager far more than just a job.