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Tuesday 27 September 2016
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Productive attitudes

Insight: Quality

Dr Lynne Maher

Director for Innovation and Design, NHS Institute for Innovation and Improvement

Having only spent a short amount of time in her nursing career within general practice, Lynne has been fascinated to gain a deeper understanding of GP surgeries by working with practice professionals to develop the Productive General Practice programme

Ninety percent of the services carried out within the NHS are provided through general practice, which is currently at the forefront of the NHS reforms in England. This provides both opportunities and pressures.

The pressures include the need to continue to provide high-quality, safe health services that provide patients and families with an exceptional experience of care at lower cost while also managing growing demand, increasing roles within the commissioning process and ensuring that the business develops. All general practice staff have a role to play, but the role of the practice manager is critical.

The practice manager is a central pillar for general practice services and has an opportunity to take a leadership role in supporting the practice to create a future where the pressures are managed and high-quality care is provided to meet the needs of the local community.

To achieve this, general practices need to examine everything they do, challenge their current ways of working and ensure every process in their surgery is as efficient and reliable as possible.

The Productive General Practice programme is the latest in the internationally renowned Productive Series and a component of the wider primary care offer from the NHS Institute for Innovation and Improvement. It supports general practices in realising internal efficiencies, while maintaining quality of care and releasing time to spend on activities that result in better staff and patient experiences. The programme has been co-designed and tested by GPs, receptionists, practice managers, nurses and patients.

Benefits experienced by practices testing the programme include:

  • A better understanding of where the opportunities for improvement are through the use of data. For example, one practice – using peer-to-peer observations – found that 10-20% of consultation time was wasted through small activities such as patients removing coats and switching mobile phones off. Staff and patients are now changing the process to make the best use of consultation time.
  • Identifying opportunities for increased efficiency and a financial return. For example, one practice team learnt that 60% of blood tests were being carried out by a nurse, at a cost of £3.50 per episode. Only 40% were performed by the phlebotomist who, by comparison, would cost £1.50 per episode. The practice reviewed their process and extended the phlebotomist's hours, which in turn maximised their cost efficiency while maintaining quality.

The programme is structured to help general practices to become more efficient, without sacrificing quality of care. It is aimed at whole practice teams and broken down into manageable, easy-to-follow, self-directed modules. These modules are implemented from the bottom up and provide the flexibility to use Productive General Practice to achieve a scale of improvement determined by the practice, depending on its level of aspiration and resource. 

Case studies

Staff development and morale achieves a Concord lift
Dawn McCaffrey is a practice manager at Concord Medical Centre in Bristol that cares for 14,500 patients across three sites. She explains how the measurement and data collection aspect of the programme improved morale, encouraged teamwork and helped to reduce staff sickness.

"As part of a workshop to look at data gathered during the 'Knowing How We Are Doing' module, we discussed the staff experience data and ended up talking about short-term sick leave and the impact it has upon the practice as a whole.

"Using the tools and techniques suggested in the module, we compared data for each quarter and presented the results visually, through graphs. Staff were shocked with the high level of sick leave in the practice.

"We continued the discussion to explore various actions to help reduce the sick-leave level. For example, using the skills matrix template provided in the programme, we looked at the skill mix available and have since trained our receptionists to undertake some new and interesting roles, such as taking blood pressures and even blood samples from patients.

"This has demonstrated to staff we are committed to developing their role and to helping the practice develop as a whole. We are also looking at doctor development and establishing in the near future an incentive scheme focused around sick pay."

Key to introducing these changes and being able to have staff-wide discussions was the element of involvement. Rather than having little information about what the aspirations for improvement were and feeling that change was being imposed upon the team, the staff responded to, as McCaffrey describes, "A designated meeting room with a pinboard displaying everything [module materials, data results and analysis] so that staff can look at it in their own time. Staff are able to add comments and sign up to take on responsibility for actions or processes, rather than being imposed upon."

Since taking more ownership of practice improvements, the team at Bristol has come up with their own initiatives: "We are working to implement induction and re-induction packs for all staff, both existing and new to the practice.

The packs will be in electronic form so that should a member of staff leave, all the knowledge doesn't leave with them. It's an example of succession planning and works to reduce the pressure on other members of staff should a person leave
the team."

Dawn sums up her positive experience with Productive General Practice programme: "It has helped us to focus. With the quick wins achieved early on, people have been able to see a few things change and the effect of these small changes has set a momentum. This has improved morale and inclusion; we are working as a team now."

DNA drops in Derbyshire
Practice Manager Rosemary Adams works for Welbeck Road Health Centre in Bolsover, Derbyshire, with 30 staff caring for almost 10,500 patients. The team in Derbyshire used the 'Knowing How We Are Doing' and 'Shaping Our Future Practice' modules along with the appointment system templates to scrutinise the surgery's current appointment system.

As a result they have implemented initiatives to improve the 'did not attend' (DNA) rate such as an automated text-messaging reminder service and changing the appointment system for the benefit of various patient groups. Adams describes how it was a multi-team effort and used several aspects of the programme.

"Determined to tackle a perennial issue in general practice, we used the 'Knowing How We Are Doing' module to look at our DNA rates. This, in turn, meant we could explore questions like 'what does a DNA look like?' and establish standards and boundaries for future analysis of this data.

"The reception staff group led on this change initiative. Our senior receptionist was responsible for the initial research, which resulted in our automated system of no cost to the practice. The decrease in DNA rate has meant more appointments available and staff are able to give patients the appointment they've asked for or that are convenient for them, which is a morale boost."

A significant drop in the number of DNAs was seen within just 11 days of introducing the new system: from up to 27 per day before text messaging was implemented to up to 20 per day immediately after implementation. This improvement was experienced after only a comparatively small number of patients were asked for their mobile phone details. The number is expected to reduce further.

Stephanie Bond, Senior Receptionist at Welbeck Road Health Centre, explains: "With the DNA text-messaging service, patients receive a message reminding them of their appointment. Prompting patients has meant more patients keep or rearrange their appointment helping to keep the DNA rate down. It worked extremely well with the flu campaign.

Receptionists spend less time with letters and phone calls for all those who need reminding about receiving the flu jab."
Staff examined how to reduce DNAs in particular patient groups too. Says Adams: "Typical DNAs in our surgery are the recurrent diabetic patients. Often they would need a 30-minute appointment. Our previous system involved us recalling them and often organising appointments that may not have been the most convenient for patients.

"We have changed this system; now we prompt patients to make an appointment. Giving them this sort of control has helped them keep appointments and decrease our DNA rate."

"Recalibration of thinking" for prescriptions
Fiona Dalziel is the General Manager of Elmbank Group Practice in Aberdeen. The surgery has seven partners, 10,000 patients and was a test site for piloting and developing the 'Prescriptions' module.

Dalziel explains that the demands of the programme were "over and above the normal day-to-day work and that accommodating the programme actions around the everyday workload was a challenge; but, as with any quality initiative, the extra time and work involved is worth it. The extra work has been relevant and helped us to drill down in to the detail.

"We helped to develop and pilot the 'Prescriptions' module. Discussing it as a group, the key aspects we found from reviewing the data were that our patients didn't understand the repeat prescription system and as a result were using it inefficiently, which led to increased work for the practice. For example, they may wait until they have completely run out of medication before asking for a repeat prescription, which means it becomes an 'urgent' for practice staff.

"Using the process-mapping technique suggested in the module was an effective exercise involving all staff, and the reaction was positive. We had a large visual representation of the prescriptions process all along one side of a meeting room wall. Using sticky notes, staff identified blocks or problems in the current system. Having it there illustratively in front of us was a great aid for discussion about the challenges we
wanted to address and actions to meet these challenges.

"An action plan was then drawn up. One of these actions was to meet with the pharmacists to review the prescriptions system with them. This was beneficial because it opened up the channels of communication. We now have a better understanding of each other's point of view, how each party contributes to the system, and the practice has a better understanding of the problems for the pharmacist in this system. We now have a joint approach to problem solving around prescriptions with the pharmacy.

"Additionally, patients have contributed to the development of a patient information sheet so that it better reflects their needs. We also plan to meet with the two nursing homes that also feed into the prescriptions system and discuss how it can be more efficient for their needs as well."

Summing up what was most important about the Productive General Practice programme experience, Dalziel says: "It has improved the future vision for the surgery we already had. The most important part was the recalibration of the way of thinking; the strategy, the mission, and being able to see what's important, which, without the Productive General Practice programme, we may perhaps have skated over and ignored. It makes you stop and look in detail at parts of the practice. This is a big advantage."

Resource
For more information on the NHS Institute's whole offer for primary care, visit:
www.institute.nhs.uk/primarycare