The winner of the Practice Manager of the Year Award 2011 explains the background behind her team's impressive project to reduce outpatient referrals dramatically...
It has been three years since I first appeared in this magazine, full of enthusiasm and drive, keen to change Tudor Lodge Surgery in Weston-super-Mare from a reactive practice to a proactive one.
However, to make any change happen successfully – and to maintain change – requires building new relationships with patients and staff, which not only takes time but also needs an awful lot of co-operation from willing parties – the word "willing" being key to negotiations. The difficult thing about building relationships is trying to make changes when the people you want to change don't think there is anything to change!
It wasn't about the staff, more about what they were doing and how we could improve systems that might produce a real benefit for everyone. It can be really exhausting trying to persuade individuals that things need to be changed, especially if they "have always done it like that".
Having a completely different management style to that of my predecessor didn't help. I am and always will be a hands-on manager. I believe business management and being hands-on are not mutually exclusive; to know a business you have to know how it works from the ground up. People respect you for that and if, on occasion, I am a highly paid receptionist/cleaner/secretary then so be it. The benefits far outweigh the risk to my time and productivity, and the GPs know I will always get the job done.
Some of my colleagues might think I am talking nonsense when I say I have never had any issues with my GPs but, truly, I am so lucky to have found a group of individuals that generally get on with each other, support me and let me manage their business with the minimum of interference. Trust is a big thing at Tudor Lodge and is the foundation upon which we build our business.
We meet each day for coffee and spend half an hour together either to offload or catch up and ask each other advice. It is a ritual that takes time and effort and again impinges on productivity, but the benefits are immense. Decision-making becomes easier and less time-consuming – the awkward discussions take place in a safe environment and so official meetings cost less in time as we now only need to have one a month to discuss the bigger issues.
Just after I arrived in post, our local primary care trust (PCT), working together with the then practice-based commissioning (PBC) board, produced a PBC local enhanced service (LES) that paid practices to attempt to reduce inappropriate referrals.
There were no set rules, but we were expected to ensure that the correct clinical pathways were followed, that referrals were timely, and that all the relevant diagnostics had been carried out prior to the referral. Some practices opted just to use the newly incepted referral support service with clinical triage attached and some (including Tudor Lodge) decided to keep control of our own referrals and review them inhouse.
We devised a system whereby a GP was given protected time out of surgery to review all pending referrals on a daily basis and rejections were discussed with the referring doctor.
Interestingly (but not surprisingly) locums were the worst offenders, as were the medical students. We used this as a learning tool rather than a stick to beat individuals with, with any gaps in learning being identified and built upon.
Before long I wondered why we weren't attempting to cancel hospital outpatient follow-ups and bring patients back into the surgery, rather than have them trekking up to the hospital. Diseases such as diabetes and chronic obstructive pulmonary disease (COPD) could and should be dealt with by our specialist nurses or GPs, freeing up appointments in secondary care for those in greater need.
We follow a simple premise: PDSA (Plan, Do, Study, Act). We plan, we do, we see what did or didn't work and we act upon it. We do it all the time and call it "management" (on occasion I take PDSA as a different acronym: 'Please Do Something – Anything'!).
Looking at the follow-up letters, it was clear there were some where inactivity was obvious. The patient had been seen and was "well", with no change in their condition/outcome? See again in six months.
I sat down with a nominated GP each day and went over the letters, taking out the ones he agreed were of no benefit to the patient. We devised template letters to send to the patient, the hospital and the appointments office at the hospital, explaining that the follow-up could be done at the practice.
Challenging consultants and meeting resistance from patients was scary, but you don't achieve anything without having to face difficult conversations, and things settled down after a few months. In fact, the hospitals recognised that this was happening and eventually began to co-operate, resulting in a total of 1,034 cancelled outpatient appointments in one year. Of those, only 16 had to be referred back to secondary care and we knew savings would be made on repeat follow-ups from those – usually two to three per patient.
To date, we are mainly seeing follow-up letters offering "open" appointments, which we treat as "real" appointments and deal with in the same way, as it does take 6-12 months before any real benefits are seen. However, we now have a smooth system in place that doesn't impinge too much on GP time and often uses no time at all, given the experience we have gained in this field.
You could say that we are nothing if not gluttons for punishment. Looking to take on more work for no reward does seem madness at times, but we truly believe that what we do is basically good housekeeping and therefore should be done if it saves the NHS money. And this certainly has – an audit by NHS North Somerset showed our new referral system has led to savings of £83 per follow-up – equating to £20,000 per year.
In addition, we need to let the patients know exactly why we need to save money and what they can do to help.
This is why the next logical move was to look at our horrendously high attendances at the Urgent Care Centre – based in our local hospital – which incidentally is two minutes away from the practice.
We examined attendance sheets each morning and telephoned every single patient to ask why they felt they needed to attend and whether we could have done anything to prevent their attendance.
Patients were really stunned when we told them how much each attendance cost – they did not appreciate that someone somewhere had to pay, and that often what they were attending for could either have waited or been seen by a local pharmacist or their GP. We had sometimes long and difficult conversations with these patients, but in the main they were receptive to any advice given and were sent leaflets on their minor ailments.
Each month we monitored the urgent-care attendances and were gratified to see that from being one of the higher users of the centre, our practice had become one of the lowest. We often followed up patients who had attended the GP centre anyway, so we were duplicating work. I must make it clear that we were focusing on those attendances that were clearly misguided or inappropriate, and we checked with our GPs at all stages along the way.
We deal with out-of-hours attendances in the same way as we do the urgent-care attendances, and can educate patients not to call 999 or go to A&E out-of-hours when it is clearly inappropriate.
The 'frequent flyers' are flagged and we look at why they seem to keep calling the emergency services. Often they need reassurance or support, being frail, elderly or both, or have no family to speak of. I now keep a list of those patients and anyone else flagged up as needing a bit more attention, and I telephone them weekly just to check if they are all right. Bereavement is an especially difficult time for families, and it is often after the frenzied activity of the first few weeks when we are left alone that we especially need to feel there is someone out there who hasn't forgotten.
We have a Carer's Champion, who picks up on any vulnerable elderly patients and ensures they don't get missed. We also have a dedicated administrative lady who deals with all our cancer patients, existing and newly diagnosed, and who is responsible for contacting them at first diagnosis and seeing that they only have one point of contact in the practice. It's far too stressful sometimes to keep repeating your story to complete strangers.
Our receptionists have become extremely experienced and adept at signposting patients to the right person – we ask them to give us an idea of their problem at the point of contact – and, yes, this has been a controversial process. We have managed, with time, to assure patients that we only ask to ensure they are placed with the correct clinician at the right time and to save them coming in at all if their problem is administrative and not clinical.
We try to be as caring and considerate as possible in what can sometimes seem to the outside world as a detached and uncaring profession.
With the advent of GP commissioning in England, I was excited by the prospect of being part of something that could possibly change the NHS for the better. It is our opportunity to get things right and we will only really get one shot at it.
I am now on the NHS North Somerset Commissioning Shadow Board as a practice manager who is a commissioner and not a provider. It is a fine line, and not without its challenges. Do I make a decision for the greater good that may adversely affect my practice and primary care colleagues? Yes I would, and have, and will do so again in the future, probably numerous times, if it will improve quality and equality for the patients of the whole of North Somerset.
Currently, we are looking towards initiatives to include in the commissioning local enhanced service (formerly the PBC LES), and some of the things we did and still do at Tudor Lodge are being discussed as being extremely relevant for the future.
We have done the hard work and can be honest about the process. It isn't going to be easy asking practices to adopt or adapt systems that one practice has devised – systems we know will give them heartache and angst. In the past we have been competitors, but I hope that we are beginning to move towards a more federated way of working.
Different practices adopt differing styles and that is what makes us special, but the one overarching theme should be patient care. Every patient should expect to be treated in the same way and to receive the same level of services, no matter which practice they are registered with.
This needs to be a two-way contract, however. Patients, service users, stakeholders, clients, customers – call them what you will – should expect to be educated and informed about their illnesses, their use of secondary-care services and why they cannot be given a referral for a tonsillectomy or breast enlargement.
Let's get some straight talking and tell it how it is. We have nothing to lose and everything to gain.
Valerie Denton is Practice Manager of Tudor Lodge Surgery in Weston Super Mare.
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