Case Study: Introducing a “hot” and “cold” appointment split (Part 1)

In this blog, the first of two from Buckingham GP Dr Rebecca Pryse, she takes us through the practical steps to launching a new appointments system split between Same Day and Any Day appointments. Rebecca will be back later in the spring with a second blog looking at how the change has worked.

So it’s the eve of D Day or “s-D-s Day”: the day we launch our new Same Day Service. We’ve had our final partnership “huddle” at our executive meeting last night; we’ve given the final pep talks to the various teams and here we go.

This has been months in the planning for what feels like a military operation. From the Saturday strategy partners meeting one year ago where I led a “we can’t go on like this /something has to change” discussion around our access and appointment systems; to our lead partner Greg poring over stats, models and spreadsheets at his kitchen table to come up with various proposals; to our management team and IT team testing out these proposals against appointment audits and staffing rotas.

In the middle of all this we went through our second merge, a little more “thrust upon us” than the first merge just over a year before that, making us the only practice in town serving about 30,000 patients. This used up a lot of leadership energy but gave us strength in terms of clinicians (we now have 13 partners, 3 salaried doctors and 7 nurses), staff members (we now have 80 staff), population numbers and a third town centre site to work from. This enabled us to move forward in more exciting ways to change our access system.

So we moved onwards taking a proposed appointment system model to our appointments committee. This is a multidisciplinary group of reps from clinicians, management, staff and several patients who have been meeting over the past 10-15 years since we first changed our appointments from completely open access to an advanced access system – quite novel back then. This group meets intermittently to keep an eye on our access stats and patient feedback and to make constructive suggestions for change. Most recently they helped support and test out the introduction of Patient Access to our patients. The new proposal was discussed over several meetings, tweaked and approved.

Next we took the proposal to our annual “State of the Nation” protected learning afternoon. This is an annual whole staff meeting to which we invite the PPG. The new model was presented to the whole team and this was followed by small group work for each staff group to reflect back their hopes, fears and expectations of the system with some useful and constructive suggestions.

So what model did we finally decide upon? We all agreed that there are broadly two types of access required by patients: I need to see a clinician today and it doesn’t matter who I see and I need to see MY doctor or nurse who knows me best and I can wait for this appointment. We also saw a need for signposting patients first to self-care where appropriate and then to the most appropriate clinician for their problem, which does not necessarily mean a face-to-face encounter.

From these principles we have devised an offer of same day appointments (Same Day Service or SDS) or any day appointments (Any Day Service or ADS). Each service will operate from a different site within the town centre. We have calculated the balance of appointments by looking at the statistics of how appointments are currently accessed, proposing that 60% of our appointments will be made available in the Same Day Service. We have also looked to extend the range of clinicians working from this service to ensure the patients are directed to the most appropriate clinician. This means that the SDS is manned by two GP’s called GP1 & GP2, rather reminiscent of Dr Seuss with GP3 on “special days” that we predict will be busier, one or two minor illness nurses or nurse practitioners, with a paramedic to cover acute visit requests and an HCA to provide urgent diagnostics. All our reception staff have been trained as Care Navigators and patients are being asked to give a brief outline of the problem they wish to bring with an initial question of “could this be dealt with over the telephone” being asked or self care advice given as appropriate. Our paramedic and two of our nurses have just completed the minor illness nurse-training course and two of our nurses already prescribe. We have just appointed a minor illness nurse who fulfills her dream of moving from A&E back to primary care.

In our other two sites the Any Day Service will run: the clinicians here will be offering slightly longer appointments which can be booked in advance by patients who benefit from continuity. There will still be some Same Day availability in this service and these GPs will be offering routine, pre planned visits to appropriate patients. It is planned that all urgent and same day work should be absorbed by the Same Day Service allowing the Any Day GP to plan their day more proactively and offer more complex care as needed without being rushed into 10 minute slots. They will of course keep a view of the SDS and be able to offer support if that system is becoming overloaded.   We have recruited a new, additional GP who will start in September. All GPs will work some time in both systems.

In the background all our staff teams have been working hard together to ensure this new system will run smoothly and there is a general buzz of excitement in the practice as sDs-Day has approached, this in itself has felt uplifting to me particularly after they have been through a couple of years of immense change already. So we have all read the protocols and checked the process maps covering all eventualities, looked at the rotas, updated our computer screens ready for tomorrow.

Our practice manager has to be particularly congratulated, as she must be googly-eyed sorting out what has become quite a complex rota. It sounded so simple at the start but when you build in the fact that as well as seeing patients in our three sites, we also run clinics in two boarding schools and one University, we look after 4 nursing homes, we provide one GP session per day to our local community hospital and we are a training practice not only for GPs and practice nurses but for our local Medical school with 2 students in most days seeing patients……… she has politely told us to stop asking if she can sort out any more “tweaks” to her system, just for now, please. But we are keen to work in a PDSA cycle so the snag/learning list will start tomorrow as soon as the front doors open!

Dr Rebecca Pryse is a GP Partner at The Swan Practice in Buckingham. You can contact Rebecca via rebecca.pryse@nhs.net The Practice website is www.theswanpractice.co.uk

Creating a Training Programme for New GP Partners

It is astonishing that despite the huge challenge the lack of GPs wanting to be partners is presenting for general practice, little if any training exists for GPs considering the step up from salaried to partner.

Taking on responsibility for a business, for its staff, for its performance, and for its liabilities, is a big commitment. While in the past GPs took it on because that was the established career route for them, that no longer appears to be the case. Increasingly GPs are opting out of being a partner, and taking on salaried, locum or portfolio careers. Even GPs who had previously become partners are now choosing these alternatives.

This reluctance by some to take on a partnership position, along with the precarious position many practices are now in, is making everyone nervous. Those considering becoming a partner have few places to go to understand exactly what is involved. Dismissing the risks on the basis that others have been able to manage them no longer feels a possibility, and a more considered examination of what is involved is required before such a big decision can be made.

It is into this environment that we are developing a training programme for GP partners. It is for those GPs who are considering becoming a partner, want to understand better what is involved, and want to develop the skills to be a good partner should they choose to make that step. It is also for those GPs who have already made the decision to become a partner, and want training and development to ensure they can be successful in the role.

The programme is in its infancy. We want to develop the programme in partnership with those who need it. Below are all the areas that we are considering including within the programme. What we would like from you is feedback on which areas you think are most important, which areas are not needed, and which areas are missing.

Section 1: Internal – understanding the business

Success Measures: What constitutes success for the practice? Is the practice there to serve patients or to make money? What does independent contractor status really mean?

Partnership: What is a partnership; why partnership agreements are important; what makes a good partnership agreement; building a strong partnership team; “last man standing” and strategies for dealing with it.

People: How to lead people, how to manage people (and understanding the difference!); dealing with difficult people (including other partners!); staff appraisals; staff surveys; team meetings; the importance of coffee.

Finances: Partner financial responsibilities; dealing with accountants; understanding cash flow; how to manage the finances.

Processes: Appointment systems: the good, the bad and the ugly; DNAs; workflow redirection; active signposting. How to implement change within the practice.

Property: Understanding premises; types of ownership of property; leases and rent reimbursement; working with NHS Property Services.

Practice Manager: What to expect from your practice manager; how to get the best out of them; understanding the difference between the role of the practice manager and the role of a GP partner; how to know if you need to change your practice manager and how to do it.

Section 2: External – understanding the environment

NHS: Understanding where GP practices fit within the NHS; the different structures and types of organisation within the NHS and how they impact on GP practices.

Commissioners: Friend or foe? Understanding the GP contract and how it works; understanding the different commissioners; how to build effective relationships with commissioners.

Regulators: The role of the CQC; surviving inspections

Other GP practices: The role of the LMC; why and how to build relationships with other GP practices; overcoming history and other barriers to joint working.

Other external relationships: Should I bother building relationships with other organisations, such as community pharmacy, community trust, local voluntary organisations, local council, local hospital? Who to prioritise; how to do it.

Section 3: Future – understanding the risks

Changing NHS: The changing NHS, including five year forward view, new models of care, STPs.

GP Forward View: What it means now and in the future; how to make the most of it.

Strategic Change: Understanding strategic options for your practice for the future; how to develop them; how to implement them.

Practice mergers: When to consider it, when not to, and how to do it successfully.

Let us know what you think. What do you think the most important training needs are for new GP partners? What would help most for someone about to take on the role? What have we missed? All your feedback greatly appreciated! Please either leave your feedback in the Comment section above or email me ben@ockham.healthcare

Why £2.4bn is not really £2.4bn

Hidden away in the latest NHS England publication[1], on page 19, is this graph (above). It is not good news for general practice.

At first glance it would seem to present a positive picture. Spending on general practice has gone up, and is planned to continue to go up until 2021. So what is the problem?

In the General Practice Forward View, published in April 2016, an additional recurrent investment of £2.4bn was promised to general practice. The parlous state of general practice was at last recognised, and (or so it seemed) that recognition was backed with real cash.

But what this graph shows is the additional investment of £2.4bn did not begin on the date of the publication of the paper. It begins around 2013, some three years earlier. A specific highlight is given to the formation of NHS England, to correlate this date with the turnaround in the funding fortunes of general practice.

The implication of this graph is that those awaiting £2.4bn of investment should really only expect less than £1bn between now and 2020/21. The graph also indicates the rate of funding increase will slow compared to the last two years. Worse, £500m of the extra money still to come has been promised for extended access, and at present most of that funding is being awarded via private tender, and not to local practices.

This should not be about headlines or political statements. It should be about properly funding a critical part of our NHS. It is no wonder that GP partners are at breaking point. According to one recent survey more than 90% of GPs have either left, have considered leaving, or have reduced their hours to be able to cope[2]. The additional funding is not a reward for general practice. It is what is necessary to keep it functioning and operating effectively at the front line of the NHS. This graph shows that not only is the funding required not going to materialise, but that the system is also going to pretend that it is.

[1] Next Steps on the NHS Five Year Forward View, March 2017

[2] http://www.weloveourgps.co.uk/

General practice organisations explained

If you don’t know a PACS from an MCP or if you are unsure of the difference between a Super Practice and a Federation then look no further! Click here to see Ockham Healthcare’s interactive guide to the confusing world of general practice organisations. The guide will take you through the eight main general practice organisations with links to the relevant guidance. The guide will open in another window. If you find this guide useful, or if you feel there are any other areas of general practice that would benefit from a similar approach – why not let us know in the comments section above.

 

 

 

 

 

 

What the “Next Steps on the NHS 5 Year Forward View” means for General Practice

Ben Gowland was excited by the promises made in the General Practice Forward View (GPFV) last year but, in this blog at the time, he expressed concern about the lack of any kind of accompanying financial plan. Now the government has published a “next steps” document which outlines the key priorities for the NHS over the next two years; and those concerns appear to be well founded.

There are 6 things general practice need to know about this document:

1. There will be £1bn less investment into General Practice than expected

In a cunning sleight of hand, the document reveals in a graph on p18 the promised £2.4bn additional expenditure into general practice uses a start point of April 2013, not the publication date of the GPFV (April 2016).   As well as leaving a bad taste in the mouth, it means the “extra” from 2016 is closer to £1.4bn, with the rate of growth of increase slowing from 2017 (now) onwards.

2. “5000 additional GPs” will become “the highest number of GPs in training ever”

Instead of saying there will not be an additional 5000 GPs and fronting that out, the document trails what will undoubtedly be the line the government and others will take in future that there are more GPs in training than ever before.

3. Extended Access is all

The one part of the GPFV the government really does care about is extending GP access. “By March 2018, the Mandate requires that 40% of the country will benefit from extended access to GP appointments at evenings and weekends, but we are aiming for 50%. By March 2019 this will extend to 100% of the country” p19. The additional funding for access, meanwhile, does not kick in until April 2019 and April 2020, a fact the document makes no attempt to address.

4. QOF will go, and be “reinvested”

Any practice bruised by the recent PMS reviews or removal of MPIG may be nervous to read the following, “We will seek to develop and agree with relevant stakeholders a successor to QOF, which would allow the reinvestment of £700M a year into improved patient access, professionally-led quality improvement, greater population health management, and patients’ supported self-management, to reduce avoidable demand in secondary care”. GPs are rightly nervous of the term “reinvestment”, as it generally means expecting them to continue doing what they are doing now, as well as undertaking additional activities to earn exactly the same amount of money, or even less if some of that “reinvested” money is siphoned off into networks, hubs, or CCG financial positions.

5. 30-50,000 is definitely the magic number

Most practices are seeing the writing on the wall that getting to this population size is going to be necessary one way or the other, but this document clearly reaffirms it. Badged as encouraging practices to work in networks or hubs, it clarifies (underlined) “the model does not require practice mergers or closures” (p21), while at the same time promising funding incentives to accelerate the move to reach this magic population number.

6. GP-led CCGs will be usurped by more powerful STPs

The whole section on STPs is crafted as a work around legislation to take responsibility away from CCGs and give it to STPs, and in some cases turn them into something called Accountable Care Systems (ACSs). These “will be an evolved version of an STP that is working as a locally integrated health system. They are systems in which NHS organisations (both commissioners and providers), often in partnership with local authorities, choose to take on clear collective responsibility for resources and population health” (p35).

Nearly exactly one year on from the publication of the GPFV it feels like we have just moved two steps backwards from the forward steps of last year. Then it felt like the current plight of general practice was recognised, whereas now that recognition feels absent once again, replaced instead with a simplistic view that operating at scale is a straightforward solution and an almost blinkered focus on extending GP access.

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