A more flexible approach to managing patient demand and future peaks in pressure – The Orchard Practice, South East

The Orchard Practice in Kent has 3.1 whole time equivalent GPs serving a patient population of 7.5k.  It participated in the Time for Care programme, which provided tailored support for the need of the practice during the pandemic, to develop a more flexible approach to managing increases in patient demand following the first wave of COVID-19, as well as any future waves of the pandemic, in a way which would cause the least disruption to patients and staff.  Time for Care is delivered by NHS England and NHS Improvement.

A system to manage further peaks of the pandemic and other pressures

Following the initial easing of lockdown measures, an increase in patients returning to the practice was expected.  In preparation for this, and any future peaks that could lead to a shortage of clinical and admin staff, the team looked at how best to manage workload priorities.  It recognised this also provided an opportunity to review how it responded to all pressures on the practice system, such as power or IT outages and unexpected staff absences.  The new model developed would allow for flexibility to deal with unexpected pressures by flexing the services the practice provided.

Using national guidance and knowledge from contacts within informal local network groups and its Primary Care Network, the team designed a system to manage problems encountered due to COVID-19 and when the practice is under pressure for other reasons.  Using a RAG (Red Amber Green) rating system, it categorised the importance of what would need to be done with Red as most urgent through to green, where the priority was less important.  This was defined for each clinical and non-clinical staff group within the practice.

Red – Essential services and urgent workload only.

Amber – Provision of essential services and routine services where safe to do so.

Green – Business as usual.

Situations where the practice would revert to Red service provision include advice from NHS England and NHS Improvement, that due to high levels of circulating COVID-19 essential services only should be provided, less than 72 hour provision of PPE, staff shortage preventing delivery of more than essential services, IT failure or power outage of more than half a day, premises closure. The system allows the team to prioritise workload and move staff around to ensure essential services are covered, ensuring a safe service is provided and staff burnout prevented.

Having the right capacity in place for patient needs

Patient data was collated based on the type(s) of medication patients were on and the QOF group they fell into.  Calculating what the appointment requirements would be for this group over the next 12 months to complete necessary procedures e.g. medication monitoring and tests required, the team found it would need 2,356  phlebotomy appointments and 4000 nurse appointments (mainly due to long term conditions).  However, with the change to appointment lengths due to social distancing, need for changing PPE and cleaning rooms, the team had to reduce its phlebotomy capacity to 1716 appointments.

The team increased the number of appointments available for phlebotomy.  Each appointment was 20 minutes long to allow for the phlebotomist to change PPE and clean down the consultation room in between patients.  During testing the phlebotomists found they did not need so much time in between appointments and could clean and change quicker.  As a result appointments were reduced to 10 mins each with a 10 minute catch up slot scheduled after every fifth appointment.  This increased to 6 appointments per hour, effectively doubling the practice’s capacity.

GP appointments were starting to fill up quickly but the reason why was not clear.  Over one week an audit of GP appointments was conducted and found 37 out of 107 appointments were avoidable.  This was due to GPs receiving appointments that should have been seen by other clinicians within the practice.  As a result patients are now navigated more effectively by reception.

A better way to manage telephone appointments

Patients were previously given a date and time for their telephone appointment.  To build some flexibility into the process, patients continue to receive a date but are now advised the clinician will call either in the morning or afternoon, rather than  specific time.  Telephone appointments are put in numerical order, giving clinicians more flexibility should they need to move them around or go over.


  • The practice now has a system in place that is prepared for every eventuality. It can manage increases in patient demand and peaks in pressure better without causing staff burnout, making the practice more sustainable in the long term.
  • Over seven weeks the practice has significantly increased the number of phlebotomy appointments available, giving patients access to a service that was previously limited during the initial peak of the pandemic.
  • Staff are doing today’s work today. Whereas patients could previously wait up to 14-21 days for an appointment, they can now ring up and get an appointment with either a nurse or GP on the same day.
  • Getting timelier access to a clinician during the pandemic is helping patients deal with their health problems when they arise, rather than allowing them to build and worsen.
  • The practice has shared what it has learned and developed with other practices within its PCN, putting them in a good place to make similar improvements without wasting time starting from scratch.

“Time for Care really helped us.  It gave us time to think about what we do and why, is it the best way, can we do it better?  Looking at data was extremely helpful, we worked out what the demand for appointments would be and which clinician in the practice could best meet patient needs.”

Julie Taylor, GP, The Orchard Practice