Note: Some sections of this case study refer to clinical commissioning groups (CCGs). On 1st July 2022, integrated care systems (ICSs) took over statutory commissioning responsibilities in England, and CCGs were closed down. You can learn more about integrated care systems (ICSs) here.
Case study summary
Mundesley Medical Centre looked at the skills within the team to identify where other members of staff would be better placed to deal with certain tasks.
The model would move urgent care activity back into general practice and federation led primary care services, accessible between 8am – 8pm on weekdays and 8am – 1pm on weekends. To enable a smooth transition of services that would go live 1 April 2017, the CCG looked at developing a preparatory service specification on improving access to general practice, which would include improvement plans for practices and federations.
Mundesley Medical Centre, is situated on the North Norfolk coast, it has five GPs, one of which is a Duty GP. The practice population is 5,600 (weighted 7,200) which increases during the holiday season. The practice was considering how to replace a four session GP however, recruitment of a GP was difficult due to the remote location. Using the Productive General Practice (PGP) Quick Start programme from NHS England’s Sustainable Improvement team, a programme that is part of the support available through the General Practice Forward View, the practice looked at the skills within the team to identify where other members of staff would be better placed to deal with certain ‘Tasks’ currently dealt with by the Duty GP.
The practice undertook the Appropriate Appointments module from PGP Quick Start, to identify ways in which staff skills could be used more appropriately, so that patients could be seen at the right time, by the right person at the right place.
Identifying the issues
An improvement working team was formed, made up of the lead GP, practice managing partner, reception and administration staff. The lead GP played an essential role in engaging all the clinical staff to undertake the Primary Care Foundation appropriate appointments audit tool, which allows clinicians to capture and submit live data electronically.
Over a period of two working weeks audit data was completed by all clinical staff in the practice. The audit enabled the practice to review patient consultations and compare them to other colleagues in the practice, as well as across England. The data was analysed and discussed between the clinical team and practice manager, to understand the variation in responses and differences in perceptions. Here it became evident that the nursing staff had low numbers of inappropriate appointments compared to the GPs. Following this an action plan was developed, with priorities ranked and agreed by the practice improvement working team.
One of the key areas that the practice looked at was their staff skills matrix, this highlighted that certain staff were underutilised, and GPs were completing work that could be done by a more appropriate member of the team. One of these roles was completing ‘Tasks’; the Duty GP was spending an hour per day dealing with ‘Tasks’ that had been sent through by practice staff. The ‘Tasks’ included medication queries, appointment requests and blood tests follow up. It became clear that the majority of these could be actioned by a nurse practitioner.
Redesigning the process
Following the Plan, Do, Study, Act approach, which tests small steps of change, a plan was put in place to test a process where a nurse practitioner completed the tasks instead of the Duty GP. Diverting this responsibility required management of risks, such as ensuring that reception staff continued to use appropriate time scales for urgent calls, that tasks were processed in a timely manner, that the GPs were available for support, and that if any of the clinicians or management felt the process was not working it would be stopped immediately. The redesigned process was communicated to all the practice and trialled for two weeks.
An hour per day of a nurse practitioner/practice nurse prescriber time was set aside to complete the tasks. The nurses found the work enjoyable and could easily complete most of it. During the trial it was identified that the hour time slot could be reduced. The practice managing partner and the lead GP of the practice, worked with the practice nurses to audit the new way of working and communicate any risks and how they were managed.
- 5 hours of the Duty GP time has been released per week.
- This has the potential to create 1,560 extra 10 minute appointments per year, or more appropriately to this practice 260 hours of GP time.
- Whilst this change alone contributes to only a small area of the work in this practice the Appropriate Appointments module and Primary Care Foundation audit, followed by a detailed action plan for changes, has provided significant evidence that a nurse practitioner can replace the vacant GP position.
- There will be a cost saving of £15,000 by employing a nurse practitioner instead of a GP.
- The benefits for patients include availability of an increased number of appointments, shorter waiting times for appointments, GPs having more time to deal with complex home visits, responses to requests are dealt with in a timelier manner, and reception education is enhanced as the nursing team replies in a more standardised manner.
- GP involvement is crucial to ensure all the clinical team complete the audit and become actively involved in making changes.
- Communication to all the practice including patients is essential to sustainability. Ensuring that patients are aware that it is not always necessary to be seen by a doctor, and they can be seen more quickly by other appropriate health professionals.
- A good project team and taking the time out to do this work is essential to success.
Recruitment of GPs in this area has been notoriously difficult. Having worked on the Productive General Practice Quick Start programme has shown us we can look at utilising the skills of alternative clinicians and ways of working.”
Linda Marquis, Practice Managing Partner, Mundesley Medical Centre