Redesigning the annual patient review process across two practices – Robin Lane Medical Centre and Manor Park Surgery, Yorkshire and Humber

Case study summary

Robin Lane Medical Centre and Manor Park Surgery in West Leeds came together in 2017 under a single support service organisation, Clinicare Health Support Services Ltd.  The organisation is made up of ten whole time equivalent GPs serving 28,000 patients.  When the two sites found there was a low proportion of relevant patients being asked to come in for annual reviews of their long term conditions, they participated in the Productive General Practice (PGP) Quick Start programme delivered by NHS England’s Sustainable Improvement team, to look at reviewing the process.  PGP Quick Start is part of the Time for Care support available through the General Practice Forward View.

The idea

Redesign the annual review process so there is a common process across both practices.

Identifying common issues

The purpose of an annual review is to ensure patients are taking the right medication and receiving the best possible care, this is done by conducting appropriate tests and checking the patient is taking the correct medication.

A cross section of staff from both sites, including GPs, nurses and receptionists came together to work on the project.  The group collectively looked at the two different review processes being used and identified where waste and issues existed.

  • Overall the process over both sites was confusing and inconsistent. Staff had no clear understanding of the process from start to finish.
  • Reviews took place on an ad hoc basis, often initiated/requested by the clinicians rather than the booking service advisors.
  • Booking service advisors were often issued with unexpected review lists that had no detail of the type of review being requested. This created delays and blockages in the system, as well as situations where there was a lack of appointments available to review patients.
  • There were situations where GPs had their own reviews that were not on SystmOne, as they assumed the patient had already been added to the system. As a result patients would not always be flagged for a review.
  • There was a significant lack of clarity regarding responsibilities and poor communication. Clinicians were unsure of the reception team’s role in the process and vice-versa.

Identifying what the issues were brought to light that both practices were experiencing difficulties. By working together and finding solutions they could design one process for both sites to use.

Designing one patient review process

The group considered how one process could be developed for use across the two sites. They used what was currently working well for each team along with ideas of different and more efficient ways of working, and incorporated them into the new process.  At every stage there was discussion and consultation with the wider practice teams where staff were given the opportunity to feed back and contribute to the changes being considered.  This resulted in a number of ideas being tried and tested across both sites that led to the following changes being made.

  • On the first Monday of each month one list is generated for booking service advisors, listing all reviews that are due the following month and details of the type of review they are.
  • Patients with multiple conditions are only contacted once by booking service advisors to arrange all relevant review appointments, where possible appointments are streamlined/amalgamated.
  • All patients are automatically added to SystmOne and coded according to the agreed list of read codes. Staff also follow a consistent approach to flagging tasks on the system so reviews are easier to identify.
  • Annual reviews for patients with chronic diseases are determined by their month of birth.

A single review process is now operating across both sites.


  • Both teams are on course to achieve their collective goal of having over 3,100 actual reviews per year, leading to better patient monitoring.
  • The huge level of collaboration has helped both teams get a better understanding of others’ roles and responsibilities, and enhanced further joint working.
  • Patients are receiving a more proactive service and in some cases saving time by scheduling all relevant review appointments during one call.

Implementation tips

  • Be prepared to put in the effort outside the hands-on sessions you have with your facilitator.
  • Get a cross section of relevant people involved e.g. GP, nurse, IT, reception.
  • Be open with staff and let them know why you are making changes and how they can get involved.

PGP Quick Start gave us a really good format to address the issue, ensuring all the right people were involved and that we were able to understand all aspects before coming up with a new solution.

Claire Turnbull, Practice Manager, Clinicare Health Support Services

The programme has also given us lots of unexpected value in terms of the opportunity of bringing staff together from across the whole organisation, who wouldn’t usually work together to address an issue which was affecting everyone.

Nadine Bleasby, Chief Operating Officer, Clinicare Health Support Services

If you would like to find out more about how you can access the Time for Care programme, visit our ‘Releasing time for care’ web page