“We’ve achieved efficiencies far more effectively working as a cluster than we would have as individual practice teams” – Chester East, North West

Chester East is a cluster made up of four practices comprising of 24 GPs serving a practice population of 37,000.  One of the cluster’s long term aims is to maximise GP clinical time, by adopting standard processes to create more efficient workflows that will enable cross-patch co-operation and sustainable working.  The cluster participated in the Learning in Action programme to help it work towards achieving this aim. The programme is delivered by NHS England and NHS Improvement and part of the support available through the General Practice Forward View.

The idea

Reduce workload pressures on GPs and staff by redesigning current systems to make them more efficient, effective and consistent across the cluster.

Identifying local projects

Having previously taken part in a half day What is Quality Improvement? learning session, the cluster had an understanding of how quality improvement could help and selected three projects to work on during the programme.

  • CCT (Community Care Team) referrals – develop a quick and easy process to ensure GPs categorised the care their patients need, and reduce the administration burden that the existing system created.
  • Voice recognition – reduce repetitive strain injuries for GPs who are concerned about the impact on their health through administrative workload and the extensive use of IT.
  • Improving workflow – reduce the total number of documents reviewed by GPs so they are only seeing those that require their attention and action.

Each project was led by one practice and supported by the rest of the cluster by contributing ideas towards better ways of working, sharing good practice and helping to test and shape changes.

Understanding the cause of the problem

The cluster first worked on identifying causes of the problems in each of the three areas.  Through group discussions and sharing of local experiences they identified the following.

  • CCT referrals – the template currently used for the transfer of care to the Community Care Team was cumbersome and complex. As a result very few people were using it and referrals were received in a myriad of ways.
  • Voice recognition – as the NHS grows more digital, the cluster found more mature GPs were experiencing repetitive strain injuries. As part of its commitment to releasing time for care, the cluster investigated voice recognition software for assistance with pain management, but also on a wider basis to look at reducing secretarial hours across the cluster.
  • Improving workflow – over a month the cluster collected data on how much correspondence GPs saw. It found that 58% of total correspondence was being seen by GPs, some of which they did not need to see or could have been dealt with by another member of practice staff.

Learning where the problems lay helped the cluster to move the projects on to the next stage, which was to find solutions.

Finding a consistent approach that works for all

The group worked together to identify solutions and changes they could test before fully rolling out standardised processes and approaches across the patch.

  • CCT referrals – a process map was developed with input from all practices that streamlined existing processes and created a one page standardised protocol that is quicker and easier to use. With more simplified layout and wording, it helped GPs categorise the care their patients need and minimised the administrative overhead.  The protocol is now used across the patch.
  • Voice recognition – speech recognition software was identified as a way to significantly minimise keyboard “stroke” hours. Two software packages were shortlisted and tested to establish how easy they were to use, whilst also maintaining high levels of information and accuracy in recognition of medical terminology.  The software chosen has been adopted by other practices in the cluster. As a result the cluster has been able to negotiate the purchase of the software at multiple sites at a discount price.
  • Improving workflow – the cluster process mapped its document flow to build one process. With GPs’ approval it incorporated what was already working well across the patch, to create a more efficient and safe process.  The path for each document type was agreed and new protocols established.  GPs are now seeing only the most complex letters or those that require further action e.g. new cancer diagnoses, discharge notification with medications changes, clinic letters with medication changes, A&E with onward referrals.

Using the PDSA (Plan, Do, Study, Act) approach, small cycles of testing were carried out on each of the changes made before they were agreed and rolled out across the patch.  This gave all practices an opportunity to have a say in any changes being considered.

The power of language

One of the key learning outcomes for the cluster was the choice of language and how everyone can view and interpret words differently.  For example, when gathering data for improving workflow each team viewed “counting letters” differently, some included emails in their counts while others omitted them.  While working on the CCT referral template it was unclear what the difference was between “crisis/urgent/now/immediate/emergency”.

The cluster, therefore, did need to agree definitions and clarify words used and their meaning.  Going forward language is something that will be considered at the outset of any future project.


The work done collaboratively on the programme has proved to the cluster that the concept of network collaboration works.  It has incentivised each practice to start looking at other areas of improvement that can work collectively across the patch, putting them in a good position to work as part of a Primary Care Network.

For the projects undertaken during the programme the impact has been as follows.

CCT referrals

  • The new simplified process and template has released 45 minutes of CCT administrator time per day for the central CCT team.
  • There is now a better understanding of patients’ needs, allowing for a swifter CCT referral and better patient experience.
  • There has been a decrease in the number of enquiries GPs receive that need further exploration of a patient’s notes by a GP.

Voice recognition

  • The new software has demonstrated that the pain suffered from repetitive strain injuries can be significantly reduced.
  • Over 30 minutes of GP time can be released per day, which GPs can spend on more complex clinical issues and time with their patients.
  • The quality of consultation notes has been maintained and patient notes are being turned around quicker.
  • The cluster is now exploring converting other daily tasks into speech recognition.

Improving workflow

  • GPs were seeing 58.3% of the incoming documents at the start of the project. They are now only seeing 27.9% of total correspondence across the patch, which is a reduction of over 30%.
  • GPs now have the time to focus on correspondence that requires their attention, allowing for quicker actions for patients to be completed.
  • A more sustainable approach to managing workflow has been developed across the four practices.

“We’ve achieved efficiencies far more effectively working as a cluster than we would have as individual practice teams.  Working together and supporting each other to make changes across the patch has been hugely beneficial, there is so much more we want to do in the future.  The opportunity to have the time to focus on best practice and improvements has been invaluable.” Tracey Palmer, practice manager, Upton Village Surgery

“Both the patients and our team are benefitting enormously from this new simpler template.  Other areas are also considering adopting the new system.” Liz Stewart, team manager, Community Care Team

If you would like to find out more about participating in the Learning in Action programme, along with details on how to apply, visit our web page.