Review of GP Practice Systems: Primary Care Redesign
Castlerigg Consulting has deep and demonstrable experience of NHS and primary care transformation programmes, often involving both the review and re-design of services and better use of technology. We are one of only a few management consultancies in the UK who are NHS IG toolkit compliant as an organisation. As a change management consultancy that specialises in delivering technology enabled service transformation exercises in both the NHS and Local Government, we have a reputation for innovation and delivering tangible results quickly for clients.
Our focus is on creating sustainable change – and that requires the evaluation of all aspects of delivery and any constraints, in terms of people, processes, technology and information flows. We have an objective, whole system approach to change, utilising LEAN methodologies alongside our own proven change methodology. We recognise that successful change is as much about introducing new technology or workflows as it is de-commissioning redundant process or practice. A key focus in successful change must be on the people who use or provide the services – they are the ones who will deliver the benefits of the change and no amount of new investment in technology or training will achieve sustainable change if users and staff do not need, support or understand the changes that are being made.
In 2013 Castlerigg undertook a review and service re-design exercise at Sedbergh Medical Centre in Cumbria. This was a whole system evaluation of people, processes, technology, assets and information. The practice had recently moved into new premises and was keen maximise its use of this new facility. This move had also prompted a desire to evaluate the practice’s clinical and non-clinical productivity.
Clinically, the practice’s configuration of session capacity against actual demand needed to be fully evaluated. Patient access to booking, viewing, amending and reviewing appointments and ordering repeat online prescriptions needed to be established. Non-clinically, the practice as a business needed to evaluate how partner time was released to support practice management.
The practice partners identified a need to undertake a review of the practice operations, in order to maximize capacity and improve services for patients. Working with Castlerigg the practice identified a number of objectives and outcomes for the review such as achieving a reasonable working day for all staff, delivering excellence in health and social care and ensuring all processes ran efficiently. The practice recognised that the review had to consider how staff skills and time were being used and whether the right staff in the practice were undertaking the right activities in order for the practice to operate efficiently. In addition, the practice aspired to move to paperless processes and consider new demand management options within the practice. Castlerigg quickly identified that increasing demands on medical staff time meant a fundamental review of patient access was essential. Working with the practice, it was agreed that the review had to be more than just increasing the utilisation of technology – staff ways of working, practice culture, performance and business management were all equally key.
The benefits were significant. GP productivity improved by 50%, patient access was improved and the workforce was re-aligned to duties, ensuring expensive GP and nursing time was better targeted and prioritised. The focus was not only on the capacity of the surgery but the quality of its interactions with patients, focussing in on patient contact to maximise time and cost efficiency and reduce avoidable contact through improved information sharing, not only within the practice but across community, mental health, acute, social care and out of hours providers, to support clinical decision making. Utilising LEAN methodologies alongside our own proven change methodology and working closely with all levels of staff in the practice we reviewed:
- practice management, planning, communications, culture and readiness for change
- key patient journeys and management information including current patient satisfaction
- key interfaces with other service providers and information flows
- review of QOF, LES, DES and income maximisation and automation
- key clinical and business processes including: referral management, prescribing, dispensary management and pathology
- a review of appointment channels (online/telephone/face to face/other service providers) and their use
- a review of consultation management by type (face to face/telephone/online) and session utilisation
- a review of front of house (reception and administration staff)
- staff development, performance management and training, particularly assessing training in practice systems, associated software and adherence (and existence of) to standard operating procedures
- workforce planning and skills assessment of GP, Nurse, and Healthcare assistant time allocation against key tasks to ensure these were efficient and commensurate with skills required
Initial findings were shared with the practice team, verified and recommendations agreed. A second, deeper analysis was made in key areas that would benefit from further investigation. A draft outline business case was then created with quantified potential benefits against each opportunity to support decision-making and prioritisation. This allowed the practice to objectively consider all its options for future delivery and agree to initiate a service re-design project for the practice. At every stage the key was to involve practice staff, ensuring there were no surprises in the final recommendations and that all improvement opportunities were fully validated and explored with the team. Improvements implemented by Castlerigg included:
- better separation of clinical and non-clinical duties across all key processes. Reducing the administrative burden on clinical time by either better use of technology and/or the administrative team undertaking appropriate tasks
- better balance of patient contact time versus practice management time for GP partners
- better information sharing both within the practice and with community, acute, mental health and out of hours services
- more consistent use across staff of practice systems, creation of standard operating procedures for key processes, better induction of staff to utilise systems
- introduction of dedicated time for telephone consultations to avoid these impacting on other duties, causing delays elsewhere in the working day
- changes to length of appointment slots across sessions and by appointment type to reduce non-productive time
- increased access to GP consultation
- improvements to available management information across clinical, non clinical and management practice functions to support continuous improvement and income generation
Patient satisfaction has continued to increase and this practice was recently deemed to be ‘outstanding’ as part of the CQC primary care inspection pilots following our service redesign exercise.
“Following our move into the new premises and increasing the breadth of services that we offered without increased staff resource, we required assistance to ensure that business opportunities were properly assessed and planned, change effectively managed, and the business was sustainable, maximised income and delivered the best for our patients.
Castlerigg undertook a review of our existing processes, then made (and helped us implement) recommendations that mean clinicians are now less bogged down in areas where their specialist skills don’t add value and have capacity to provide and undertake additional services and tasks in an ever changing and developing health economy. Our Practice Manager was supported to ensure that change in our practice became properly embedded and monitored to ensure it delivered the intended outcomes. Castlerigg also supported us to articulate our desired future state and implement a better approach to business planning with improved business controls around finance, management of risk and decision making which will assist us greatly in achieving our future state and sustaining our business.”
Chrissie Hunt, GP and Practice Partner, Sedbergh Medical Centre