Being bogged down with a heavy workload is a familiar story for those working in general practice. But there are ways to ease the pressure with a multidisciplinary team
The crisis in recruitment retention and morale in general practice was highlighted via a survey in Oxford. In association with a group of north and north east Oxfordshire GPs, Dr Andy McHugh produced and distributed a questionnaire[1] designed to assess the state of general practice across England. Within three weeks he had received 2,769 responses which told a sorry tale. Workload is becoming unsustainable. GPs approaching the end of their career are choosing to leave early. Midcareer GPs are emigrating in increasing numbers, and there is a drastic shortage of newly qualified doctors entering general practice.
Two years ago, in response to an inexorable increase in the pressure of work, my surgery conducted an ‘away day’ with an external facilitator. The event was a great success. I would recommend the process to any practice struggling with workload and/or progression planning. What I think made the event such as success was:
- Holding the away day away from the surgery – this avoids distractions.
- Using an external facilitator with a proven track record. Don’t be tempted to let one of your partners do it to save money.
- Emphasise the importance of coming to the away day with an open mind.
Getting to the route of the problem
The main outcome of the day was the unanimous, but not previously articulated, realisation that partners wished to reduce the pressure of the GP working day. This might sound obvious and you are probably thinking that everyone knew that without the need to have an away day. Of course everybody did know it, but until it had been identified as a common goal, nailed to the table and agreed, there was no way that we could produce a plan to achieve it. You need to be aware that teasing out the collective consciousness of your practice can take time. It took us approximately three hours to arrive at the collective recognition that the intensity of the GP working day is our problem.
Having decided to reduce the intensity, the partners were faced with two choices: to employ more doctor time or to substitute doctor time for allied health care professionals. It was decided to explore the possibility of substituting doctor time. We considered the various aspects of a GP working day and considered which of these could be undertaken, more cost effectively, by an allied healthcare professional without reducing the quality of the health care delivered. The aspects that we identified included:
- Review of results.
- Surgery consultations.
- Dictation.
- Telephone consultations.
- Home visiting.
- Visiting of nursing/care homes.
- Management of repeat medication.
- Surgery business management.
By three o’clock in the afternoon we had decided that home visiting and to some degree, visiting of nursing/care homes could be performed by a paramedic or emergency care practitioner. It was hoped that by starting home visits early to mid morning, the pressure to squeeze in home visits between morning and afternoon surgery would be significantly reduced. It was also recognised that any admissions resulting from visits earlier in the day would be easier for local acute trust to deal with, rather than the traditional 13:00-14:30 surge following GP home visits. We also decided we would employ a pharmacist to manage repeat medication. There was a realisation that much of the management of repeat prescribing was being done between 20:00 and 20:45. It was hoped that the employment of a pharmacist to manage repeat prescribing throughout the day would give GPs back these 45 minutes and in doing so, the chance of regaining a semblance of a home life.
Between 15:00 and 16:30 we decided on our recruitment strategy. By the time we left, we had a definite plan. We knew where we would advertise, what would be our budget, who would do what and when we aimed to have both of these posts filled. We left the hotel having spent around £5,000. In retrospect, that was the best £5,000 we have ever spent.
The pharmaceutical role
You should always be prepared to amend a plan in the light of new information and insights. Following our away day we spoke with a respected, recently retired pharmacist about our plan to recruit. She advised us that we didn’t need a pharmacist. Providing the partners could produce robust, clear protocols for the management of repeat prescribing, we should be able to employ a pharmacy technician. She advised us that while we could delegate the task of management of repeat prescribing to a pharmacy technician, we could not delegate the responsibility. She also provided us with a shortlist of four candidates who she thought would do the job extremely well.
One of the problems we encountered in progressing with the recruitment of a pharmacy technician, was that we did not have a job description. While there are job descriptions for dispensers within dispensing practices, there seems to be no existing job description for a pharmacy technician in a prescribing practice. Rather than see this as a barrier, we wrote a very bland job description with the explanation that as this was a new role, the job description would develop within the first year to 18 months.
We appointed a pharmacy technician. The GPs and the reception staff were slightly wary at the start. The management of repeat prescribing from prescription request to issue of prescription was going to change, and that is always seen as threatening.
Within a matter of two weeks it was realised what an excellent idea this appointment had been. The GPs did get back their 45 minutes at the end of the day, but in addition the minutiae of repeat prescribing were being handled much better. Patients who might previously have slipped through the net for recalls were being contacted. Medication queries from patients were being dealt with at the time the patient called in, rather than waiting until the end of surgery. The true value of this appointment was realised when our pharmacy technician went on leave and the partners once more had to take on the management of repeat prescribing. It was at that point we realised that we probably needed another 0.4 full-time equivalent pharmacy technician to cover leave and sickness.
Emergency care practitioner
In seeking to appoint a paramedic/emergency care practitioner (ECP) we had slightly more to go on as another practice within Banbury had made just such an appointment. Having spoken to our neighbouring practice we placed our advertisements and recruited an excellent ECP. Again, when she arrived we were not quite sure how we would use her. We had drawn our plans that included her seeing ‘on the day’ emergency appointments between 08:00 and 10:00 and then starting home visits as the requests came in.
As they say in the military: “No plan survives contact with reality.” It quickly became apparent that ECP was best employed in taking on home visits. She quickly gained a reputation with nursing/care homes as a highly competent clinician, able to respond quickly and effectively.
Any concerns we may have had that patients would feel ‘short changed’ by being visited by an ECP rather than a doctor quickly evaporated as we received report after report of just how good she was. The GPs, particularly the partners with an unlimited liability for visits, were delighted. Our ECP had given them back a significant portion of the time between morning and afternoon surgery.
The employment of our pharmacy technician and our ECP has achieved our stated aim of reducing the intensity of the GP working day. Metaphorically, it hasn’t taken the lid of the pressure cooker but we are certainly operating with a much lighter weight.
The success of our appointments has rippled out to our federation. The federation received a small tranche of money from our clinical commissioning group for projects to improve access. The constituent practices of the federation decided to use this money to employ another ECP to provide a visiting service to the Banburyshire GP practices as a pilot. Feedback has been unanimously positive.
The introduction of an ECP early visiting service formed a core part of our federation’s application for the Prime Ministers Challenge Fund second wave. The federation is also drafting a business case to provide integrated care to nursing/care homes within our area. Part of this business case will be the employment of a pharmacy technician or possibly pharmacist to review prescribing within all nursing homes within the area.
What we have learnt
Our experience with these two appointments has taught us that the composition of our multidisciplinary team is not set in stone. It should be a dynamic structure, capable of changing according to the changing needs of the population we serve.
Three weeks ago we held another away day, again with an external facilitator, but scheduled for only half a day. We returned to our previous theme of reducing the intensity of the GP working day. The outcomes of that day were as follows:
- Delivering the plan from the previous away day has been very successful.
- Intensity of the multidisciplinary working day was again rising inexorably due to or arising list size, the increase being predominantly elderly complex patients.
- The absence of any form of triage led to GPs seeing patients who could more appropriately be seen by an allied health care professional.
- Recruitment of multi-skilled healthcare assistant to be a priority in order to make better use of the clinical skills of existing nursing team.
- To introduce clinician-led telephone and face-to-face triage to
- ensure that patients are seen by the most appropriate clinician, in the most appropriate setting, within the most appropriate time frame first time.
- In conclusion we would recommend four things:
- Review the structure of your multidisciplinary team.
- Seriously consider employing an ECP/paramedic for home visiting.
- If you’re prescribing practice, seriously consider employing a pharmacy technician.
- If your practice is feeling the pressure, hold an away day.
Reference
McHugh A, Dr Dawson L, Dr Moncrieff D, Dr McDonald B, Parton S and Dr Gillies H Are In You In Despair For Your Future In General Practice? Results Of Survey Monkey Questionnaire 2014 pracmanhealth.files.wordpress.com/2014/08/are-you-in-despair-for-your-future-in-general-practice-final-report1.pdf (accessed 1 April 2015)
Andrew McHugh is a manager of a GP surgery in Banbury, North Oxfordshire.
