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“Hands on” management in a forward-thinking practice

15 December 2008

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Valerie Denton
(Opposite, main picture, and right)

Practice Manager
Tudor Lodge Surgery

Valerie qualified in 1993 and has an AMSPAR diploma in practice management. In 1999 she took a career break and lived in Turkey for three years, but returned to practice management when her family moved back to the UK. She is currently on the board of directors of the Weston Practice-Based Commissioning Group

I have been a practice manager for 15 years, and it is only in the last 18 months that I can honestly say I began to question what on earth I was doing in the job – or rather, what my role actually was.

Where does the time go? My days were filled with writing reports, filling in forms for clinical governance, Standards for Better Health, auditing infection control, creating a disaster recovery plan, a pandemic flu plan – you name it, a plan needs to be written for it. Boring, boring, boring.

The deadlines were getting shorter too – or perhaps that is just an age thing, like policemen looking younger. Anyway, I knew things were getting out of hand when I found myself planning writing a plan on how to write a plan! At the start of my new job in Weston-Super-Mare in August 2007, I was feeling more than a little “planned” out. And that’s not to mention patient surveys – please don’t.

It was with this slightly jaded attitude that I began my new job. The partners wanted a business manager, not a practice manager, but quite frankly I was hankering after the good old days. You know,  when you could spend time on reception because you wanted to, not because you had to due to staff shortages or lack of funding for additional posts.

I don’t mind the finance, but I can’t resist asking questions. “Why?” is my downfall, I am afraid. “Why do we do this or that?” “Why do we do it like this?” “Why don’t we try something different?”

I argued that I was a “hands on” kind of person who needed to work with the staff and remain close to the patients. No matter how much business acumen you have, if you don’t know what’s going on at the coalface, you just aren’t going to improve the business. To the partners’ credit, they listened and agreed to let me manage them – a major coup, as any of my colleagues would agree.

Getting the unanimous agreement of six partners is nothing short of a miracle, and I made the most of it. I hired a skip. We spent a whole weekend clearing what should be a paper-light practice of every kind of accumulated rubbish we could lay our hands on. It was hugely therapeutic for all of us, and at least one partner can now see his desk and his floor! There have since been three weekend “skipping” sessions, which have gained us valuable storage and office space and enabled us to plan a refurbishment of the building.

Rooms are being decorated, old furniture replaced, carpets thrown out and clinical flooring laid. The surgery’s overhaul has pleased the patients, made life easier for staff and achieved many of the targets for premises and infection control.

The partners, far from being put off by the financial outlay, began to take an active interest in colour charts (our Plymouth Argyll supporter wanted green and white stripes on his walls!) and heated debates have taken place as to whether or not we should have a fish tank in the waiting room.

We all agreed to wear uniforms and badges, which had only been worn by reception staff before. Although a minor change, this did help to integrate everyone into the team.

The Quality and Outcomes Framework (QOF) presently remains at the forefront of the business. But so caught up are we in making sure all those boxes are ticked by the end of the financial year, it can be all too easy to forget about the personal side of patient care. “Points make prizes” is often quoted, which doesn’t send out the right message – but if targets aren’t achieved, finances suffer and so ultimately does the patient. We really wanted to adopt a new way of working that helped us achieve our aspirations and improved patient care.

Developing a multiskilled team
I am fortunate that the team was prepared to listen and try out new ideas. They were more used to “owning” one particular task, but were persuaded to share their knowledge with each other, with the ultimate aim of having everyone able to do everything, and cross-cover when necessary.

A work plan was set up, giving each receptionist a morning or afternoon out of reception, to concentrate on a specific area of the QOF. We ensured dedicated time for training, admin and contact with patients who have cancer, dementia or mental health problems.

The receptionist responsible for cancer care makes personal contact with relatives to offer support and help during what is a stressful time. This ensures that the patient and family only have to deal with one named person.

The receptionist has visited the hospice and attends regular palliative care meetings. Any fast-track referrals are copied to her, so that she can ensure any newly diagnosed patients are not overlooked. This ensures they not only have the required review within six months of diagnosis, but that they continue to receive a high standard of care.

We also offer practice chaplaincy, which has been extremely successful. Our chaplain visits patients at home if need be and is a referral point for GPs whose patients do not necessarily require counselling, but just need someone to talk to. Anyone of any faith or nonfaith can access this service.

We are in the process of expanding our “personal” touch to include learning disabilities, ensuring that every patient is offered a full annual health check. A working group has been set up that will liaise with a key worker from the Learning Disabilities Team. They will make sure the patient understands exactly what that health check entails, whether by means of a large print leaflet in simple English, a DVD or audio tape. Some of these patients would never attend unless they were really ill, and some never come to surgery. Our aim is to make sure they can access our services more easily.

A new member of staff is being trained on diabetes recalls and blood test results – she has a brother with diabetes and wanted to become more involved. We intend to have most of the current hospital follow-ups done in practice by our nurse specialist, which will save duplication and hospital waits, and be more convenient for our patients.

New appointment approach
Access is a big issue in any practice. Having completed an audit of demand over capacity, the partners agreed to scrap the current system of on-the-day-appointments only and replace it with a system that allows booking up to 10 working days in advance.

Our duty doctor does not have a surgery, but offers telephone advice, triages, home visit requests and sees emergencies. This ensures he can cover if another GP goes off sick at short notice and prevents cancellations of appointments.

Our nurse prescriber sees mostly minor ailments on busy days. The reception team also works to strict protocols for minor illnesses, such as conjunctivitis and cystitis, enabling them to request prescriptions without the need for the patient to come in. This has eased the pressure on appointments considerably and given staff the confidence to offer patients alternatives to appointments.

We recently replaced an outgoing partner with a fulltime clinical pharmacist prescriber, who was working in medicines management at the primary care trust (PCT). This now means GPs are able to initiate treatment and then refer patients on for monitoring and medication reviews.

Our pharmacist prescriber can also deal with minor illness, insulin conversion, asthma, emergency contraception and numerous other things that will free up appointments for chronically sick patients who need continuity of care from their GP. We are confident that this approach will also enable us to achieve our prescribing targets and cut our expenditure on prescribing.

Our medication review dates are set at eight months; all other reviews are linked in with that date. This means the patient need only attend once for everything instead of receiving numerous letters or calls for repeated appointments. This obviously takes much longer than a routine appointment but 45 minutes out of one day can possibly save much more time over the year.

We now actively look at the patient record when patients call in, so that we can deal with outstanding items like blood tests at the same time as a routine appointment. We call and remind every patient who has a double appointment booked, and this has reduced “no-shows” by about 40%.

New clinics
The practice team is being trained up for the launch of a new “No Worries!” teenage health clinic. This will tie in with our recalls to teenagers on their birthdays for any vaccinations they may have missed at school. Each week, two nurses will run this after-school clinic following their child immunisation sessions. Although we won’t earn anything by running these clinics, we believe we should be developing services like this to cater for our patients’ needs, and this may help identify problems before they develop.

Our nurses will also run a private travel clinic we are planning. We have just registered as a Yellow Fever Centre – an upstairs room is being converted into a clinic room that will be used for this purpose. We hope to have a travel “shop” in place in the next few months, and perhaps an occupational health service after that.

Our QOF inspection by the PCT came and went without a hitch, I am pleased to say. This year, the team was involved in the whole process from start to finish. They even interviewed the receptionists responsible for those “special” areas and have suggested this is adopted across other practices.

Commitment to quality
When I said I wanted to be a “hands on” manager again, I really meant it, and in the last seven months I have been just that, which has enabled me to make the changes that have taken place. True, it’s meant giving up holidays and working long hours and weekends – not only for me but also for my wonderful deputy, Rosie, who has sacrificed her comfortable office to move into mine and help me run the practice in a completely different way – but I wouldn’t have changed it for the world.

The coming year will be so much more rewarding and easier where QOF is concerned, and I am confident that our patient survey next time around – yes, I mentioned it! – will be a positive exercise.

I still have to write the plans, and meet the deadlines, but I do feel that we are achieving something out of it all at last.

I am fortunate to have found a practice that is so forward-thinking, and partners who are happy to let us try out new ideas. Yes, we are still under threat from private companies and 24-hour conveyor belt polyclinics, but general practice is about quality, not quantity. A bit more lateral thinking and a commitment to change the way we do things can and does work wonders.