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Big idea: the challenges of forming a joined-up surgery

1 June 2006

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Chris Jenkins
Senior Practice Manager
Hall Green Health

Originally from the North East, Chris moved to the Midlands from Tower Hamlets in London’s East End. Before becoming senior practice manager at Hall Green Health, she spent 10 years as practice manager at Greenbank Surgery in Birmingham. Survival techniques include a sense of humour and large glass of wine after work

Having spent 10 happy years as a practice manager in a four-partner, forward-thinking practice in a leafy part of Birmingham, life was far from dull, and any new initiatives the primary care trust (PCT) continued to throw at us were pretty much under control. It therefore came as quite a surprise one morning to be asked by one of the partners how I felt about a radical scheme being mooted by several local practices: namely, to plan a large new health centre that would house us all, together with as many other primary care services as possible, in order to form a huge “one-stop shop” for patients.

Like most practice managers I’m up for a challenge, so my first reaction was: “OK, might be worth thinking about”. This was immediately translated by the partners as meaning, “OK, put me down for it – when do we start?” And why not – with 15 partners, 25,000 patients, five practice managers and more than 50 members of staff joining together in one building, what possible problems could there be?

Why the new “supersurgery”?
The reason for the plan was that some of the partners were increasingly frustrated at their inability to extend services to patients and develop their own special interests due to cramped premises and lack of resources. Doctors in each of the surgeries had identified areas into which they, as individuals, wished to develop, either clinically or academically, but were prevented from doing in the smaller setups. A site within the locality had become available, and the opportunity to build a large surgery they could all share was seized as the ideal solution to space restrictions.

A common goal between all the existing partners to change their traditional working pattern meant that the decision was the logical one. At the same time, the concept of one large “super” practice in a three-storey building was daunting and difficult to sell to staff and patients alike, all of whom were very comfortable in their familiar surgeries, and largely unaware of the frustrations of their doctors to move on and make a difference.

However, as is usual in general practice, the old wartime spirit lives on, and the bulk of the staff unquestioningly gave their support to the scheme. The site was secured, with our submitted plans triumphing over those of a well-known fast- food outlet, and with the support of local councillors we began the onerous task of planning our new practice. The scheme was unique in that many surgeries relocate to new premises and manage the problems arising from such a move, but I know of no others who have merged lists and businesses with other practices at the same time. Practice managers beware! This is not a project to be undertaken lightly – trust me.

Visits were arranged to other large sites to glean ideas for the layout and structure of the building, and several meetings were planned to facilitate the merging of different staff groups, previously unknown to each other, who would become working colleagues overnight. One valuable piece of advice from a GP who had recently undergone a major surgery rebuild was always to ensure that the building was designed around the way the practice worked, rather than having to change working practices to fit in with the design. But – help! – we didn’t know how we worked, as we weren’t a united practice yet, and the architects were keen to get the plans off for approval. So yes, you’ve guessed it, we ended up fitting around their designs after all.

The plan
One year of theoretical planning followed, covering colour schemes, fittings and fixtures (we actually managed to get 15 doctors to agree a colour scheme in one sitting), legals (a new partnership agreement and a tenancy agreement, as this was to be a private finance initiative [PFI] scheme, had to be arranged), and operational and managerial structures, all of which helped with the “getting to know you” process.

Patients – not forgotten in the grand scheme of things – were issued with information leaflets and given many reassurances by the loyal receptionists that they would still have the same staff and doctors in the new “superbuilding”. There were further advantages for patients in that other services, such as physiotherapy and chiropody, would be located in the same place, so no more travelling long distances for these services would be necessary. Life was exciting, challenging and full of promise.

One year on from the Big Idea, planning permission was finally approved and construction began. The building seemed to creep up almost overnight; what had began as an interesting paper exercise became a fairly daunting reality. Completion was due one year from commencement. We were sceptical over this deadline, confidently expecting the customary delay common to all building works. But wouldn’t you know it, the building was finished on the very day, giving those of us involved in the planning, and reassuring of (by now) very worried staff, even more sleepless nights.

… but also
Not only were we planning to open a new, very large practice, but at the same time we also needed to wind up our old practices, which involved terminating all staff contracts (to be restarted with the new practice), closing practice accounts, selling buildings in some cases, and sadly saying goodbye to some members of staff who had opted not to move across and were either retiring or had found posts elsewhere. Looking back, I can hardly believe how much was achieved by so few in so short a time.

The new centre opened on Monday 1 September 2003. Despite all the planning, the problems we encountered as soon as we opened were massive.

The problems
Key issues were:

  • IT – one system for all was decided upon. Ideally, the separate practices would each have transferred their data to this a few months before moving, but conflicting timescales meant the whole system was untried and untested until the opening day. It was only then we discovered that not enough allowance had been made for the number of users and the system slowed to a crawl – something that took a frustrating three months to resolve.
  • Telephones – we expected that, with the same number of staff and patients, the volume of calls would remain the same. In fact, it quickly became clear that extra staff and more lines were needed at peak times to deal with the capacity. Calls took longer due to the slow speed of the computers, and frustration built up rapidly for staff and patients.
  • Building layout – the architects had put the reception desks and records room in separate parts of the building, which meant that staff could not multitask by filing, answering telephones or dealing with walk-in patients as they had in the previous surgeries. We didn’t have enough staff to cover all these areas simultaneously. Also, the sheer size of the building meant staff were spending valuable time delivering notes to consulting rooms situated far away from the records room.
  • Patients expected the same access to the doctor of their choice and were extremely unhappy when this was not achieved, unaware that their doctors’ motivation for moving had been to work differently and diversify into more specialised areas, such as teaching.

The solutions
During the first few months, we shed many tears and lost a few members of the team, doctors and staff alike. However, there was no going back, and we were more determined than ever to make it work. Many more staff were employed for telephone, reception and data input duties, more telephone lines were installed, and the computer bods finally got it right by installing a hard disk big enough for the whole of Birmingham.

Six months on and we were at last where we had planned to be, looking forward to using our size to enable us to work innovatively. The new GP contract was introduced the following April, seven months after we merged. Although we started from a less advantageous point than more established practices, the new system made us focus on areas we had not yet addressed, so a high Quality and Outcomes Framework (QOF) achievement at the end of the first year meant more to the team than mere points and pounds – it represented how far we had come in a relatively short time.

Moving on
To date, we have already achieved many of our short-term objectives. We have developed clinical teams, which consist of a lead GP, a specialist nurse, a healthcare assistant (HCA) and admin support. Each team looks at the roles required for service delivery and identifies the best person in the team to deliver this, thus making best use of clinical time.

Learning opportunities are encouraged across the staff base, and we have internally trained our own clinical nurse specialists in diabetes and respiratory medicine. We are now setting up our own training programmes for reception and admin staff, which have the benefit of addressing matters relative to the way we operate.

The amount of clinical expertise among our team of 20 doctors, many of whom have special interests in particular branches of medicine, is second to none, and enables us to provide the wide teaching environment we envisioned many years ago.

In hindsight
Although we all understood the principles of new buildings and contingency planning, no one could have predicted the problems we encountered in our first few months. However, there have also been many benefits for us as a team, and patients are now more appreciative of the service they receive, although they may not agree with the concept or understand the way the doctors are working to develop more and more specialised clinics for chronic disease management. This approach ensures a first-class service for those who need it, and is the way forward for general practice today.

Would we do it again? During the first 12 months the answer would probably have been no. However, I think it’s a measure of how much we have achieved, and perhaps more importantly how much we plan to achieve in future, that I value the role I now have. The scheme has uncovered talents I didn’t realise I possessed, and I am fortunate to be working with a very special team of colleagues.