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Joined-up thinking: new 3-in-1 health centre

17 December 2009

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Practice Manager
Woodford Medical Centre

Dave has 18 years of experience working in the health service, including 11 as a practice manager. He is Chair of the East Midlands Regional Council of the Institute of Healthcare Management


Practice Manager
Fieldhouse Medical Centre

Margaret has been a practice manager for five years. Her background is in continuing professional development, personnel management and quality assurance. Margaret holds the CMA in Business and Administration

CIM Dip Management

Practice Manager
Littlefield Practice

Mercedes has worked in management for eight years, including three years as a practice manager. In addition to management qualifications she holds a degree in International Relations, and has a special interest in IT

“We did it!”

These were the words resonating in our heads on 7 September 2009, when we finally moved to our state-of-the-art new premises – at more than 7,000m2, the largest by far in the area.

The “we” consists of three practice managers from separate practices in Grimsby, North East Lincolnshire: David Holmes, Woodford Medical Centre; Margaret Kersey, Fieldhouse Medical Group; and Mercedes Mello-Jenkins, Littlefield.

It was a life-changing project to say the least. The challenges were immense. These were three well-established practices in the town and, although they share a similar ethos and vision, they were still three different businesses with their own interests. However, we did it! And there are many reasons why it worked.

Plan, talk, plan, talk …
The project started five years ago, and from the beginning it became clear that the managers’ role would be pivotal to the delivery of the project. It was the managers who collated the ideas, defined the vision of the project and worked as a conduit for all the information shared.

Anyone wanting to take on a project like this must be sure that the vision is agreed upon by all involved, otherwise fragmentation will arise, delivery of the overall project and product will be compromised and the very necessary integration of the teams for a project of this size, with the concepts originally agreed, will never be possible.

We knew exactly what we wanted out of our building. Although we still remain three separate practices serving our individual populations, we are willing to come together to provide a number of services and improve patient care/experience.

To this end, we secured space for a number of different health professionals in the building, including our district nurses, health visitors, adult social care, social care workers and both secondary and primary care mental-health professionals.

Other services available in the building include physiotherapy, podiatry, a dental surgeon, a pharmacy, a minor-operations suite and the local health-informatics training suite. In the very near future we hope to add ultrasound and audiology to this list, and we are looking to add further services in the coming months.

The only possible way to achieve our goals was a commitment by the three practice managers to working closely together and, without forsaking the interests of our individual practices, trying to reach compromises. It was a bonus that our strengths seemed to lie in different (and complementary) areas.

The practices
The three practices serve a total population of around 32,000 patients; around a fifth of the total population of North East Lincolnshire. All three practices previously worked from town centre locations but serve patients across the whole of North East Lincolnshire, in both urban and rural locations.

Littlefield is the smallest practice, with around 5,600 patient population, two GP partners and two salaried GPs. The practice is heavily involved in training, providing placements for two registrars, one FY2 doctor, one Year 5 medical student and four Year 3 medical students.

Littlefield offers a range of services, from minor ops to colposcopy, and it has a non-appointment system, which means anyone wanting to see a doctor on a given day can do so without prior booking. The practice holds the RCGP Quality Practice Award (QPA), Investors in People (IIP) and the Chartermark awards.

Woodford has a patient list of 10,000 patients, five GP partners, one part-time salaried GP and one long-term, part-time locum GP. The practice has been a training practice since the start of the local Vocational Training Scheme (VTS) in the 1980s. A GP from the practice has been the local VTS lead since the scheme’s inception.

Woodford has two GP trainers and currently has two GP registrars. It also takes Year 5 medical students from the Hull/York Medical School. The practice offers patients a wide list of services, has a very active patient participation group (PPG) and an appointment system that is a hybrid of “Advanced Access” (on-the-day bookings) but also offers patients the ability to forward book, using both the traditional methods of appointment booking plus online booking. As with Littlefield, the practice holds the QPA, IIP and the Chartermark awards.

Fieldhouse has a patient list of 15,000 patients, four GP partners and four salaried GPs. The practice is currently applying for training-practice status and holds the IIP award. The practice offers an extensive range of services, including minor operations and a very active drop-in family planning service.

Fieldhouse has a mixed appointment system, with pre-bookable appointments up to four weeks in advance as well as on-the-day appointments. The practice facilitates online booking and repeat-prescription ordering, and has an active PPG.

The success of this project was also greatly influenced by the nature of the practices themselves. Although each practice operates in very particular and individual ways, we found common ground in our innovative approach to care, supported by our long history of working together. Our diversity is also one of our strengths.

Benefits for the patients
Despite all of the above, the most important question is: what will this move bring to our patients? The cost benefit of the whole project is so easily proven by the quality of the premises we are occupying now.

The old buildings were dated and overstretched, which was becoming a hindrance to the practices’ innovation. Littlefield and Woodford worked from Victorian buildings, which had both been adapted many times over the years, and neither offered patient parking. Fieldhouse worked from a bespoke medical centre built in 1993, but which had itself been adapted three times since it was built. Patient parking was extremely limited.

By contrast, the new Freshney Green premises have plenty of expansion space (the developer built 25% expansion space at their own risk), and the practices are already holding talks with various services providers to offer outreach secondary care services such as ultrasound, audiology tests and hearing-aid provision. The building has the potential to become a “one stop” health centre, and this is what we aim for.

Ensuring patients were kept informed and involved in the project proved one of the greatest challenges, but with the help of our PPGs we were able to do so. We advertised the move in various media, including radio, television, newspapers and on our websites, in addition to using the more traditional methods of waiting-room notice boards, newsletters and so on. Since January this year, every patient who visited one of the surgeries was given a Frequently Asked Questions leaflet that included details of bus routes and what to expect from the new building.

Patients have been overwhelmed by the new facilities. The space, the modern and clean look (without feeling too clinical) have eased their way to adapting to change. Making sure so many added services were here from the start – such as district nurses, health visitors, dentists, the pharmacy, etc – has also contributed.

Change management
Moving buildings is a major task and can be very unsettling at many levels. Everyone is affected, both staff and patients. As previously mentioned, the managers were central to managing this change. We found ourselves stretching our knowledge and moving so very far away from our comfort zones to what was, at times, nearly breaking point.

We were involved in every aspect, in every minutia and detail. Being involved in the tender process was vital, as we could transmit exactly what we expected for our building. We also found ourselves having to stand our ground as never before with developers, contractors and suppliers. From our perspective, although we were moving from being owner-occupiers to being tenants, we considered that this was our building, whether or not the practices own it – we were the ones who would be working at the new centre here, and it had to fulfill all of our needs.

This approach helped us immensely. Hand­over to the practices, and therefore access to the building, took place four weeks before the opening day. We planned each step of the move well ahead. We discussed every aspect with the involved parties and asked for their input in what could be done to minimise downtime.

Selecting the right people to do the job at hand is key. We had to believe that our developer would deliver what we wanted. We had to have confidence in our suppliers, from the removal company to the telephone systems company. IT for example is a major upheaval, but the Care Trust Plus’s team that worked with us ensured that on Monday 7 September, at 8:00am exactly, we could access our clinical systems and see to patients should the need arise.

Giving everyone the chance to comment, get involved and help with decisions took a lot of the fears and worries away. From an early start we were aware that it would be impossible to please everyone, but compromises can be reached.

Training and educational ethos
For a very long time, all three practices have had a strong educational and training ethos. The whole new building is a testimony to this. The training suite and facilities are second to none.

In preparation, and knowing that we would have the perfect premises, we jointly applied to be a pilot site for the advanced training practice project being rolled out with the support of the strategic health authority. The aim of this project is to develop “Pathways into General Practice” for receptionists, administrators, practice nurses, healthcare assistants, senior staff and managers using already-available local resources while also developing new resources such as competency frameworks across all disciplines.

This work, allied to having existing training cultures in all three practices and the excellent training facilities, is a very exciting development for everyone concerned.

Ownership of the building
The premises development is a Private Finance Initiative (PFI) scheme run as part of North East Lincolnshire Care Trust Plus’s Estate Strategy. Freshney Green Primary Care Centre is the sixth scheme in the strategy, the aim of which is to deliver fit for purpose, expansion-proof buildings for primary care in North East Lincolnshire.

The developer chosen was Assura, who own the building. They were chosen from a total of four tenders after the three practices had researched similar-sized projects around the country.

The tenants are the three practices, a local NHS dentist, Assura Pharmacy, Assura (for the expansion space), the district nursing teams employed by Yarborough/Clee Care (a company set up by the practices to employ the district nursing team) and the Care Trust Plus, which employs the adult social care team, the mental health team and the health visitors, all of whom are linked as teams to the three practices.

What we are not!
We are not a polyclinic. We are not a “Darzi centre”. In managing change to our patients and staff, one theme was consistent across time: that is that we are “family doctor practices”. We knew that, in Grimsby, that is what patients value – family doctor services and continuity of care. Everyone in each practice, from doctors to admin staff, are working very hard in order to maintain the family-doctor feel that we always had, only in much more suitable and modern premises.

Lessons learned

  • Immerse yourself in the details right from the start. You will find that not knowing clearly what is in the room data sheets – and then the plans once they are agreed – may well come back to bite you. Once set, the room data sheets are immoveable.
  • Although very time consuming, thorough planning pays off at the end of the project.
  • Assume nothing. Minute every meeting and conversation – do not assume others leave the meeting/conversation with the same assumptions as you.
  • Include as many people as possible in discussions (about design for example), but ultimately you will have to make many, many decisions yourself.
  • Do not assume that private suppliers are there for anything other than to make profit. Make it very clear in the contracts that you sign what is expected of them – costs, delivery schedules and what they will do with regard project-managing their part of the project.
  • You will be way outside of your knowledge base and comfort zone, so don’t be afraid to ask what you may think are silly or basic questions. If you think we have some strange terminology or acronyms in primary care, wait until you are dealing with contractors and builders!
  • Keep everyone – staff and patients – informed of progress all along the way.
  • The project will take over your life. Have someone to share the load with if possible. You will have to find a way to manage your normal work, especially the further into the project you go. Share your concerns with others and delegate wherever possible.
  • Take time out when you can, and plan a holiday for after you move in to allow yourself to recharge!

Freshney Green Primary Care Centre is a magnificent building. It provides the base to enable the doctors and staff to deliver 21st-century healthcare to the patients of North East Lincolnshire and is, we believe, as future-proofed as any such building could be.

So remember: however difficult things become, however stressed you are, it is worth it!