Joanna Bircher is a GenerationQ Fellow and Clinical Director for the Greater Manchester GP Excellence Programme. She is also a GP partner at Lockside Medical Centre in Stalybridge and Quality Improvement Clinical lead for Tameside and Glossop Clinical Commissioning Group.
Bryan Jones is an Improvement Fellow at The Health Foundation.
Mike Jones is a GP and GenerationQ Fellow. He is also a Deputy Medical Director of the Hurley Group GP Partnership and the National Quality Improvement Clinical Champion for the Royal College of GPs.
In recent years an increasing number of GP practices across the UK have been using quality improvement (QI) methods to improve the way key services are designed and ultimately to offer higher quality patient care. This has included using QI to make COVID related services, such as vaccination clinics, as efficient and safe as possible, and focussing on long-standing issues including how to improve patient access to appointments and services. In doing so, many practices have worked closely with neighbouring practices in their federation, primary care network or GP cluster. For many practice teams it has been a liberating experience. Here we share our learning from two QI interventions which were planned and delivered during the pandemic to show tangible examples of what can be done.
Case Study 1:
This focuses on efforts to improve triage processes by a practice in East London. In March 2020, during the early pandemic, NHS England advised all GPs to move to a ‘Total triage’ model, where every patient contacting the practice is triaged before an appointment.1
The Hurley Group, an NHS partnership serving 100,000 patients across London, had already consulted electronically for 7 years – providing an additional access route into surgeries. Pre-pandemic around one quarter of consultations were started online. Patients opting to consult electronically were generally happy, with 82% surveyed choosing ‘satisfied’ or ‘very satisfied’.
COVID meant there was a need to step up a gear. The team wanted to convert all eligible on the day demand to online (eConsultations2) by June 2020, while maintaining patient satisfaction.
The electronic route is not appropriate for every patient, e.g., non-English speakers or the very young, so a bespoke hybrid model was introduced whereby a code and pop-up were added for around 30% of patients to whom teams were asked to consider offering alternative consultation pathways.
Data relating to on the day demand was measured, including both timing and volumes of calls and eConsultation submissions, and when each case was processed. The team calculated proportions of phone, face to face and eConsultations which were offered, and collected patient satisfaction scores and feedback via surveys automatically sent out one week post-consultation. The quality of eConsultation management was audited throughout.
The programme’s multi-disciplinary working group identified a range of primary and secondary factors, and devised change ideas, which would help achieve the objectives:
- Prioritising patient engagement meant patients were kept up to date via texts, emails, letters, and an evolving website and telephone message. They were invited to contribute to the transformation throughout.
- Swift optimisation of infrastructure meant that tech support, laptops and software quickly facilitated remote working, meetings, and communication. The dedicated cross-site remote-working eHub team was expanded and admin processes were remapped.
- Staff engagement comprised wellbeing and pastoral support programmes, enhanced communications which included regular COVID newsletters, and more frequent huddles. Some colleagues volunteered to be ‘eConsult First champions’ which helped further cultivate support and reduce anxiety within teams. Some staff were redeployed, and videos and documents were created to augment education on a 1-to-1 or 1-to-group basis.
Impact and learning
Initially, all clinical cases arriving electronically between 8am and 2pm were looked at on the same day. This eventually stretched to include work up to 6pm. Proportion of consultations started electronically soared to 65% in 6 months. Moreover, while satisfaction scores transiently dipped to 64%, they bounced back up after 6 months to 76% once the process became more familiar to patients.
…..the empowerment of all those on the ground to speak up…..
- Regularly checking in on the ‘health’ of colleagues – both individually and as a collective team.
- The ability to collect and interpret good quality data. Robust searches developed at the outset helped hugely.
- Readiness to adapt quickly, e.g., to revisit those in the ‘consider alternative pathway’ cohort, or to modify numbers of slots for eConsultations depending on proportion of staff working at home, on site, or off sick.
- Well-defined channels of communication, both from and within the working group – including dedicated time to stand back, observe, and study progress. Especially the empowerment of all those on the ground to speak up when problems arose, e.g., the admin team who noticed the practice inbox was full when it all felt ‘too quiet’. Clear governance procedures, including recognition and reporting of, and learning from such significant events proved crucial.
Case Study 2:
This looks at an intervention by Lockside Medical Centre. This is a suburban single-site training practice of 8,100 patients in Greater Manchester. For years, the leadership team had puzzled over how best to match the clinical workforce with day-to-day patient demand. Prior to the pandemic the practice offered routine face-to-face and telephone consultations and a book-on-the-day service. The only criterion that needed to be met for a patient to have access to the same day service (which was a telephone appointment in the first instance) was that the patient felt their issue could not wait until the next available routine appointment.
No requests for routine appointments were triaged and the average wait for a routine appointment was usually between 14 and 21 days. It was clear that a service based mostly on pre-booked appointments provided very little workforce flexibility to account for days when demand for care was higher. This traditional model also failed to recognise the ‘hidden’ work of general practice, for example dealing with complex results, post-discharge follow-up, patient queries related to hospital appointments and the management of a safe repeat prescribing system.
The team took a QI approach to looking at the issue in terms of:
- Understanding the context.
- Understanding the problem.
- Testing out some changes.
Understanding the context
The move towards a total triage model as advised by NHS England at the start of the pandemic resulted in significant changes to the traditional model described above, which was helpful when approaching the project – patients were open to new ways of working. A wide range of QI projects have been implemented over the last 7 years so the whole team was familiar with the concepts associated with this. Finally, many of the clinicians were not full-time and were able to be flexible within certain limits.
Understanding the problem
Some aspects of the issue were already understood:
- Pre-booked surgeries make it harder to be flexible when on the day demand changes.
- Much of GP work is hidden and yet can involve significant time and patient contact.
The things that remained unclear were:
- How much hidden work do GPs do, and how much time does this take up if we aim to deliver this to a high quality?
- How much work can a GP comfortably do in a day and still get home on time, and how is this impacted if that GP is also supervising a Specialty Trainee or medical student? How much work can a Specialty Trainee comfortably deliver whilst maintaining their educational experience?
The new appointment book was designed so that all patient-related activity (other than the management of normal investigation results), would be recorded and measured. The set-up of the appointment book was a parallel QI project and was subject to several small cycles of change during the project period, and is still being adjusted.
There was a six-week measuring period in August and September 2020. The total number of patient encounters per day was measured and clinicians were encouraged to work at the pace they felt was comfortable for them and the average number of patient-related activities per clinician, per session was calculated.
For the first time the team had a detailed picture of their work.
For the first time the team had a detailed picture of their work. They used this data to set the number of clinical sessions needed each day to be able to match patient care needs/demands which accounted for the complexities of work including training and supervision. The clinicians have offered flexibility in their sessions to fit with this model of working, something that has been facilitated to a certain extent by remote working. Whilst clinicians can still arrange suitable follow up for their patients, there are no longer any delays for routine appointments and all patients who contact the practice receive a response on the same day.
Impact and learning
For the first few months of running the model, workload seemed to match the workforce. However, in terms of daily workload, it would appear that the move to faster access to care has fuelled greater demand. Despite good access to other first contact services such as NHS 111, community pharmacy, optometry, podiatry and MSK services, the online consultation model may have the result of making general practice the most accessible of the NHS services, alongside the emergency department. It is possible that long waits for a routine appointment, or waiting times for phone calls to be answered, whilst not a good experience for patients and being potentially unsafe as it may mean people with serious conditions don’t consult, did serve to limit demand, as some people decided to look to another service to help, or found their condition improved without intervention or advice.
Key learning points:
Factor in enough time to understand the challenge you are trying to address and to plan your approach.
Lockside found the time they spent at the start working out what they understood, and, crucially, what they didn’t understand about their improvement challenge, had a vital bearing on their ultimate success. Their experience shows how important it is not to rush to implement a solution before you’ve fully got to grips with the problem you’re trying to solve.
Think about what data you need to collect and how you’re going to analyse it to help you measure the impact of your changes.
For the Hurley Group, getting agreement at the start about what searches were needed and how they’d be delivered and analysed, proved to be a key success factor. The same was true of Lockside – only by building a complete picture of everything the practice’s GPs did over their working days, was it possible to match capacity with demand.
Pay close attention to the day-to-day impact of the changes you are making, and be ready to intervene quickly to adapt your intervention if necessary.
Factor in enough time to understand the challenge you are trying to address.
Think about how you communicate and take the time to find out how people are coping with the changes being made.
For a large partnership like the Hurley Group, getting the communications right was of paramount importance. As well as ensuring effective communication within the working group leading the intervention, they worked hard from the start to build awareness and support among other staff and patients. A key goal of this engagement activity was to understand how people felt about the changes, and to use this feedback to adjust their approach if necessary.
Expect the unexpected and think about how you’ll respond to unforeseen impacts.
No improvement intervention ever runs entirely according to plan, and sometimes – as Lockside discovered – it can cause some unforeseen consequences. It pays, therefore, even when you’ve met the aims you wanted to achieve, to keep an eye on how it might be affecting other aspects of your practice’s work, or other parts of your local healthcare system.
Further reading
RCGP. Quality Improvement Guide for General Practice. 2016
Health Foundation. Quality Improvement Made Simple. Third Edition 2021
References
1. https://www.pulsetoday.co.uk/news/uncategorised/nhs-advises-total-triage-as-gp-groups-look-to-limit-patient-demand/
2. The Hurley Group employs the ‘eConsult’ system
Featured photo by Matt Ridley on Unsplash
