Locums are in high demand as GP surgeries look to better manage increasing demand and provide equitable access to care. However locum GPs are expensive and also increasingly becoming hard to find.
Until a few months ago, we were regular users of locums at our practice Portland Medical in south London. Our patient list has been growing rapidly – it now stands at more than 14,000 – and we were experiencing high numbers of patient contacts. Some of our GPs had retired, and we needed the reactive cover that locums could provide.
Yet we saw that the one or two locums we used each year were not helping us deliver improvements in access and managing demand. People were still having to wait several days for an appointment. The pressure on staff meant morale was low, and staff absence rates were high.
The financial impact was also noticeable. Even though we could use NHS England's winter access funding to cover some of our locum costs, our locum spend was around £70,000 every year. We knew we had to find a better solution.
Optimising our practice workflow
Our answer has been to improve our workflow and adapt our workforce so that we can quickly and effectively direct patients to the right healthcare professional. We have made use of total triage technology to enable us to make this change.
We mapped out a patient journey that began when an individual contacted the surgery, and then looked at technology solutions that could help us improve this. We opted for a system called Klinik, as it provides the digital triage and patient flow technology that could support our objectives.
With Klinik, patient enquiries are handled in the same way whether they go online, or they contact the practice by phone or who walk in.
Patients, practice call handlers or receptionists follow a simple, clinically-designed questionnaire and symptom body map to indicate need. The technology adapts the questions dynamically according to the responses given, so that patients do not get asked for irrelevant information.
The system then analyses those responses to prioritise cases in order of urgency and provides helpful differential diagnoses. The resultant patient information is passed to a triaging clinician based in a traige hub in the practice staffed by our clinicians working on a rota.
Urgent queries are reviewed immediately and, when required, forwarded to the relevant team. Routine enquiries are offered an appointment at the patient’s convenience. Out of hours, patients are redirected automatically to other services such as 111.
Often the triaging clinician can make a diagnosis based on the suggestions provided, and deal with the enquiry directly with a text or a quick call back. As this does not involve other staff, this reduces the pressure on the whole practice team. When patients do need further support, the triaging clinician can direct patients on to the right pathway for their needs.
Ensuring patient safety
We recognise that there is a concern that using technology such as this could mean that something important may be missed. We made sure we were rigorous in reviewing sample cases before we went live to ensure the accuracy of the system’s recommendations. This led to some improvements in how the information was presented to us. Since we have been using the triage software we have never found anything important had been overlooked.
We still undertake regular and thorough checks to validate the recommendations provided by the system. It is important to remember that the suggestions provided by the software are there to reinforce and not replace the clinical decisions made by the triaging clinician. All cases are seen by a human, who will ultimately decide the outcome.
How we changed to better meet demand
To ensure the effective introduction of this new way of working, we tested out the system with patients and staff in a development environment. By doing this we could see how the technology would work in practice, and this led to some minor adaptations to how information was captured and processed.
Of course there were some negative reactions from patients at first. However once people had seen and used the system a few times, they could see how it would help us provide a more effective primary care service.
In addition, the data captured by the system has given us much greater insight into the clinical needs of our population. This has had a positive impact on our workforce and our locum spend.
As a result of knowing more about what our patients need, we have expanded our multidisciplinary team to include a wider range of skillsets that can closely match patient demand. A physio, for example, is often better than a GP at treating musculoskeletal issues. Our expanded team of allied healthcare professionals includes paramedics, pharmacists, physician associates and nurses who work with GPs to provide the right care for our patients.
Better matching resources to demand has also meant we have been able to cope with a reduction in GPs, that has happened as a result of GPs retring, from approximately 8 to 4.5 full-time equivalents. This reduction was due to cutting our use of locums, and through natural turnover as older GPs retired. We have now been able to reduce our locum spend to zero.
Equity of access has also improved. Around 60% of patients now contact us online, which has freed up phone lines and staff so we can provide fairer access through other channels. The Monday morning rush for appointments has gone.
Changing how we work
The impact of sharing practice workload means we can deal with greater demand without causing more stress to staff, and we can give them more flexibility in their role.
GPs are now able to rotate more easily between triage, remote consultations and face-to-face appointments. Patient call-handlers can work remotely, using a structured process that delivers consistent results.
Patients also benefit, as GPs can more easily have an extended 15-minute phone call consultation. Face-to-face appointments can be extended to between 20 and 30 minutes, which means we are able to deal with all the patient's problems in one go without them having to return later.
Staff absence rates have fallen from up to 8% to between 2-3%. Patient and staff satisfaction rates are good. Call times have increased slightly, but reception teams are much less stressed because they know they are helping patients based on need.
How could others approach this?
Our improved workflows and evolving workforce enable us to answer patients much more efficiently. Making this happen has not been without its challenges; some staff and patients were initially reluctant. However, by involving them in the development of our new approach, they soon recognised the benefits.
Numerous systems are available to help support the improvements similar to ours. We chose the one that works for us. We would advise others to take a look at what each system can do and speak to other customers. And good luck. Change is never easy, but we have found it can be very positive too.
- Dr Tomar is a GP in south London
