The General Practice Improvement Programme - Case Study

Fast, practical improvement

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General Practice Improvement Programme

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The perfect storm facing genera We believe general practice is facing a perfect Practices tell us they are under pressure from:

Practice Brief This short brief will show you how the General Practice Improvement Programme (GPIP) works and how to get the most out of it for your practice.

• Ageing population, resulting in increased activity per pa • Increasing prevalence of lifestyle related illnesses, resulti and more activity per patient.

• Increasing demands from patients both in terms of qualit time for services offered.

• Increasing scrutiny from central and regulatory bodies w GPs and other practice staff.

• Increasing running costs against fairly static funding arra

We understand that in general practice this pressure gets pe practice staff of all types feeling a huge amount of personal

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How the General Practice Impr Programme (GPIP) helps

Provides practices with fast, practical improvement and support to cope with the huge and increasing pressures of patient expectations, age related activity, lifestyle related dependency & activity, scrutiny and uncertain funding arrangements. Helps practices create “head space”in the perfect storm.

ward downham improvement design

A joint development by KM&T and wdid

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The General Practice Improvement Programme (GPIP) provides fast, practical, practice improvement to help reduce pressures and release efficiencies within general practice.

Working through 5 high impact areas, and following a ‘Teach, Simulate, Do’ philosophy, practice staff are empowered to make real and lasting change that benefits both patients and practice staff.

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Chasing the Tail Improvement Area:

Chasing the Tail

Practice:

Large, urban, multi-site practice, 20 000+ list size, England

Date:

March to June 2014

The Practice This practice is a large, urban practice across three different surgeries. It is a well respected practice that consistently delivers high quality care and experience for its patients. A large proportion of its 20 000+ patients are registered to its university surgery. This adds a layer of complexity and variation on demands to its services. It’s other surgeries offer services to a more typical demographic spread, facing the pressures from the increasing prevalence of lifestyle related conditions and an ageing population.

The practice is professional progressive and ambitious. It is not only looking to grow its range of high quality services offered, but also its list size. The practice believes in tackling the pressures it faces through improvement and so were keen take up GPIP. GPIP was commissioned by the practice’s CCG – a CCG that is keen to support practices with the demands they face, through building improvement capability and confidence.

The Improvement Area Chasing the Tail is one of the key improvement areas in GPIP. It is a unique and new look at how a practice manages its high frequency patients.

With expert GPIP coaching, the practice learns how to collect, analyse and interpret datasets from their practice systems. Then the practice carries out a structured MDT meeting format (and data collection) that uses a structured problem solving approach to identify interventions for high volume users their ‘frequent flyers’. These meetings, held bi-weekly, help to release capacity, identify risk and increase consistency across the practice.

As with all GPIP work areas, the work started with a short briefing from the GPIP expert coach. This was with the team which the practice manager had brought together to work on Chasing the Tail. In this case the team consisted of two GPs, a practice nurse and the practice manager herself.

“The programme gives you that way of thinking and questioning what’s happening from a positive viewpoint. We’re very quick to react when things go wrong or are not working, for me this was a way of looking at things that were working, but how we could make them much better.”

Practice Manager

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Diagnosis Deciding on the improvements: The improvements associated with Chasing the Tail are centred around the patient, the practice and strategic practice level.

The practice looked at what the data was telling them first. This meant looking at the graphs and taking the organizational learning from them. At a high level there were three vital pieces of learning for the practice: 1. That they have a large proportion of patients who have not attended in the past year (approx. 40%). Although it was expected to some extent, the number was not. This identified challenges on two levels. The first being that the practice needed to engage in dialogue with those patients not attending, and identify those at risk or who should be using additional services such as smears. Secondly, that due to the large number of patients in this zero attendances group, it would pose a business risk if there was a significant shift in their activity. This is because the practice is already flat out and has already received funding for these patients. Thus the practice identified that it needed to explore this group of patients in a deliberately cautious fashion.

2. That the age of a significant proportion of the patients who are medium to high attenders (30+ attendances/ year) was much lower than first thought.

3. That if the practice could look at reducing its overall activity (65k+ contacts / yr) by just 5% (through internal challenge of the frequency of some patient groups) it would provide the opportunity to increase the practice list size by around 1150 patients – without the need to increase resource. Thus potentially bringing in £74k extra revenue.

The Benefits • Large group of zero visit patients now targeted for communication.

• Practice to explore the provision on Mental Health and Eating Disorder support for the newly identified patient group of med/high attending yet young patients.

• Opportunities for greater levels of supervision identified following initial patient review.

• Greater awareness of business issues across the whole senior practice team.

• Renewed awareness of the need for regular multi-disciplinary reviews of patients.

• Opportunity to increase practice list by 1150+ patients.

• Potential increase of 74k+ revenue.

“We would have never done this with everyone in the room - reviewing patients - unless it was a serious incident or a palliative care patient.”

GP Partner

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Chasing the tail Improvement Area:

Chasing the Tail

Practice:

Medium sized practice, market town, semi rural setting, 8000+ list size, England

Date:

March to June 2014

The Practice This highly thought of practice is situated in a historic market town around ten miles from a major city. As with other practices in market towns, the population the practice serves features a large proportion of elderly patients who, in addition to having complex health needs, are often isolated and vulnerable.

The practice is well regarded locally and is seeking to grow both in terms of list size and services offered. It is situated on the boundary between catchment areas which means in some cases there are grey areas in the availability of some support services. The practice has a relatively stable workforce and has had some relatively new appointments to the senior team. The practice has undertaken GPIP as it is looking to meet the increasing demands it is facing through improvement.

GPIP was commissioned by the practice’s CCG - a CCG that is keen to support practices with the demands they face, through building improvement capability and confidence.

The Improvement Area Chasing the Tail is one of the key improvement areas in GPIP. It is a unique and new look at how a practice manages its high frequency patients.

With expert GPIP coaching, the practice learns how to collect, analyse and interpret datasets from their practice systems. Then the practice carries out a structured MDT meeting format (and data collection) that uses a structured problem solving approach to identify interventions for high volume users their ‘frequent flyers’. These meetings, held bi-weekly, help to release capacity, identify risk and increase consistency across the practice.

Analysing the data: The practice worked up to a valuable meeting with all of their senior team. To ensure this meeting was well used the data extracted and early analysis was done beforehand. The first piece of analysis looked at the top 23 of the most high frequency patients on their list.

“We did have one patient who was our highest user who we spoke to nearly every day and we did manage nearly 10 days without management. They are not contacting us as much through the Chasing the Tail work. They had 102 doctor contacts in the last year. We now have a plan for the patient which everyone understands and we can put into action what we have collectively agreed. ” Practice Manager

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Diagnosis Deciding on the improvements: Considering both patients a total of 18 separate actions were identified. These were transferred to an action plan where clear accountability for who was taking on the action was visible. After the first review, the next two Chasing the Tail sessions covered 24 patients. This essentially meant a rapid six-minute review per patient and requires the practice to keep to the structured approach to ensure the most is gained from the time put in. Across the 24 patients 80% had opportunities to be managed differently identified by the multidisciplinary team – the majority being around a greater holistic nature to their care.

The practice found those patients where only clinical areas were identified as opportunities for improvwement as relatively straightforward and quick to review. For those patients where the opportunities in the areas of mental health and/or social support the review took a little longer. While the reviews were designed to be rapid both the practice and the GPIP coach took great care when reviewing the patients as many of this high frequency group were also the practice’s most complex and vulnerable patients

The Benefits • Greater understanding of the activity characteristics of their patient population.

• Greater understanding of where their capacity is used across the practice.

• 18 improvement actions identified in just the first two 6 minute patient reviews.

• 80% of patients reviewed had opportunities identified.

• A huge buzz from the practice team and GPs competing to become the next lead for improvements.

• Confidence that improvement methods really can make a huge difference.

• Greater understanding of each others roles and expertise across a multi-disciplinary team.

• The practice has now gained a forum for structured nurse to GP and GP to nurse check and challenge.

“The numbers that came out of that were a real eye opener and everyone we have told within the practice in terms of the value of the piece of work and understanding where all your appointments disappear to – that for us was the biggest game changer as it is making us realise there are things we can do to create this head-space that this is all about. ” Practice Manager

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Workforce Planning Improvement Area:

Workforce Planning

Practice:

Large, urban, multi-site practice, 20 000+ list size, England

Date:

March to June 2014

The Practice This practice is a large, urban practice across three different surgeries. It is a well respected practice that consistently delivers high quality care and experience for its patients. A large proportion of its 20000 + patients are registered to its university surgery. This adds a layer of complexity and variation on demands to its services. Its other surgeries offer services to a more typical demographic spread, facing the pressures from the increasing prevalence of lifestyle related conditions and an ageing population.

The practice is professional, progressive and ambitious. It is not only looking to grow its range of high quality services offered, but also its list size. The practice believes in tackling the pressures it faces through improvement and so were keen take up GPIP. GPIP was commissioned by the practice’s CCG - a CCG that is keen to support practices with the demands they face, through building improvement capability and confidence.

The Improvement Area Workforce Planning is one of the key improvement areas in GPIP. It is centred around the use of pragmatic planning techniques to ensure the correct planning of staff at year, month and day level. After all, it is not good having the best staff in world if they are not in at the right times.

The Improvement Area involves some analysis but this can all be done with a calculator. I.T skills are a struggle. The entire improvement can be completed in three half-day visits.

The staff at the practice were feeling under pressure on delivering their services. Working days felt very busy and staff were having to work late to catch up as clinics overran. The senior team felt that they had to do something to alleviate the pressure and that the way they organised their team was one area to look at.

Taking the learning from the data: During this sense checking stage, observations about the analysis were listed, as were some potential new working principles that come from the observations. While these observations and principles were not a ‘solution’ they would help structure and speed up the discussion with the senior team so that decisions could be made when they met later in the day.

“It has already highlighted further pinch points for the coming year – so that we can now do something about it before they happen.”

Practice Manager

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Diagnosis Deciding on the improvements: The senior team, facilitated in combination by the GPIP coach, practice manager and lead GP, worked through the analysis, observations and improvements. Because the meeting was well structured, a lot of ground was covered in a very short period of time. The senior team very quickly made the connections with this work and some of the big strategic decisions the practice faces

The Benefits • The decision making process, on a complex area, was achieved in a short time-frame – while still being inclusive (something the practice had previous had difficulty in achieving).

• The proposed contracts for new GP recruitment have been changed to better suit the practice requirement.

Previously they would have just repeated the pattern of spreading sessions evenly over the year rather than when the practice actually needed them (busiest times).

• Agreement was made on new ways to manage holidays and sickness.

• The senior team are now more aware of the impact of individual actions on the whole practice’s staffing.

• New visual staff availability planner has been put into action.

• Pinch points have been identified for the coming year.

• A new ‘standard’ level for sessions has been calculated to take into account natural fluctuations such as sickness, holiday and training.

“We now have a staff availability planner where we have the minimum levels that we won’t drop below, so we can afford at certain times a year to give so many sessions to meetings or leave, but once we reach the level we set there is no point asking as we are not going to drop below that level. It has provided a safer working environment.”

Practice Manager

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Feedback “I would encourage practices to do the programme. One of the things in general practice is that there are so many things going on all the time and people are very busy. People may be worried that this is something else being added to the mix.

But I would really encourage them to undergo the programme, it’s been a very worthwhile process.”

Practice Manager

“GPIP has allowed us to free up a significant amount of time just by intensively looking at a very small cohort of patients. Something we have wanted to do for years but never had the chance to do so.”

GP Partner

See what practices and CCG’s are saying about the programme at:

www.gpip.co.uk/video

This short brief will show you how the General Practice Improvement Programme (GPIP) works and how to get the most out of it for your practice.

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ward downham improvement design

A joint development by KM&T and wdid

GPIP is a joint venture between KM&T and wdid KM&T and wdid are the perfect match for developing high quality improvement programmes and campaigns.

KM&T (Knowledge Management and Transfer) offer a track record of supporting national improvement programmes for the NHS, expertise in large-scale mobilisation, considerable resource and a high level of technical improvement expertise. www.kmandt.com

ward downham improvement design

wdid (Ward Downham Improvement Design) offer local and national improvement programme development and leadership expertise. They are the team behind many of the most successful improvement programmes ever seen in the public sector. www.wdid.co.uk For more information on GPIP: Website: www.gpip.co.uk

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How it

For more information on GPIP: Website: www.gpip.co.uk Telephone: +44 (0) 247 623 6275 Email: info@gpip.co.uk GPIP Support Line (for practices implementing GPIP): Telephone: +44 (0) 247 623 6275 Postal Address: GPIP Team KM&T Ltd The Techno Centre Puma Way Coventry CV1 2TT ©Copyright Knowledge Management and Transfer Ltd/Ward Downham Improvement Design Ltd 2014 – All Rights Reserved

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