Success Factors for Working at Different Sizes: Impact, Resource, Expertise, Complexity, Secure/Robust, General/Specific

1. Success Factors Working at Different SizesDr Mike HolmesMr John McEvoyPartners, Haxby Group

2. PRESENTATION SUCCESS FACTORS WORKING AT DIFFERENT SIZES

5. Impact Resource Expertise Complexity Secure/Robust General or Specific ? Communication Inclusivity Local/Personal Simplicity General or Specific ? - EFFECTIVENESS + - SIZE +

7. Workforce Evolution • ‘Invert the Toblerone’ • Upskill Clinical Teams – move work away from GPs where possible (safe) • Evolve the role of the GP

8. IMPLEMENTATION OF PRIMARY CARE PRACTITIONERS WITHIN A GENERAL PRACTICE SETTING Dr Michael Holmes, GP Partner, Haxby Group Dr Kevin Anderson, GP Partner, Haxby Group Jo Smith, Head of Nursing, Haxby Group Shaun Knott, Mark Coultate & Kamilla Gordon, Primary Care Practitioners, Haxby Group Dr Mathew Fortnam, GPST2 and Leadership Fellow in Primary Care, Health Education England Introduction As set out in the General Practice Forward View 1, ‘the success of general practice will also rely on the expansion of the wider non-medical workforce’. Similarly, the difficulties in GP recruitment are well publicised nationally2, with a similar trend being reflected in Hull4. These drivers for change have led to expansion of the non-medical workforce in the form of three Paramedic practitioners, who are helping to aid the provision of urgent care in our four Hull-based sites, which are embracing new ways of working. With the implementation of Paramedics in Primary Care becoming more widespread 3 nationally, the aim of this project was to explore how this process was managed, what governance structures exist and what arrangements are in place to support this relatively new role within the Primary Care workforce, so to inform implementation elsewhere Methods The evaluation currently comprises quantitative and qualitative data, analysing training needs, capability in dealing with an array of presentations in primary care, supervision arrangements and patient reported outcome measures. In order to gain qualitative data, semi-structured interviews with Paramedics and GP’s were performed, whilst patients were asked to fill out a patient satisfaction survey. Quantitative data comprised of number of patients seen, array of conditions seen and the number of patients requiring GP follow-up. What they said.. “There has been a noticeable reduction in our urgent care caseload” Dr Kevin Anderson, GP Partner “Working with the PCP’s has helped me develop my debriefing skills and given me more confidence” Dr Jayne Marston, GPST3, Kingswood Surgery “We have patients ringing up specifically to get another appointment with their PCP” Karen Phillips, Practice Manager, Kingswood Surgery A Day in the life of.. A PCP at Haxby Group On a normal working day, the Primary Care Practitioner works alongside the duty General Practitioner, seeing predominately acute cases independently, selected appropriately via a COMPETENCY-BASED TRIAGE SYTEM, seeing on average ten cases per session. Appointment lengths vary according to experience, however all of the current PCP’s are working to twenty minute appointment slots. The range of cases seen varies according to assessed competencies, with all current PCP’s now working to a high level. They are required to take histories, examine patients, formulate a diagnosis and management plan and currently initiate investigations and prescriptions to be countersigned by their GP supervisor. • The benefit to the organisation • Increased time for GP’s to manage the most complex cases • Broadened skill-mix within the clinical team • Broadened inter-professional learning opportunities • Leadership development opportunities for all staff members involved in the implementation of new role • Cost-beneficial? • The benefit to the PCP • Get to use existing skills in new career • More flexible working hours based around family commitments • Increased professional development and inter-professional learning opportunities • Well supervised working environment • Mentored throughout process • Conclusions • Analysis still ongoing • Demonstrable benefit to the PCP and organisation • Effective utilisation dependent on good quality triage system, supportive mentoring and supervision arrangements. • Building effective working relationships takes time • PCP’s not yet working to full capacity as currently training posts to aid development • Potential for further development of role with greater prescribing responsibility PCP’s in numbers BASED ON RETROSPECTIVE AUDIT DATA Manage99% of cases in Primary Care See 426 patients a month See patients with an average age of 26.8y Manage 95% of cases without need for GP follow-up for same condition within two weeks. Have caseload dominated by patients with ENT, Dermatological and Musculoskeletal problems (see right) @HaxbyGroup References 11 NHS England. Chapter Two: Workforce. General Practice Forward View. 2016 April 2 Royal College of General Practitioners. New league table reveals GP shortages across England, as patients set to wait week or more to see family doctor on 67m occasions; 2015, February 8th [cited 2016, Jul 4, accessed online at http://www.rcgp.org.uk/news/2015/february/new-league-table-reveals-gp-shortages-across-england.aspx]

9. @haxbygroup PROACTIVE PROJECT A Prospective Review of Access, Time Management and Workload to Improve Efficiency Dr Michael Holmes, GP Partner, Haxby Group Sue Heslop, Business Intelligence Team Leader, Haxby Group Julie Lund, General Manager, Haxby Group John McEvoy, Non-Clinical Partner, Haxby Group Lisa Smallwood, Business Intelligence Team, Haxby Group Dr Mathew Fortnam, GPST2 and Leadership Fellow in Primary Care, Health Education England BACKGROUND As the demand for Primary Care services increases, matching the availability of access to capacity is becoming an increasing challenge. This project therefore seeks to review demand, access, capacity and workload in General Practice amongst six surgeries at Haxby Group, an Advanced Training Practice based across York and Hull which serves a combined population of 49,723 patients. The main aim of the project is to develop a model to help distribute workload dynamically to the entire GP team to meet the needs of the patient population. METHODS Over a ten-month period, data has been compiled from across six surgeries, comprising of audit data on administrative workload, task allocation, the demand and utilisation of appointment types, the manner in which appointments were booked and the number of appointments that were unused or not attended. The data has been placed into a monthly dashboard (pictured right) and analysed to show linear trends and reproducible patterns over time. RESULTS • The analysis has proved vital in allowing for specific changes to be made, including: • Increased promotion and utilisation of online environment (Fig. 1) • Increased effort to reduce DNA’s through proactive supportive measures (Fig. 2) • The increased utilisation of the wider GP team through the development of a nurse-led urgent care system • A forecast of reproducible demand to inform capacity in appointment provision across sites and by profession (Fig. 3 & 4) • Delegation of administrative tasks to non-medical workforce (Fig. 5 & 6) Fig 1 Fig 2 Fig 4 Fig 3 Fig 5 Fig 6 • IMPLICATIONS • The data has highlighted a number of different areas requiring improvement and re-design and has led to increased understanding of how the practice can provide their patient population with the best possible service. • The system provides a robust metric to analyse the ongoing impact of specific changes that are made. • The system indicates the value of the evolution of the wider GP workforce through accurate and proactive distribution of workload.

10. QUALITY IMPROVEMENT IN A PRIMARY CARE VASECTOMY SERVICE Dr Michael Holmes, GP Partner, Haxby Group Jo Smith, Head of Nursing, Haxby Group Dr Mathew Fortnam, GPST2 and Leadership Fellow in Primary Care, Health Education England Introduction Day-case vasectomies are increasingly being performed in community-based settings (HSCIC, 2014), with Haxby Group Practice having offered vasectomies to any patient registered with any GP practice in North Yorkshire and York regions for the last ten years. As a result, this has shifted the provision of this service locally towards Primary Care. As an organisation which is striving to provide both a caring and quality service, the team which delivers the vasectomy care were keen to evaluate their work and continuously improve using Quality Improvement methodology. This poster therefore showcases both the nature and the impact of the specific interventions that were made. TEAM PHOTO Methods A prospective audit was carried out to determine potential areas for development in the productivity and efficiency of the service. One key theme emerged; the need for ‘lean’ thinking(Jones & Mitchell, 2006)to streamline and improve patient flow. This encompassed the opportunity to embrace technological innovation, maximise utilisation of resources and improve the patient experience. Data was compiled over fourteen months from April 2015 to June 2016, with baseline data preceding an improvement programme, first implemented at the beginning of January 2016. • Interventions • The implementation of a pre-recorded video explaining the procedure, played during the patient’s pre-operative ‘check-in’ for day-case surgery to aid the consent process, reducing time between patients. • Reduction in the number of days when procedure is performed to create one list, on one day per week at one site. • Full use of three adjoining rooms to the procedure to maximise pre and post-procedural efficiency. • Maximising the role of Healthcare Assistants in the team to aid in the pre and post-procedural process • Results • An average post-intervention increase in productivity of 50% via improved patient flow • An increase in the number of cases performed per session • Reduction in number of sessions held per month • Increase in Patient Satisfaction Service User Feedback “Video was informative and a good time saver ..” “I liked the video - I felt informed & re-assured” “Video - Excellent idea, editing can make sure everything is mentioned and nothing left out..” “Video - very good. Excellent pre-information by nurses then doctor, fantastic a relaxing and care. Very impressed and very professional” Discussion The implementation of service improvement methodology has not only improved productivity and efficiency, but improved the patient experience of the service. To what extent does this improvement programme have the potential to be replicated in other day-case community settings? References Health and Social Care Information Centre (2014) NHS Contraceptive Services: England, Community Contraceptive Clinics. Available at: http://digital.nhs.uk/catalogue/PUB15746/nhs-cont-serv-comm-cont-clin-eng-13-14-rep.pdf Jones, D. and Mitchell, A. (2006) Lean thinking for the NHS. Available at: http://www.nhsconfed.org/~/media/Confederation/Files/Publications/Documents/Lean%20thinking%20for%20the%20NHS.pdf