General practice is in meltdown. We are struggling to recruit new GPs and a cohort of experienced full-time GPs are due to retire soon. Few GPs seem to want the responsibility of becoming partners. There is an unstoppable cultural force of change; more of the same won’t work. Patients, doctors, staff and care are all suffering.
We and similar practices in Scotland were facing all these challenges. We decided a business based on a social enterprise model, such as that of John Lewis, would allow more equity and free resources to develop the care we deliver.
What we did
We accepted the new reality: more money will not solve the fundamentals. We acknowledged that GPs want to work hard but also want a balanced, controlled environment. Patients, above all else, want access. We sought to address both these issues through our business overhaul.
We now operate at scale with 65,000 patients over five sites in Glasgow, Edinburgh and West Lothian. Culture is key: we have developed a flat management structure, only first names are used and all clinical staff are encouraged to wear scrubs, in a colour of their choice. All non-GP staff are paid more than recommended salary levels and share equitably in a bonus scheme, making payments twice a year. Partners’ income has been capped and all resources are reinvested.
Our guiding group principles are ‘less medicine is more medicine’ and a service based on ‘today’s work today’.
Time is our most limited resource so we have also implemented changes to manage our time closely. We have broken the working day into ‘tasks’ and expressed these as ‘work streams’, as follows:
- Paperwork - centralised paperwork with admin processing 80% of documents and the rest being sent to a single dedicated GP to address.
- House calls - managed by a paramedic (a senior, highly trained and experience clinician).
- Telephone consults and acute prescription requests dealt with by duty doctor sessions.
- Reports completed centrally by one single GP within a declination session.
- Results returned to the requesting clinician and all results communicated by phone or text even when normal. On-call/duty doctor screens all results, acting as a safety net by dealing with all urgent abnormalities that need to be addressed that day.
We used skill mixing with senior nurses taking clinical roles as GP nurses or ANPs - vital in hard-to-recruit areas. We used pooled resources to employ counselling staff, physiotherapists, pharmacists and facilitate weight reduction programmes. These operate to our remit, for example the physios offer an assessment and advice but not ongoing treatment. Counselling is limited to three half-hour sessions with signposting to additional resources. We do not want to reinvent the wheel; we are trying to manage the waiting times for these services.
Importantly, all clinical staff are managed and supported. We have practice policies to limit the use of psychoactive red drugs and antidepressants. We act collectively. We do not see drug representatives.
We addressed access by ensuring that 80% of appointments are available ‘on-the-day’, ensuring the appointments system is not dominated by a small group of frequent returners. We ensured all telephones were answered within five rings even in busy ‘hot’ times, like mornings. We open 7 till 7 in one site and open Saturdays till 4pm. We limit the ability of clinicians to ‘bring back’ patients. We simplified our offering - appointment, telephone call back or house call. The patient decides. Triage does not work.
Changing culture is hard, changing clinical practice is harder still. The art is to have clarity over what you seek to achieve and to keep systems as simple as possible; so much of medicine is over engineered and needlessly complicated, putting unnecessary barriers between patients and clinicians.
Rapid growth has been challenging. With such a large organisation, we found communication was an issue so we now provide a lunch for a weekly practice meeting, and have a WhatsApp group to disseminate information. We also run in-house CPD every few months focused on common clinical scenarios to create some clinical consensus.
But the greatest challenge to general practice is not changing at all.
In general the GPs find the work is more social, the structure inclusive and the skill mixing interesting. Liberating GPs from paperwork and house calls has been a godsend; everyone leaves on time. Morale, running counter to the current narrative, is very high.
We estimate that we are 20% more efficient as a consequence of the changes.
We took one practice with long queues of patients at 7.30 am looking for an appointment, to a situation where we often have free appointments in the afternoon. We have large numbers of patients choosing to join our practices.
We have also been able to recruit and retain staff. This has been further improved by, for example supporting two staff who started in admin through University, both of whom recently returned to work as nurses in the practice.
We regularly seek patient opinion and feedback has been very strongly positive about our changes. We acknowledge we can still do better.
We hope to expand further but most importantly we want to be a catalyst for change. We believe general practice should remain in the hands of clinicians and staff, not corporations. We are evolving into a social enterprise salaried model, where doctors can become salaried partners, which values innovation and efficiency and rewards all staff: an organisation based on a Charter that people can believe in. Importantly, we are actively consulting on a legal framework to ensure that business will pass into the hands of all the staff – clinical and admin – in a model similar to that of John Lewis. Our aspiration is that we want to be the best place to work in primary care. Our only advice to GPs is to embrace change, for it is not a choice. If we can do it, so can you.
Dr Des Spence and Dr Fiona Taylor are GP partners and Kim McWilliams is practice manager at Barclay Medical Practices