Productive practice

Dr Lynne Maher
Director for Design and Innovation,

NHS Institute for Innovation and Improvement

No one will have failed to notice the current debates about healthcare policy and considered the potential impact of the emerging reforms for general practice. Funding has reduced, demand for general practice consultations is rising, the number of patients with complex and multiple conditions is increasing and staff within general practice will be taking on additional responsibilities.

Discussions with general practice teams have highlighted that:

Current processes in their practices are creating additional work and can waste valuable time.
There are increasing demands on their time and practice capacity from external factors like commissioning, the Quality, Innovation, Productivity and Prevention programme (QIPP) and other regulatory requirements, such as Care Quality Commission (CQC) registration.
Changes in profiles and demographics are an increasing concern in terms of capacity to cope and increasing demand.
Work levels in general practice are having, or have had, a negative effect on their work/life balance.

At the very least, practices will be required to take on extra responsibilities with the same resources, and in many cases with fewer. But we all know that there is a limit to how much longer and harder practice teams can work – just continually working harder and harder is unsustainable.

Practices will need to find ways to change the way they work, to become more efficient and release time to take on the new opportunities and responsibilities, while maintaining an excellent quality of care based on the needs of their patients. There could not be a better time for the NHS Institute for Innovation and Improvement to develop the Productive General Practice programme.

As Dr Jagdeesh Dhaliwal, a GP in Smethwick, West Midlands and Clinical Lead for the programme, said: “The current combination of constrained finances and structural change in the NHS offer us a tremendous opportunity to cut waste and streamline services. Patients so often applaud the care and compassion of staff while lamenting the inefficiency of systems. NHS professionals so often express their frustration at the waste of systems that hinder rather than help them to care.”

Productive General Practice is a practical, flexible programme designed to help practices reduce waste and streamline services for the benefit of staff and their patients. It is the latest in the NHS Institute’s internationally renowned ‘Productive Series’.

The Productive Series is a range of programmes that have been implemented in many healthcare settings, for example wards, theatres, community hospitals and community services. These programmes have adopted efficiency techniques previously used in car manufacturing and safety techniques learned in the aviation industry.

The results have been highly effective. For example, ward teams have increased direct care time by up to 40%. This has led to increased safety and quality as well as reductions in length of stay for patients. Successful implementation of the Productive Operating Theatre can provide an average trust with an improvement opportunity of more than £7m, and teams working on Productive Community Services have increased the number of visits by 25%.

The Productive General Practice programme builds on the same methods used within other productive programmes. It enables general practices dramatically to improve internal efficiencies and increase support for clinicians, it results in enhanced quality and continuity of care, increases safety and works to better meet the needs of the local population.

Productive General Practice is:

A team programme based on tried and tested systems and lean thinking.
Aimed at whole practice teams and broken down into manageable, easy to follow, self-directed modules that will allow practices to change areas of their work.
Developed to make it easy for practices to work through each module so that they can build up to completing the whole programme.
Designed to help practice staff achieve vital improvements benefiting patients, staff and their business.

The programme has been developed with involvement from many colleagues from the frontline of general practice, including GPs, practice managers, practice nurses, receptionists and other partners. This includes 17 practices who are actively testing the modules and more than 60 development partners who provide review and comment  on progress.

These practitioners have told us that they need more time to spend with complex patients, improve their service to patients, increase safety, improve team working, manage their increasing workload and take on the opportunities that are offered by the NHS reforms.

Priority areas that practice teams felt could be made more efficient were the organisation of the workplace, the consultation process and the management of demand and capacity. The programme has been developed according to these insights and from working closely with test-site teams. We also have a unique development partnership with NHS Scotland, where two of the test sites are based.

The programme supports staff to:

Identify opportunities to improve how they work.
Use data to drive improvement.
Design out waste, inefficiencies and costs.
Plan ahead for capacity and demand.
Involve patients in service redesign.

Productive General Practice consists of a range of modules (see Table 1) that practices work through in a way that suits them – the practice sets out what it wants to achieve and the pace that fits their local context. The modules provide the guidance needed to examine a single key process in the practice and improve it, or fundamentally to redesign the whole service that they offer.

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The approach encourages the practice to decide on ‘what’ the focus of any improvement should be and then provides a step-by-step process to follow in order to achieve and sustain that improvement, while also building the skills and confidence of staff in improvement tools and methods.

The benefits
Although the modules are still being tested, practice staff have reported a range of findings they are currently acting upon that will result in better quality and lower-cost care. A few examples are described here:

One site established that out of eight consultations undertaken by a GP, one could have been performed by a nurse, two could have been performed over the phone and one wasn’t needed at all. They also established that 10-20% of consultation time was wasted through activities such as patients taking coats off and switching off mobile phones. Staff and patients are now changing the process to make the best use of consultation time. There is significant potential to release time for GPs and streamline the process for patients.
One practice team learnt that 60% of all blood tests were being carried out by a nurse, which they calculated to cost £3.50 per episode. Only 40% were performed by the phlebotomist, who by comparison would cost £1.50 per episode. The practice reviewed their process and extended the phlebotomist’s hours, which in turn maximised their cost efficiency while maintaining quality. This is a high-volume activity and therefore the improvement can yield significant financial return.
The level of did not attends (DNAs) and cancellations had not been the subject of regular monitoring for one of the test sites, as they felt that they had an average level of DNAs. During the programme they monitored DNAs in detail and discovered that they cost the practice £15,000 per year.
One practice discovered that 73 out of the 760 procedures performed by nurses in a single month resulted in appointments that were either DNAs or cancellations. This equated to 9.6% of appointments with nurses and, looking at the detail, this resulted in 16 hours and 35 minutes of lost appointment time for nurses during that single month.

Dr Jim Lee, Nethergreen Surgery, Sheffield, who took part in the pilot, said: “Doing this work has definitely given us a fresh slant on how we do things and provided some really useful insights. It’s a different way of looking at things; you spend hours and hours a week seeing patients but you never sit back and think about what’s happening in the consultation in terms of the processes you are going through. One thing we’ve found is that the things you do over and over again aren’t always the most efficient or productive.”

Practices have also identified that they actually have an abundance of data already available to them that can point to areas where there are opportunities for improvement. However, at the moment this data is often not accessed or presented in a format that provides useful information. Many sites have addressed this by displaying data in a useful format that is visible to all staff.

The Productive General Practice programme can be accessed now, including information about the modules, case studies and films, on the NHS Institute website (see Resource). The test phase will be completed in September and the programme is expected to launch towards the end of October this year.

Resource
Productive General Practice
www.institute.nhs.uk/productivegeneralpractice