Seeing double: expanding GP capacity through teamwork and redesign

UNDER PRESSURE

Like many practices, we’ve felt the pinch from a shrinking GP workforce. Over a period of some years we’ve suffered from GP turnover: younger GPs emigrating to Australia or Canada, with the more senior among us contemplating approaching retirements. Recruitment has faltered and failed.

We responded with some radical ideas and embraced change. This year we merged with a ‘super practice’ to ensure our future viability and we also decided to recruit two advanced nurse practitioners to spread our workload. But we also came up with a novel idea to redesign the GP consultation involving our practice nurses, effectively expanding GP capacity.

CONSECUTIVE CONSULTATION

The idea was simple but challenging. For suitable patients, might it be possible to split the consultation such that history taking and basic observations or examination could be done by the nurse, with the GP then completing the consultation after a brief handover? The nurse then starts a new consultation in the next room — and so on.

Would our nurses support this? Well, it turned out that the nurses saw an opportunity for improving their minor illness and assessment skills through close teamwork with GPs. So a trial session was booked in May 2016. Patients were booked at 5-minute intervals, but each patient experienced a 10-minute consultation between two clinicians consecutively, with the nurse and GP alternating rooms. We scheduled two blocks of 18 patients with a half-hour break between. It was fully booked yet we ran to time and informal patient feedback was encouraging. The GP’s appointment capacity had effectively been doubled.

CLINIC ROLLOUT

To benefit the practice and expand capacity, we needed to deploy these sessions throughout the week. We coined it ‘1-Clinic’ to emphasise its suitability for one problem. To simplify patient booking, we wanted to exclude only the severely ill (physical or mental) or frail. The direct GP input helps support a much wider range of presentations than just ‘minor illness’. Patients are told at the time of booking how the appointment will work and asked whether this is acceptable.

Rollout required our other nurses and GPs to support the clinic and we invited this initially on a voluntary and trial basis. Adaptation of GP consultation style is required, yet only one GP opted out. Far from being a minor illness clinic, we routinely make hospital referrals and sometimes admissions, and have achieved major diagnoses. We have also found the system suitable for follow-ups, medication reviews, and some chronic disease management. We work as a two-person team handling one complex patient stream and, effectively, we have achieved the appointment capacity of an additional GP for the cost of a practice nurse, assuming consulting room availability. Yet the nurse is also available to chaperone, take ECGs, or monitor patients before admission.

ONE YEAR LATER

From day 1, we found that the nurse could often complete a consultation and perhaps just need a prescription signed, particularly if trained in minor illness. This releases the GP to call another patient, and in fact the clinic has naturally morphed into a more flexible operation where consecutive consultation is employed when needed. 1-Clinic continues to remain an essential element of our capacity management.