The burden on general practice continues to increase year-on-year, with an estimated 307 million general practice appointments having taken place between November 2017 and October 2018 in England.¹ It is no wonder that GPs and practice staff find it challenging to keep pace with this demand.

Practices are under pressure to find ways to be more efficient and make the most of their resources and staff. There are many examples of how they achieve this. Some are working in partnership with patients to empower more control over self-help methods such as the ‘Promoting Self Care’ programme; others are declining non-compulsory non-NHS work such as private sick notes, and occupational health vaccinations.

SIGNPOSTING

One of the ways of dealing with the burden is the change in skill mix in general practice. There have been significant workforce transformation changes with the introduction of varying roles, for example, practice-employed pharmacists,paramedics, physicians, who are all helping to free up some GP appointments, along with the well-established group of practice nurses, advanced nurse practitioners and healthcare assistants. Between January and October 2018, 45% of appointments in general practice were undertaken by other healthcare professionals, with GPs taking 52% – data was not available for the other 3% of appointments.¹

But is this confusing for the patient? Are some appointments wasted as patients are signposted to the wrong healthcare professional? How do the overburdened reception staff know which clinician a patient should see?

Active signposting initiatives should be implemented to ensure patients are seen by the right clinician.

WORKFLOW OF DOCUMENTS

Some practices are introducing new workflow systems for documents, to enable non-clinical staff to better manage inbound correspondence.

Implementing this way of working enables many practices to work more efficiently with staff, patients and hospital correspondence. This includes using trained non-clinical assistants to process inbound correspondence.

There are undoubtedly advantages and risks in this approach. By using a clear and agreed workflow, non-clinical staff can carryout delegated work where it is safe to do so, leaving GPs to deal with those letters requiring medical input or oversight.

Historically administrators at the practice would have the responsibility of scanning letters onto the practice system, which were then forwarded to a GP for action. This would mean that GPs had responsibility overall correspondence. Some of those letters may however not necessarily have needed to be seen by a GP.

By introducing the new workflow system many practices have implemented a change in the practice process, which includes:

• Developing a workflow practice protocol ensuring the process is safe and clinically appropriate.
• Training administrators to deal with high frequency, low risk letters, ie those that do not need to be seen by a GP – such as certain low risk ‘did not attend’ letters and diabetic retinopathy screening notifications.
• Training administrators to add Readcodes for diagnoses, procedures and values from the letters onto the computer system, so that on viewing the letters, the GPs can deal with  actions that are required without the workload of doing the coding.

Nick Sharples, from NHS Networks, stated in an article entitled ‘A Guide to Effective Fast-Track Implementation’ (January 2018) that “Correspondence Management and Workflow Optimisation programs, often combined as a single program, deliver significant reductions in the amount of correspondence reaching the GP’s desk (about 80%) saving around 45 minutes per GP per day.”²

TOP TIPS

There are some key points to consider when implementing a correspondence management system:

• It is essential that staff dealing with correspondence are trained in both ‘Read coding’ and document handling, particularly on the type of letters that need to be seen by a clinician.

• You will need more than one member of the team to be fully familiar with ‘Read coding’ and document handling.
• Are there protocols in place and flowcharts accompanying the training?
• Following training, are staff assessed for their competency on this process?
• Training should include the importance of maintaining patient confidentiality;do staff undertaking this task sign a comprehensive confidentiality agreement? This is extremely important, as many of the non-clinical staff may live in the practice locality – and ensuring patient confidentiality is essential.
• Staff should be reminded throughout the training that if they are not sure about a particular letter, they should ‘ask’ rather than ‘second guess’ its importance.• When the process is in place, clinicians should undertake regular audits, sampling 30 – 50 letters per week.
• Maintaining an incident reporting log for staff to complete if a letter has been incorrectly workflowed is also essential.These incidents should be reviewed and discussed, and any action from the discussion implemented and documented.

PROFESSIONAL OBLIGATIONS

The medicolegal risk for clinicians is considerable in this process: for example, a letter that is not followed up could lead to a delay in diagnosis, and subsequent harm to the patient.

When a clinician delegates a task to a non clinical member of staff, they must ensure that the processes are robust and safe,and that members of staff are trained and competent to undertake this task.The GMC states in paragraph 4 of its Delegation and Referral guidance:⁴

“When delegating care you must be satisfied that the person to whom you delegate has the knowledge, skills and experience to provide the relevant care or treatment; or that the person will be adequately supervised.If you are delegating to a person who is not registered with a statutory regulatory body,voluntary registration can provide some assurance that practitioners have met defined standards of competence and adhere to agreed standards for their professional skills and behaviour.”

The GMC goes on to clarify in paragraph 5:

“When you delegate care you are still responsible for the overall management of the patient.”

A ROBUST AND SAFE SYSTEM

Delegating the task of reviewing letters to non-clinical assistants may be an attractive proposition to reduce some of the workload pressures on GPs. However, before implementing such a workflow system,clinicians need to consider the risks and benefits carefully and ensure the system is robust and safe, and includes staff training,monitoring, audit and incident reporting.

TIPS

• Provide signposting training for reception staff to assist them to coordinate the flow of patients to the appropriate clinician.

• Develop a flowchart of the roles and responsibilities of the clinicians and types of medical conditions each healthcare professional is competent to review. Make this available on the reception desk.You may also wish to display a larger edition of the flowchart in the reception area for the attention of patients.

• Detail the roles and responsibilities of the allied healthcare professionals on the practice website to assist patients in their understanding of the roles of each clinician.

CASE STUDY

NHS Networks provides information about the process, including some case studies of practices who have successfully implemented the system.

For example, Wincanton Health Centre in Somerset detailed how they approached adopting a new system of working.³ The five GPs at the practice were feeling overwhelmed with burgeoning admin work, but found the solution was in working smarter, not harder.

A senior member of the admin team would firstly go through the post and weed out the letters that needed to be seen by the GPs, sending the remainder to the admin team for task completion, coding or simply for scanning if no action was required.The initial letter reading was checked by a second senior staff member to ensure there were checks in the system. The general rule of thumb has been if there is any doubt then the letter should be presented to the GP.

The impact was notable. The number of letters being workflowed to the GPs dropped to about 10% – 20% of what was previously being received. The GPs are now feeling more in control of their workload and regaining more of a sense of work-life balance

REFERENCES

1. NHS Digital. GP Appointments. Comparison to Other Collections (December 2018). digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice/oct-2018
2. NHS Networks. A Guide to Effective Fast-Tracked Implementation (January 2018). networks.nhs.uk/nhs-networks/nhs-cumbriaccg/medicines-management/guidelines-and-other-publications/repeat-prescribing-practice-guide
3. NHS England. Clerical Staff processing letters, Wincanton Health Centre. networks.nhs.uk/nhs-networks/releasing-capacity-ingeneral-practice/messageboard/documents/4-5-medical-assistants-clerical-staff-processing-letters-wincanton-healthcentre
4. General Medical Council. Delegation and Referral. 2013. gmc-uk.org/-/media/documents/delegation-and-referral_pdf-58834134.pd