Clinical Workforce

Induction & Development

An ageing population and an increase in the number of people living with long-term conditions has meant a significant rise in demand for GP appointments. The average person sees a GP six times a year; double the rate a decade ago. The number of GP’s and GP appointments however is not increasing to match this demand leaving the profession feeling stretched and burnt out.

The incorporation of new roles into General Practice is providing a solution but for the greatest efficiency and safety of the service it is important there is a process for signposting patients’ requests for appointments to the most appropriate clinicians. ​

Co-Formation’s Stratification Tool has been designed to enable delivery of care directed by population segmentation and provides a blueprint for tier-based care. At a time where there are not enough GP’s to deliver care to every patient, this tool facilitates the practice team to employ health professionals other than GPs and direct patients based on their health needs to the clinician most skilled to meet their needs. The role of the GP will span all 3 tiers but not always need to be the primary deliverer of care. For instance, in Tier 1 with low complexity patients the GP role becomes that of the overseer, providing advice and support to the other clinicians for the more challenging problems. This we call the GP Consultant role.

The tool firstly involves population stratification and segmentation based on a patient’s medical complexity looking at:

• the presence of long-term conditions (LTC),

• physiological risk e.g. extremes of age, pregnancy

• social care need - defined by age, frailty, vulnerability, and safeguarding issues.

The significance of using long term conditions in our stratification is based on the impact we know they have on NHS resources. In the U.K. 30% of the population, approximately 15 million people have LTC’s and this is set to rise to 18 million by 2025. This 30% account for 70% of all costs across health services, 50% of GP appointments, 64% of outpatient appointments and 70% of all inpatient bed days. By matching the appropriate skill mix of our staff to each tier we aim to provide the most appropriate delivery of care to the individual and for the health system.

How the tool works

The Stratification tool is automated through searches on the practice’s clinical system (SystmOne or Emis) of coded patient data and divides the patients into two Tier’s - Tier 1 being those with lower complexity and Tier 2 higher. A flag is then placed on the patients notes which is visible to all clinicians and receptionists. This means as patients request an appointment either over the phone or through e consults, they can be allotted appointments by reception with the Tier 1 or Tier 2 clinicians. Stratification of patients’ problems and appointments already occurs instinctively by some receptionists, but it is user reliant, happens at the point of contact and does not follow any specific guidelines. By incorporating this pre-emptive stratification, it will allow the decision of where and by whom the patient is best seen to be made in a more-timely fashion and allow the use of signposting and care navigation where appropriate.The clinicians working within the practice are designated each day to work in a specific tier depending on their skillset, with the least experienced clinicians delivering care to Tier 1 patients. As the patients in tier 2 are more complex these appointments are 15 minutes long, but the tier 1 appointments remain at 10. Patients can be stratified by clinicians into a further tier - Tier 3, identifying a small cohort of the most complex patients where continuity and rapid interventions will have the most impact on their care. Tier 3 patients could include care home patients, palliative care, and those whose health needs are complex and escalating.​

GP Consultant Role

The stratification tool adds more variety to the role of being a general practitioner. The GP will rotate their working week through the tiers, playing a supervisory role when working in tier 1 – the GP consultant, the more traditional GP role in tier 2 and leading MDT’s for the most complex patients when in tier 3. To work safety within general practice certain roles require ongoing supervision from a GP on a sessional basis such as the non- prescribers including (at present) Physician Associates who practice under delegation, Paramedics, Pharmacists, some nurse roles and allied health professionals. Others require more temporary support as they build their confidence within the general practice setting, for example advanced nurse practitioners making the transition from a hospital setting or newly qualified GPs.Depending on the size of the team this can necessitate the need for a sessional dedicated supervising GP, a GP consultant. This GP will have

either blocked support slots for supervision alongside seeing their own reduced appointment list or in larger teams have no booked list of their own. This means that a team of nurse practitioners, physician associates, pharmacists, ANPs, paramedics, minor ailment nurses and physiotherapies can work alongside a GP consultant referring to them for advice or a second opinion on the spot. Members of the tier 1 team may feel quite confident to manage some presenting problems but need assistance if they are more complex, this is where they can access the GP consultant. This also allows for an overview of patients who need scripts but have been seen by non-prescribers. This approach means a practice can see more patients for the same cost ( i.e. 2 nurse practitioners for the cost of 1 GP), it also prevents patients having to re book to see another clinicians if the one they are seeing finds their medical needs exceed their skill set and promotes ongoing education for the team.

An aid for training and inducting clinicians

into General Practice

The development of Primary Care Networks and GP shortages has led to

the introduction of new roles into primary care including:

• Pharmacists

• Physiotherapists

• Physician Associates

• Paramedics

• Occupational Therapists

Many of these roles traditionally have sat within secondary or community care, so the transition for these clinicians into primary care needs support. For the roles who will be seeing similar patients to GPs in a generalist role, the stratification tool will help their induction and training. The tool allows

the new clinicians to firstly focus on tier 1 patients where, due to a lack

of background medical complexity, they can focus on the presenting problem and develop skills to manage the common presentations seen in general practice. In general practice it is important to be trained to recognise what

is within the scope of normal and what problems need rapid escalation and management. For example, a new cough in a 12-year old with no other medical problems is a different type of consultation and complexity from a

79 year old with an ongoing cough and a background of emphysema and heart disease. The GP consultant can support the clinician initially to develop and hone the skills around managing the most common presentations in general practice before adding in the complexities of multiple co-morbidities and polypharmacy.

The next step is ensuring the clinicians are competent in their management of chronic health problems, which might need additional training. Then the clinician can move into seeing tier 2 patients where the 2 skills are combined.

Data Analysis

The tool can also capture historic data about the delivery and

use of appointments across the practice. This can help in service redesign including appointment schedules, staff recruitment

and calculating the costs of appointment delivery.

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