Induction & Development
Induction & Development
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.
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.
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.
into General Practice
The development of Primary Care Networks and GP shortages has led to
the introduction of new roles into primary care including:
• Physician Associates
• 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.
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.