A nurse-led general practice has improved service provision, preventative care and patient satisfaction, and avoided unnecessary hospital referrals
Sarah J. Banham, MSc, ANP, RGN, is advanced nurse practitioner, Rowley Healthcare, Rowley Regis, West Midlands.
Banham, S.J. (2009) Improving patient satisfaction with general practice through nurse-led care. Nursing Times; 105: 22, early online publication.
A nurse-led general practice adapted its services to reflect patient feedback and avoid unnecessary referrals to acute care. Changes included planned extended services delivered collaboratively with other practices.
The work by Rowley Healthcare to redesign services comes at a time when the NHS is keen to promote and spread innovation in service delivery.
In April, health minister Lord Darzi said that strategic health authorities would receive funding to support innovative local projects. An Innovation EXPO where NHS staff can learn about innovations is being held this month in London on 18 and 19 June (NHS Institute for Innovation and Improvement, 2009).
Keywords: Patient experience, Patient satisfaction, Primary care
- This article has been double-blind peer reviewed
A patient-focused approach to care has had several benefits:
- Patient satisfaction is high – Rowley Healthcare was ranked third in England in the 2008 GP Patient Survey (The NHS Information Centre, 2008);
- Relationships with patients are excellent because staff are accommodating and happy to listen;
- Preventative interventions are successful because patients are willing and able to talk about lifestyle issues;
- Unnecessary visits to acute care and surgery are avoided by having services delivered in nearby GP surgeries;
- Staff are free to develop specialisms and widen their expertise;
- More services are offered closer to home by several GP practices pooling resources in a community interest company.
- One of the clearest messages from the Department of Health’s (2003) national consultation was that patients want the right information delivered at the right time and suited to their personal needs.
- In 2007 the GP Patient Survey also highlighted significant variations between GP practices in levels of patient satisfaction, together with lower satisfaction rates for people from some black and minority ethnic (BME) groups (Department of Health, 2007b).
- Rowley Regis is within the Sandwell PCT area, which is part of the Spearhead Group of PCTs. These are the group with the worst health and deprivation indicators in England (Office for National Statistics, 2009).
- Rowley Regis has more patients with long-term conditions and cancers than average for Sandwell PCT.
- Rowley Healthcare uses patient feedback and statistics to deliver a wider range of services in the way patients want. Training and greater freedom to work helps nurses and doctors meet the new, greater demands of the practice.
Rowley Healthcare is a small GP surgery based in the West Midlands. Rowley Regis, the area served by the practice, has some pockets of immense deprivation. The population is mainly white and working class, and includes many older people with long-term conditions.
Until 2004, the practice was not responsive to the needs of this challenging population.Patients, especially older people, felt afraid to raise concerns with their GP. Policies on appointment times and other matters were inflexible, and non-medical staff felt undervalued. Patients with long-term conditions were referred unnecessarily to acute care.
The practice has addressed these challenges by seeing its 4,500 patients as customers and using patient feedback and statistical research to deliver services patients want. In last year’s independent GP Patient Survey, the practice came third in England for patient satisfaction (The NHS Information Centre, 2008).
The practice adopted its patient-focused approach when its owner changed in 2004 from a retiring GP to an advanced nurse practitioner. Since then, it has taken advantage of numerous NHS initiatives to deliver a better service to its challenging population.
Changes to practice include longer opening hours and active management of long-term conditions. An integrated care organisation (ICO) has been formed with other practices to deliver planned extended older people’s, dementia and pain-management services.
A new model
Before the practice changed hands, it had a traditional, hierarchical structure that often undervalued the knowledge and skills of non-medical staff.
This approach forced frontline staff into daily confrontations with patients about inflexible policies such as rigid appointment times. Patients were afraid to voice concerns to GPs because of their perceived authority.
Rowley Healthcare has adopted a different model of primary care that focuses on patients’ needs, values nurses and non-medical staff, and encourages learning.
The Department of Health’s national clinical director for primary care, Dr David Colin-Thomé, justified this model by showing that successful practices make effective use of the skills of all staff, not just GPs.
The DH’s national improvement team (NIT) also found that the best practices listen to patients, act on what they say and explore new models of providing primary care services.
The NIT visited Rowley Healthcare when preparing its report (Colin-Thomé, 2008). This report cited the practice as a ‘prime example’ of how a different model of management can be successful in providing primary care services.
The practice is owned by an advanced nurse practitioner and is therefore nurse led. In addition to two salaried doctors and the ANP, there is a specialist practice nurse, a practice nurse and a healthcare assistant.
Practice figures show that nurses are as efficient as GPs at seeing and referring patients, carrying out investigations and prescribing treatments.
Care provided by nurses has been shown to improve patients’ physical and emotional state so they can cope better with long-term illness (Mok and Chiu, 2004).
The NIT showed that good practices carry out capacity planning. They also open in the evenings, at weekends and routinely during the day (Colin-Thomé, 2008). Polls have found most patients support extended surgery opening hours (InTheNews, 2008).
Almost one-third of GP practices still had restricted opening hours in October 2008 (DH, 2008), despite one-quarter of patients not attending their GP surgery due to inconvenient opening times (Smith, 2008).
Before Rowley Healthcare changed ownership in 2004, it also had restricted opening hours. The surgery now opens all day during the week, except Thursday afternoons. Two days a week, the surgery opens until 8pm. Saturday opening was trialled, but the service was underused.
Thursday afternoons are spent on home visits. Home visits are seen as appropriate since Rowley Healthcare serves a large population of frail, older people. Many have long-term conditions and find it very difficult to get to the surgery.
Opening hours were extended following patient feedback. Before changing opening hours, the practice asked visiting patients to indicate their satisfaction with the service and preferred opening times. Around 99% of patients completed the survey on opening times.
In addition to this survey, every year Rowley Healthcare conducts a general practice assessment survey (GPAS) of patients visiting the practice (see Box 1 for 2007 results). This is in addition to the annual independent GP Patient Survey for England.
The survey results were complemented by practice figures, which showed that patient demand was weighted towards the beginning of the week. Extra capacity is therefore provided at these times.
Rowley Healthcare’s ultimate aim is to provide care 24 hours a day, seven days a week, in collaboration with other practices.
The practice philosophy is that patients needing an appointment are always offered one.
This requires administrative and reception staff to be confident to offer advice to patients and, most importantly, be unafraid to ask a clinician to see someone. To guarantee this, all practice staff work more intensively and for longer hours.
Sometimes, older patients or those with learning difficulties can become confused over appointment times or mislay their medication. Practice philosophy dictates that attempts are made to solve the problem, or see the patient, rather than sending them away.
As a practice we believe that, although this system can be abused, the only way to change behaviour is to build relationships with people. Only then can negative behaviour and health inequalities be tackled among these groups.
Nurses are experienced in making preventative interventions and listening to patients. As the DH’s (2007a) report shows, nurses routinely share their skills and knowledge with patients with long-term conditions and their carers to improve self-care and health outcomes.
Older patients rarely present with one issue and can end up inappropriately admitted to hospital. We therefore prioritise the management of long-term conditions by attempting to identify problems before they arise. The practice also focuses on prevention by targeting patients at risk with routine diabetes, vascular and COPD screening.
Mental health is part of this issue. A large proportion of patients presenting in primary care have mental health problems, which are often linked to drug or alcohol abuse. In the present economic climate, mental health difficulties are also associated with stress about housing and jobs.
The practice offers self-referral to both drug and alcohol counsellors, who provide care at the practice. We also have general counsellors, and manage extended care for patients undergoing drug rehabilitation.
Dr Colin-Thomé has described hospital outpatient clinics as a ‘relic of 19th century medicine, never mind the 20th’ (cited in a speech by Patricia Hewitt, 2007). National NHS policy is that services should be redesigned to reduce referrals to hospital outpatient departments (Darzi, 2008).
Redesigning care reduces duplication, increases quality and saves money, which can then be reinvested into more appropriate services. Rowley Healthcare has expanded the range of services it provides so more patients’ needs can be met in primary care.
The practice is part of Pathfinder Healthcare Development, a community interest company (CIC) formed of GP practices in Smethwick, Quinton and Capehill.
Pathfinder provides services in primary care that had traditionally been provided in acute care. These services include dementia and older people’s care, and pain management.
Under Rowley’s plans to become an integrated care organisation (ICO), patients will enjoy better care, delivered in a community setting by the most appropriate agency. The group will tackle inappropriate interventions and hospital admissions to achieve savings, which it will invest in providing more primary care services.
Innovation is not restricted to clinical care – management is also under redesign. Plans for the ICO include employing one business manager for all Pathfinder practices who will manage the practices’ budgets. A customer service manager will work at reception and focus on further improving patient satisfaction.
When Rowley Healthcare changed hands in 2004, the practice inherited the existing staff. Many have continued working there and helped deliver the changes to services. To help them adapt to the new demands of the practice, staff have been given training and freedom to innovate.
There is no staff hierarchy, which allows easier communication and improves relationships. Many staff live locally so their knowledge and understanding of the local community is invaluable.
Staff are given the freedom to widen their area of expertise. In particular, nurses are encouraged to use all their skills in, for example, first contact, public health, palliative care and managing long-term conditions, regardless of their job title.
Nurses at Rowley Healthcare are encouraged to abandon the ‘silo’ effect of disciplines (lack of communication) and geographical restrictions on where they can visit. This allows them to work more efficiently and respond to the new demands of the practice.
Training is key to the provision of quality care. All staff are encouraged to develop their skills by completing courses, which are sponsored by the practice. All clinical staff are undergoing further training.
In addition, a junior member of the administrative team is completing a diploma in management studies at a local college to develop her business planning, management and customer service skills. Such skills are vital in supporting the delivery of good-quality clinical care.
Rowley Healthcare has adopted an entrepreneurial, patient-focused approach to GP practice that delivers high levels of patient satisfaction. Staff are given the freedom to develop their expertise to respond to the new demands placed on them.
Box1. Results of Rowley Healthcare’s Patient Survey 2007
- Most patients (87%) felt that opening hours were good, with 10% feeling they were fair.
- The likelihood of getting to see a particular clinician had improved; there was an increase from 4% of patients in 2004 to 35% in 2006 being able to see their doctor of choice on the day. A further 40% could see the doctor of their choice within two days, compared with 23% in 2004.
- Nearly three-quarters (74%) of respondents said they could always be seen on the day when it is urgent.
- There was an improvement with telephone access, with 80% reporting that the service was good to excellent.
- Some 70% always or mostly saw their doctor of choice, with 89% feeling this was good to excellent.
- During consultations with clinicians, most people (92%) felt they had been asked thoroughly about why they had come, but 4% did not. Most (91%) felt they were listened to (see Figs 1 and 2).
- Most patients felt at ease during consultations, and 86% felt they were involved in decisions about
- their care and that things were properly explained.
Colin-Thomé, D. (2008) Report of the National Improvement Team for Primary Care Access and Responsiveness.London: DH.
Darzi, A. (2008) NHS Next Stage Review: Our Vision for Primary and Community Care. London: DH.
Department of Health (2008) GP Extended Opening Hours Data.
Department of Health (2007a) Supporting People with Long-term Conditions. London: DH.
Department of Health (2007b) GP Patient Survey 2007: Results Within Your Primary Care Trust. London: DH.
Department of Health (2003) Building on the Best: Choice, Responsiveness and Equity in the NHS. London: DH.
Hewitt, P. (2007) Speech by the Rt Hon Patricia Hewitt MP, Secretary of State for Health, 17 May 2007: NHSAlliance Spring Conference, London. London: DH.
InTheNews.co.uk (2008) Public: Large support for more opening hours. InTheNews.co.uk poll 6 July 2008.
NHS Institute for Innovation and Improvement (2009) Innovation EXPO.
Mok, E., Chiu, C.P. (2004) Nurse-patient relationships in palliative care. Journal of Advanced Nursing; 48: 5, 475-483.
Office for National Statistics (2009) Health Statistics Quarterly 41 Spring 2009.
Smith, R. (2008) Patients are confused about where to get treated urgently. Telegraph.co.uk, 26 September.
The NHS Information Centre (2008) GP Patient Survey 2007/08.