For practice managers, one of the biggest headaches is staffing. Recruiting new staff, retaining existing people, managing salary (and pension) costs and generally ensuring a practice has the right balance of personnel is tough. Then there’s the CQC’s safe staffing agenda to worry about.
According to the CQC, Safe, effective staffing is about “having enough people with the right skills, in the right place, at the right time”.
Writing in a recent blog post, Professor Ted Baker, Chief Inspector of Hospitals, explained: “In our inspections, we always assess staffing as part of rating a service on safety. These assessments include observing how care is delivered, listening to staff and patients, and assessing the outcomes of care. We also discuss staffing needs and challenges with clinical managers, including how they monitor and meet planned staffing levels. However, we do not use staffing ratios as the sole determinant of a rating.”
Instead, the CQC explains that safe and effective staffing is all about team work, not silo working. “It’s about developing staff to support each other in new roles – making sure patients follow the smoothest possible journey on their care pathway,” it adds.
More than numbers
Professor Baker adds that the CQC wants to support providers to look at staffing in a flexible way, which is focused on the quality of care, patient safety, and efficiency, rather than just numbers and ratios of staff. This may mean that providers need to think differently or consider redesigning a service to make the best use of the range of skills they have available.
“Care providers should also think about how they work with the whole health and care system to enable different disciplines to support each other to make sure that patients have the best possible journey on their care pathway,” he says. “This supports the ambitions set out in the NHS Long Term Plan to make sure the NHS is fit for the future and is focused on integration and collaboration.”
Under resourced, under pressure – a case study
One creative approach to safe and effective staffing has been running in Mid and South Essex for a while. GPs in the region were struggling to meet demand due to lack of resources – including a shortage of qualified GPs. To address the problem, primary care clinicians across the area came together to look at the evidence and to:
- estimate the likely case mix of attendances in primary care
- then secure an estimation of alternative staff needed to deliver against that need
Data was collected from a network of 37 practices on reported morbidity problems. Health professionals interpreted the data, split it into two groups and estimated that:
- 37% of appointments needed a GP
- 63% could be delivered by other appropriately skilled members of the primary care workforce
The group of GPs tested the approach against a registered population of 41,800 across Canvey Island. The local medical committee estimated a GP only model of delivery needed 43.5 WTE GPs to deliver care safely. This suggests a significant deficit against Canvey Island’s current WTE of 28 GPs.
Even if funding were available, there are not enough qualified GPs in the area to staff this model.
When mapping out the assumed demand of appointments per week in terms of GP only appointments, it could be suggested that the new staffing model results in a minimal GP deficit of 0.4 WTE. The GP to patient ration increases to 1:2600 under this new model, compared to the national average of 1:1700. The model further predicted that 2,633 appointments would need to be distributed across other professionals within primary care.
The solution: An alternative primary care workforce
When considering the availability of an alternative primary care workforce, clinical leads broadly defined four key skill mix categories – medical, physical, mental and social – that would need to deliver the estimated 2,633 appointments.
Clinical leads also estimated the distribution of these extra appointments across the four domains:
- 30% medical
- 32% physical
- 24% mental
- 14% social
Following on from this, it’s possible to estimate the number of WTEs required to deliver the extra appointments. Continuing the example of Canvey Island, 40 WTE would make up the workforce model. 16 GPs and 24 other healthcare professionals. They based this on the productivity of the workforce being 110 appointments per week. This calculation was based on the number of 20-minute appointments delivered in 7.5 hours, five days a week.
This model is being used in Mid Essex CCG and the Mid and South Essex STP. Overall the response so far has been positive. Staff have seen an improvement in the care they are able to give to their patients.
Another example of effective and creative staffing shared by the CQC was instigated by the Southern Health NHS Foundation Trust. Under mounting pressure, it considered extending the scope of a physiotherapist.
The trust wanted a musculoskeletal (MSK) physiotherapist to work in a GP practice as a first contact practitioner. It was thought this could improve the patient pathway and have a positive impact on GP capacity. The trust proposed this would result in fewer face to face contacts, quicker access to care and the need for fewer prescriptions. The extended MSK role allows the clinician to make radiological referrals, provide injection therapies and refer directly into secondary care.
This project was part of a vanguard pilot and collaborated with a local GP practice; it has now expanded into other practices and as part of a primary care access centre providing first contact work.
Results so far suggest it’s working, with the MSK physiotherapist managing 64% of patients with advice and guidance, referring less than 20% of patients for physiotherapy – compared to a GP practice (30%), making significantly fewer prescription requests (8% compared to 40%) and providing quicker access for diagnostics and direct surgical referrals with full diagnostic work up before referral (such as MRI). Patient satisfaction is also high.
These two examples show how a creative approach to staffing may be the way forward for GP practices up and down the country. Indeed, creativity may have to be the new focus of any practice manager, given the GP staffing crisis shows no signs of abating.
How are you being creative with your staffing? Share your stories by commenting below or take it to the Practice Index Forum.
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