Practice profile: bigger can be better

LIZZIE PAGE has a surprisingly modest office for the general manager of one of the largest GP practices in England. The Brookside Group Practice serves over 26,400 patients at three sites in the borough of Wokingham, near Reading.

Lizzie works at the main surgery in Earley and her office is a small narrow room with a single Velux window looking out over the rooftops. In the office door is another thin window with a curtain she keeps open to let the staff or doctors know when she is available to talk.

"The curtain is only closed if I’m doing salaries or if someone is crying," she says.

Chatting with Lizzie you soon understand why a grand office would not fit in with her management philosophy. Despite a team of around 130 people Brookside seems refreshingly democratic (though in a loose sense of the word).

"We work on a matrix structure where everybody has a say," she says. "I don’t think I could bear to work in a hierarchical structure."

Lizzie describes Brookside as a "relational organisation" and in practice this means 18 separate management groups with staff at all levels contributing to decision-making on a variety of issues including medical records, finance, staffing, QOF, patient education, training and communication. The partnership deals with major management decisions under the guidance of an executive subcommittee but many of the day-to-day decisions are devolved to those most involved in outcomes.

"We do everything in groups," says Lizzie. "Nobody ever works alone; you are always in a ‘we’. It’s resource hungry but I feel it’s the most effective way of doing things."

GROWTH AND DISLOCATION

This is just one of many unique aspects of the Brookside Group Practice. It was established in 1977 when Dr Derek Munday took over a single-handed practice in Earley. That same year a private housing estate at Lower Earley was constructed which effectively doubled the local population – now said to be one of the largest such estates in Europe. This led to a rapid expansion in local primary healthcare demand.

In the intervening years Brookside has grown from one to 15 GP partners with five associate doctors and an everexpanding staff of practice nurses, healthcare assistants, patient services and support staff, district nurses, health visitors, midwives, dieticians, smoking cessation advisers, physiotherapists and counsellors. Brookside doctors see average of 1,900 patients per week while the practice nurses consult with roughly 750 patients. Each month over 200 new patients register with the practice. Lizzie feels the practice may now be nearing the limit in terms of size.

"I imagine we could get bigger and more efficient but I’m not sure the patients would feel better served," she says. "The same goes for our staff. I feel if a member of staff doesn’t feel individually known and significant they are never going to pass that on to a person they are speaking to or treating."

Certainly the sheer scale of patient contacts at Brookside poses many unique challenges to the practice. Just managing the telephone lines requires a staff rota of six answering phones in a call centre monitored by specialist software.

"Calls for all three sites come into the centre," says patient services manager, Julie Maughan. "On Monday mornings in the first couple of hours we handle something like 500 calls."

These include patients arranging appointments, worried about symptoms, calling for test results and countless other reasons. All have to be answered or routed to the correct extension. It’s a balance of efficiency and ensuring a personalised service to patients. And Lizzie is convinced a personalised service is vitally important to the unique patient community Brookside serves – lying as it does within the vast commuter belt of London.

"We often deal with households where there is no extended family, no grandparents, a husband commuting. It can be very isolating. We have a lot of mental health problems, depression. There can be a real sense of dislocation. People will come to the doctor because they don’t have anywhere else to go. An inner-city practice might have more problems but we’ve got a lot of worried well."

INNOVATING TIPS

But in general, the healthcare and social challenges at Brookside run the gambit. Just as in most practices urgent appointments are available on the day and routine or nonurgent appointments are bookable up to four to six weeks in advance. These include consultations for chronic conditions such as asthma, diabetes or hypertension – and likely to be with one of the specialist practice nurses.

"We believe that while doctors are best at making diagnoses, practice nurses can be very good at management details – routines and protocols," says Lizzie. "We have some specialist doctors but you don’t always want all the diabetics seeing a diabetic GP specialist because you end up deskilling the other doctors and you also lose continuity of care. Continuity of care is absolutely essential."

This constant consideration of the way service is delivered seems typical of Brookside and has led to a number of innovations over the years. The practice has recently introduced a texting service where patients can be reminded of pre-booked appointments or can be recalled for reviews. Another example can be found in the waiting areas. To avoid breaching confidentiality by calling out names, each patient is given a coloured disk with a number at reception and can watch a screen to see when their appointment is about to be called.

Such ideas often come out of the regular staff team meetings or from practice-wide training sessions known as TIPS or ‘time to improve patient services’, an initiative started nearly 10 years ago throughout the PCT. TIPS are conducted four times a year and are themed to cover a particular topic such as dealing with bereaved patients or improving doctor-patient communication.

"At exit interviews often people say that TIPS were what they enjoyed best working at Brookside," says Lizzie.

Another key factor in the apparent success at the practice is a strong team ethos among the staff – this being a particular challenge with such a large number of employees spread out over three different sites. Brookside encourages staff to work at different sites whenever possible. Doctors do all their 'lates' – late and Saturday sessions – at the main Earley practice. Other staff will move between sites to cover absences. Each Friday all the partners meet for lunch and twice a year there is a full staff social event.

PURPOSE AND VISION

Recently at one of the TIPS meetings Lizzie conducted a session on what makes practice staff happy, using a survey tool from the BMJ. To her surprise ‘financial remuneration’ came in at fourteenth on the list. Good relationships and a clear sense of vision were the main issues that emerged. To provide this vision the practice established a statement of purpose which is given out to all new staff in the form of a laminated card:

"Together to further the health and wholeness of the community we serve through providing and developing primary health care services."

This along with a set of stated values informs everything the practice does and reflects the “Christian foundation” of Brookside’s founding partners – which is another interesting aspect of the practice. It must be one of the few GP practices in the UK to offer the services of a chaplain.

"We are in to whole-person care – and there is obviously a spiritual dimension to that. But it’s not something we force on our patients or our staff," says Lizzie.

Indeed Lizzie’s own background includes working for a church in addition to experience as a director of a large supply business. That she is enthusiastic about her role at Brookside is clear.

"I love the fact that we work as one team. Some practices have a coffee room for doctors and another for everybody else. Our doctors are just as much part of the team as anybody else. It’s not a 'them and us'."

Only one thing stands out as a constant frustration in her job and that’s the growing bureaucracy in general practice and the "increasing external demands for onesize- fits-all measures of success".

"So much of your time can just be taken up with filling in reports that nobody reads in order to prove that you do something well according to tick-box definitions of quality," she says.

"You need to keep your eye constantly on the ball and remember you are not here for the government or the PCT but for the patients."

Jim Killgore is an associate editor of Practice Manager