As more vaccination campaigns and QOF deadlines loom for practices, Dr David Coleman says astute use of wider teams can make all the difference
Most general practice teams are likely to be anticipating another difficult winter, playing catch-up on QOF indicators while simultaneously attempting to deliver vaccination campaigns. The intensity in general practice is now such that we no longer seem to get seasonal lulls over summer, which makes preparing for winter all the more testing. New QOF indicators, another Covid-19 booster programme, flu vaccinations and all the other winter challenges lie ahead. To make matters worse, many practice teams will be facing these with strained capacity due to workforce gaps.
While I can’t conjure up additional staff (I’m not the health secretary, after all), I do have some tips for optimising your approach and making the best use of the wider practice and PCN teams.
1: Covid-19/flu vaccination campaigns
Among the big general practice headlines this summer was the announced reduction of the item-of-service (IoS) payment for Covid vaccination administration to £7.54, and now the changed schedule for administering these.3 There was widespread debate about whether it would even be possible to deliver the service specification at that level of payment, although thankfully the government has come to its senses and increased the payment again. While it now appears deliverable, it will still pay to be as efficient as possible. There will be lots of other challenges this winter, so teams can’t afford to focus solely on Covid and flu.
Maximising co-administration of the two vaccines wherever possible is essential. Some PCNs may have some Covid support monies available that could support workforce costs; another option is to use extended-access capacity for vaccination, effectively killing two birds with one stone. PCN ARRS staff can be deployed to deliver housebound vaccinations at scale as part of roving teams. This will make sure vulnerable patients receive their vaccinations without impacting nursing capacity at practice level.
2: A team approach to lipid management
Many practices are still grappling with the changes to QOF guidance this year, and we’ve found the new lipid indicators to be particularly demanding. If your team is smaller than you’d ideally like, you’re probably playing a game of catch-up by this point in the year.
Just as practice workforces differ, so do practice approaches to lipid management, with doctors, pharmacists, nurses, nurse associates and administrative staff all potentially performing key roles. However, a collaborative team approach that includes patients will serve you best. A practice should consider suboptimal lipid results to be everyone’s business.
While NICE1 advises reduction of non-HDL cholesterol by >40% from baseline with statin therapy, QOF indicators2 have adopted the Joint British Societies’ JBS3 consensus recommendation – a non-HDL cholesterol target of <2.5mmol/L (LDL-C <1.8mmol/L).
If there is uncertainty about this target, a clinical meeting with all teams represented would be a good starting point. Admin teams can be briefed to search for patients who are not treated to target. It may also be beneficial to change the language of statin prescribing. Rather than discuss each dose change, practices could pitch statin dosing as a variable concept, adjusted based on results (like warfarin and INR, for example). This could reduce the need for hundreds of time-consuming discussions. SMS messaging can be used to keep patients informed, although if we make the target clear they can monitor their own progress via the NHS app. In this way we can empower patients to take control of their own lipid management as much as possible.
3: Can extended-access services help?
Appointments with all members of the practice team will be at a premium this winter, so it makes sense to tap into all available support. PCN extended access looks different in every locality, but there is usually a significant nurse, nurse associate and healthcare assistant component. Locally, our extended access capacity is often underused. Our approach is to analyse which work we might struggle to deliver in house and consider reviews that don’t necessarily require continuity. For us, cervical screening seemed to be a priority area, and as it involves working age women, evening/weekend appointments are often convenient.
We also use extended access for asthma and hypertension reviews, but prefer to maintain continuity for specific areas such as dementia and learning disability.
4: Collaborate with your PCN pharmacists
PCN pharmacists are a valuable resource and can be a lifesaver for overstretched practice teams. It is worth considering that requirements under the PCN Investment and Impact Fund (IIF) framework4 have been significantly scaled back this year, potentially freeing up pharmacists to assist in the more medication-heavy elements of chronic disease management. At my practice, our PCN pharmacist plays a vital role in managing atrial fibrillation and heart failure, for example. Have a chat with your team and your pharmacist to see if they have any areas of interest that they’d like to collaborate on.
5: Care co-ordinators can lighten the admin load
What if the workforce crisis affects your admin team? Winter is a huge challenge for administrators, as vaccination campaigns and the looming QOF deadline compete for attention. It can take time for new starters to bed in, and chronic disease management and the QOF may still seem new to staff who started during the pandemic, when these were lower priorities. PCN care co-ordinations may be able to lighten the admin load, although their role differs from network to network, so it will be necessary to seek advice from PCN leads. But if your admin support is non-existent, co-ordinators could offer a lifeline this winter.
6: Maximise time with poorly controlled asthmatic patients
Most practices now have access to SMS messaging systems. If yours supports questionnaires, all the better. Send out Asthma Control Test (ACT) questionnaires to your asthmatic patients to determine who will benefit most from your precious clinical time. If a patient response suggests excellent control, a further SMS with supporting information and resources for inhaler technique could complete the review without the need for a face-to-face appointment.
7: Support nurse associates and healthcare assistants to develop their skills
Nurse associates and HCAs are performing increasingly complex roles within primary care. They can support chronic disease reviews, spirometry and dressings. Nurse associates can train to conduct cervical smears. Maximise their potential and ensure reception and admin teams book patients with them for tasks they can carry out. If your nursing team is thin on numbers and you’re the only person who can provide expert diabetes care, you don’t want to be booked up with dressings and smears. However, remember to factor in some time for supervision and mentoring.
8: Use the admin team for obesity casefinding
Obese patients can be referred to the NHS Digital Weight Management service5, a 12-week online behavioural and lifestyle-based programme. While these could be identified in person during chronic disease reviews, a more efficient approach would be to work with the admin team to design a casefinding approach. Patients can be identified using clinical searches and offered support via SMS. Careful wording will be key, but this may be an opportunity to reach more eligible patients and hopefully convert them to the support programme. There’s also an active Weight Management DES, so each referral will generate additional funding for your practice too.
9: Discuss how the doctors can support the nursing team
If all else fails… no, I’m only joking. We’re all in this together and doctors can and should support chronic disease management – especially when agendas clearly overlap. I recently did a QOF tutorial for our new GP registrars and I was clear about the importance of chronic disease management, especially for housebound patients. Most housebound elderly patients receive home visits at some point in the year. Conditions like COPD, dementia and diabetes are often integral to the decision making, so my teaching point to the budding GPs was that it makes sense to document the key components of the chronic disease review while on the visit. By helping in this way, doctors can free up nursing capacity without much extra effort on their part.
10: Support your colleagues – and yourself
In any workforce crisis, looking after existing employees and colleagues is vital. Regular team meetings can be a great way of checking in on each other and brainstorming ideas to improve processes and address issues that make working life harder than it needs to be. But remember to take the opportunity to celebrate successes and reflect on good care.
References
- NICE. CG181. Cardiovascular disease: risk assessment and reduction, including lipid modification. 2023. Link
- NHSE. Quality and Outcomes Framework guidance for 2023/24: lipid management. Link
- Colivicchi A. 25% cut to Covid vaccine IoS ‘threat to patient safety’, BMA warns. Link
- NHSE. Investment and Impact Fund. Link
- NHS Digital Weight Management Programme. Link
