Category: Editorial Comment

Designing Your Surgery

As a child In the 1950’s I remember attending a sit and wait Surgery in what really was a large house in my home town of Stafford. There was no appointments system in those days.nPatients waited in the sitting room whilst the doctor eventually called patients in to what was his dining room. The receptionist kept drawers of records in an under stairs cupboard and handed records to patients through a stable door which led to the kitchen. The doctor’s desk was a roll top bureaux, cluttered with record folders, instruments and paperwork. The Practice moved to new purpose built premises in the sixties a few streets away. It was a single storey building with three consulting rooms. At the time I was still at Secondary School and had no idea that my career path would involve helping design new surgeries and that I would work in such surgeries for around 25 years.

Internal garden becomes records store

My first venture into the world of modern surgery design was managing improvement grants and visiting health centres in central London in the early 1970’s. The first health centres were built in London and where supposed to house all four Family Practitioner Services along with Community Nursing. It would however have been unusual to find a GP, dentist, optician, chemists and community nurse base in a health centre. Over the years the design of health centres has proved problematic with an excess of doors, flat roofs and internal garden quadrangles. The excess doors provided access to examination rooms which tended to be locked or walled up with a cupboard. There was also a preponderance of long corridors and sub-waiting rooms.

Development Tip – At one flat roofed Surgery in Leeds a central quadrangle with no useful purpose was covered with a new roof and converted to a records storage room with skylights bringing day light in to a relatively dark area. The records were stored in a roll store thereby maximising the space.

Inspection teams assess the quality of GP surgeries

Later in the 1980’s I was part of an inspection team that visited surgeries in the Black Country, West Midlands. The team included a GP and lay member of the Family Practitioner Committee and took with it the Standards of Accommodation set out the the Red Book, Statement of Fees and allowances. The inspections concentrated on the décor, screened couches and the provision of hot water. Nowadays of course the CQC look for evidence of curtains being washed. The inspections probably helped create a trend to modernise or replace buildings that had been in use since 1948 and before.

Cost Rent Scheme abounds

In the 1980’’s improvement grants were overtaken by the cost rent scheme and I was involved in approving the design of some 30 new building projects in West Yorkshire. The buildings varied in size, and some had an upper floor. The doctors involved all accepted the need to build a future proof surgery with sufficient rooms to develop into. Depending on the amount of space available on the site would determine whether additional floors were needed and whether the common room and administrative rooms would be on the upper floor. One doctor who wanted to construct a three storey building insisted that all the clinical rooms should be accessible by those wheelchair bound. The cost rent scheme originally only encouraged accessibility on the ground floor but these days new premises providing health care will require a lift and/or stairlift to provide ease of movement throughout a building. It has always intrigued me as to why many dental surgeries are found on a first floor without provision for the wheelchair bound.

Private funding takes a hold

Surgery premises design took another leap forward with the advent of private funding, PFI and LIFT projects. My experience of these buildings has been more as a patient and Locum Manager in the last 12 years. Inevitably, these buildings are built on more central sites with more than one floor often sharing facilities with more than one Practice as well as community services. In Leeds for instance, such premises have become extended hours or out of hours hubs.

Development Tip – I found that where a Practice was delegated a first floor suite rather than ground floor rooms, patient registration was effected negatively. Added to that it was necessary to take part in a management committee with other occupiers and argue about service charges and maintenance costs. My view at the time was never the twain shall meet and basically they didn’t.

Voice of experience

In my final few years as a full time manager, I had the opportunity to help design, plan and manage a major surgery extension costing over £1.4 million, which virtually doubled the size of the premises.. I was involved in the conception, design and decision making throughout the whole project. I had picked up many design principles over the years, which helped me work with the architect.. The reception counter was much to my regret open, but nevertheless deep so that violent patients could not reach the staff. Interestingly many surgeries have enclosed their reception counters during the Pandemic only to remove them again. I just wonder why as episodes of violence increase and adequate screening helps prevent the airborne transmission of disease. The reception became a room shielded from the main office which provided for privacy fitted with panic alarms and a live video camera. The main entrance had controlled locking introduced as well as automated opening. A serious incident with a violent patient subsequently confirmed the need to control entry and exit from the building. Extra rooms were provided for visiting clinicians, a physiotherapist and counsellor as well as extra consulting rooms as we could see the patient list rising. One potential problem was with door closers which all needed adjustment to provide for gentle closing.

As big turns into small

It’s strange to me how the Covid Pandemic has driven Practices to take a different approach to how they use their premises. Counter screens were installed in many surgeries only to be taken down as the Pandemic subsides. I think that Practices too have tended to use their more spacious rooms for face to face consultations. The seating arrangements for those waiting has changed as fewer seats are laid out for use. Posters and Notice Boards were cleared and new technology with apps galore have developed new ways of working. On reflection I wonder whether the ever changing state of general practice has reached the stage where large more recently surgery buildings will become white elephants as the new ways of working promote the idea of smaller premises not centrally located. Just a thought!

Robert Campbell
May 2022

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“I’m not bothered particularly about seeing a doctor or nurse face to face as long as they can and do make a judgement to see me if it warrants it today!”

I am sure you have visited a public convenience and found at the exit a touch screen asking you to vote on your visit with a smiley face or a miserable face. Really the FFT just amounts to a simple similar measure of satisfaction or dissatisfaction that has become elsewhere commonplace in our lives. But does it really measure anything? If there is going to be a simple satisfaction survey doesn’t it need to be a bit more inquisitive?

Consider This…..

I am often reminded of attending a year long management course before practice computing and smartphones took hold. Our project was marketing and I struggled to see the relevance of it working in general practice. The theme of the course was ‘Putting the Customer First’. This was demonstrated by visiting a Rolls Royce sales showroom in Regent Street, where no sales promotion was necessary, they simply kept in touch with clients when a service was needed or an MOT or car insurance needed renewal. We visited a London Transport training centre and a British Airways air crew training centre where customer care was always foremost. We also looked at the way MacDonalds tried to sell one additional product to each customer and then ‘smile’ at the customer. How pleasant!

Limited Promotion

At the time we just had Practice Leaflets providing basic information for our patients which were never in ample supply being printed in quantities of 2,000 by an advertiser. Mobile phones, emails and websites were not even in their infancy. It was down to walking into the surgery or telephoning the surgery to ask for an appointment. My recollection is that an appointment was rarely refused. Most GPs worked full time.

Putting Patients First

Marketing attempts in the 1970’s included a Patients Charter, now the NHS Constitution. We had attempts to improve access for patients with Advanced Access and Doctor First. We now too have Primary Care Networks with their own funding but I wonder whether patients understand what that is all about other than seeing a variety of clinicians replacing or supplementing GPs with prescribing nurses. Is the problem in general practice to do with lack of medical manpower or an increase in patient demand. It might be something else such as the ‘now’ culture. Patients want and expect a better standard and that the service should be available almost straight away, certainly within a day.

Is it to do with marketing and communications?

Move on to the current day and general practice is busier than ever. It has always supposed to be the first port of call for patients seeking treatment and care. It is not an ‘emergency’ service, yet I hear telephone answering messages telling me not to ask for a service after a certain time unless it’s an ‘emergency’. However, general practice is now complex in the way it is provided. It has been seriously affected by the pandemic instilling in Practices the need to provide treatment and care in different ways and at weekends and bank holidays. There are still, however, pressures on out of hours services and A & E. My view is that the idea of signposting patients to other services causes confusion, uncertainty and lack of continuity. Hence, the negative responses to patients surveys.

Is it time to let Practices off the hook?

Yes, I have been faced with over 100 extra patients wanting to be seen on a day. I have been faced with tweaking appointment system to cope with demand. Luckily, I have not been faced with too many slow consulters, and locums who will only do a bare minimum for such high cost. My view has been to ‘keep it simple’. We are in a world now where Practices do need to sift and sort what is thrown at them each day. We have had Covid rammed down our throats for two years. There cannot be many people who are not aware of the recommended preventative measures and how irritating it can be when someone in front of you in a confined space has decided wearing a mask is not for them and they sneeze. Why on earth has each UK nation had different rules other than to make a political point?

Back to the plot

• Do we really need lengthy telephone answering messages rather than a human voice straightaway?
• Do we really need to be told to speak to a pharmacist or ring 111 or look at the NHS web site?
• Do we really need to be waiting two or three weeks for an appointment that we will probably forget, unless we get a text reminder.
• Do we really need to look at a website that has so many links that eats the choices on Netflix.
• Do we really need to be told at 8.05am that there are no appointments today.

So is it really all about how we manage information? Is it the difference between positive and negative marketing?

Just getting through the numbers

A recent experience suggests to me that Practices do need to look at continuity and not have a number of different types of clinician involved in a patients care. A GP told me to take an extra tablet each day. A retail pharmacist also told me to take an extra tablet each day too. However, the Practice Pharmacist told me not to. A few weeks later my GP called me to highlight my confusion, apologised and reaffirmed her advice to take the extra tablet. Three interventions when one would have been sufficient but which one! Maybe that is a prime example as to why patients are critical of current day general practice.

Another example of the serious problems facing general practice was my own observation yesterday of a village surgery with a dispensary normally open at least three days a week. Apart from a visiting physiotherapist the surgery was closed but patients were still rolling up with their repeat prescription requests to find the door locked. They persisted in braying the door which was answered by the physiotherapist who could not help them. There was an explanation on the Practice website. The surgery would open in two days time. Two doctors had suddenly left the Practice as had three Staff. Recruitment had failed. It’s not easy in rural Cumbria. But patients were left on the doorstep of the surgery confused, angry and without their medications. Again, is it down to communication?

Keep it Simple and Clear

So in summary, keep telephone systems simple, short messages and prompt replies . Never say there are no appointments today. Bring back an element of continuity of care, keep websites simple but informative. Is it time to give less prominence to Covid rules? It is all to do with marketing and perhaps if websites are less complicated and telephones simply answered patient surveys like Family and Friends might produce far better and more positive results.

What I’d like to see –

A promptly answered phone and a pleasant voice
No lengthy answering machine messages
Not to be told I’m in a long queue
Not to be told the doctor I usually see only works on Thursday
Not to be told there are no appointments today.
To get an uninvited text asking me to attend an appointment
See the same doctor or nurse practitioner for the continuity of my care

It may seem a bit simplistic but are these the issues patients have with Practices?

Robert Campbell
May 2022

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Drawings versus a Pay Rise

Now is the time of year to be thinking about staff pay and a cost of living pay rise. But are you being faced with the NO word. If you are is there any justification for a NO. What do you think Practice Staff should and deserve to receive?

My State Pension will increase in April by 3.1%.   If I worked 37.5 hours per week this would give me just £4.50 an hour. Curiously this is the same rate of pay an Apprentice might receive under the National Minimum Wage.

However, some Practices have already decided either not to give any pay rise or give one according to whatever advance information they have heard from  NHS England. In the mainstream NHS the usual practice is to wait until funding is clear and received usually around October before coughing up.

I can understand that some Practices might find it difficult to balance their books. Over the years a Practice might not have been a high earning Practice leaving little or nothing spare in the kitty.  

Nevertheless, I’ve always asked myself whether the partners drawings have gone up, gone down or remained static. I have experienced on a number of occasions where a partner or partners have decided not to take their drawings for a month or more whilst ensuring that the staff are paid. 

I can understand how tight budgets might be where Practices employ more Salaried doctors leaving little or no flexibility in managing the money.  So, where does the answer lie. My view has always been that GP Practices if they want to be regarded as part of the NHS and proudly use the NHS logo on their headed notepaper and on their sign boards should stick with NHS terms and conditions and more importantly pay. Otherwise Practice staff continue in the pay stakes to drift away from their colleagues elsewhere in the NHS. Remember this affects the value of your pension. You might not think that now but you will when you retire.

So ask your employer for a cost of living increase! Do your research on the current state of the cost of living. Look at the Consumer Price Index, and the increases awarded for the National Living Wage. Mention the cases put forward by the trade union UNISON  and the RCN. Point out that Salaried GPs should follow NHS increases. Argue that Nurses will expect the same term, conditions and pay, although should not all Practice Staff be on the same pay, terms and conditions.  A decent increase will help retain staff and stem the tide of staff leaving or wanting to reduce their days and hours

And finally, think of yourself and your own salary. You are usually an employee.  Your role is to present the arguments. If no at first try again. Good luck!

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“Recruitment Specialists, Reeds say that two thirds of applicants look for a salary in an advert!”

Do you advertise a salary or just the job?

Are you about to advertise a post in your Practice? Maybe it’s your job or a new post such as a Business Manager or Deputy/Assistant Manager.

Here are some points to think about unless you are not in the driving seat and the Partners are simply saying do it this way. I might be wrong, but I would say that there is an upward trend to advertise jobs as a Practice Manager or senior position in a Medical Practice without mentioning a salary (or the list size of the Practice. It’s the same anywhere in the world of recruitment. There is a tendency to say that the salary is either negotiable or dependent on experience. Alternatively, the advert might say that a competitive salary is on offer. But the advert does not mention an annual salary. Can you read the minds of your potential employer?

It’s Our Business

An employer, even in medical practice, may have a business reason for not openly offering a salary in a job advert.

It may regard a salary as commercially sensitive and not want staff in fellow local practices to know what’s on offer. It might also not want its own existing staff to know what they pay their senior staff (or even their junior staff, for that matter). The Practice might even want to pay a lower salary or a much higher salary than they currently pay but not want to openly declare it to all and sundry especially any outgoing Practice Manager. Basically it becomes a mystery. However, declaring a salary might mean that more good candidates might want to apply and move to a better paying Practice. You could argue that Practices in a Primary Care Network should have a common salary structure. So why don’t Medical Practices who are members of a Network have common grading structures? The answer of course is the independent nature of general practice. It’s a matter of each Practice to its own devices.

Applicants look for Betterment

Perhaps the more obvious point about any job applicant is that they surely are looking for a better salary.

By not declaring a salary or salary range in an advert is the employer hoping that candidates will not press for a higher salary? I wonder how many candidates drop out once they realise that the salary offered is inadequate. Certainly, my recent experience is that candidates often do not turn up for interview having already had a better offer. So, if there is no salary mentioned in a job advert, would this put off people applying. Virtually all job applicants are looking for a salary improvement, so a reasonable question would be can you afford me?

What ‘package’ is on offer?

• Applicants are looking for betterment, but this might extend to the package on offer not just the salary.

One does wonder why employers might want to keep quiet about what salary along with terms and conditions they might be prepared to pay. In general practice, I’m afraid that there is a tendency to offer a bare minimum. It has to be said that the National Living Wage is still quite prevalent for the lowest paid workers and ‘we pay the National Living Wage’ is included in an advert for clerical staff. hardly impresses. Why not offer the National Real Wage?

Guessing the Salary

• Research suggests that job adverts without a salary might work against female candidates or candidates of colour, so employers need to be aware of possible discrimination.

Only a small minority of Practices use NHS Salary Bands, making it even more difficult for candidates to guess the salary. However, you can be sure that candidates will ask what the salary of the outgoing manager might be. And what salary is on offer. What if the Practice really have no idea what salary to offer? When a candidate looks at the background information about a Practice, the list size, the number of doctors and staff and then reviews the number of premises and services offered it should be apparent how big a Practice is and possibly what it can afford. Sadly, I suspect that many Candidates would have no idea. So, is it fair not to give at least an idea of what the salary might be?

The Recruitment Nightmare

“One recruitment firm says that on average an advert might attract 250 CVs, but only 4 to 6 will be called to interview.”

Certainly, during the last two years, I have seen a number of recruitment exercises for Practice Managers first-hand and noted that being vague about or not including a salary in an advert can result in a large influx of applications that display content that makes them hardly worth reading. Including a starting guide salary at least avoids applicants who already earn much more. I did however come across applicants who were happy, not the right word, to take a lower salary. Out of around 100 applicants, I would say that only 10 were worth further enquiry and interview.

It’s not just the salary but the ‘package’

• There’s not just the salary, but the terms and conditions of service.

Applicants who already work in the NHS, would not only expect salary progression in line with what they might achieve in the mainstream NHS, but also expect annual leave and employers sick pay to be comparable. For a senior position it might not go down well to offer 28 days leave including bank holidays! Another area that might cause problems is the length of probation and the periods of notice. Really, you don’t want to end up with an unsatisfactory employee on probation but with three months-notice. It could be costly. Obviously, membership of the NHS Pension Scheme is always an attraction.

Give applicants a chance

My suggestion would be to make sure that there is adequate information given in the advert or information sheets issued to candidates to allow at least an educated guess. For instance, how about a ‘salary range’ such as the lowest you would pay and the highest you would pay. A range of £5,000 might be reasonable. The inquisitive applicants will ask anyway. They might ask to speak to the incumbent manager or a partner, who both need to speak with one voice. They will no doubt look at the Practice web site, the NHS web site and search for a recent CQC inspection report. But such internet searches will probably not reveal the salaries offered in the Practice. Good luck in your endeavours to better yourself.

Robert Campbell – February 2022

(5)

Now that Care staff are required to be double vaccinated the Covid-19 Passport will have an extra lease of life as it will too when all NHS and Practice staff are required to be vaccinated.

You can at present ask for a hard copy passport or down load a time limited version to show your nightclub or passport control on your holiday abroad.

But is there now a role for the passport to play for frontline NHS staff to show their employer. There is something niggling me though about who should be allowed to walk into NHS premises or GP surgeries. The requirement to be double vaccinated applies to visitors and workers employed by other parts of the NHS.

Clearly there will need to be a vetting system in place and a way to show and check the validity of a passport.

One wonders cynically tmy why this has not been done before. And is the booster vaccine going to be recorded on the passport too!

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