Edward Bellamy, Director of Egton Digital, looks at how even the smallest of changes can improve GP practice efficiency, helping us tackle an ever changing and sometimes challenging primary care environment.

General practice management is under increasing pressure. There is barely a week that goes by where there isn’t some report in the healthcare press about budgetary cuts. As I flick through the pages of the latest periodical, I am given cause to recall that not too long ago we were in a halcyon age of healthcare funding. Its decline, made all the more dramatic by the effects of recession and considerable budgetary constraint, has been keenly felt. What this has meant for practices is national, regional and local change, often to the personal detriment of those involved.

However, the system is not unmanageable. Efficiency savings can be made to release the pressure that is building. People and processes are the key to these savings and understanding their impact can help practices deal with the difficulties they are encountering.

Recognising the pressure points

The King’s Fund recently released a paper looking at the pressures general practices face. They painted a picture of burden that far exceeds what we have come to expect. The situation we are presented with is not just a question of funding versus present need, but also an issue of pressures derived from the future needs of a changing population. The below infographic sourced from Kings Fund website highlights some of the challenges facing general practice.

Kings Fund - Pressure on general practice infographic

Structural changes under the auspices of central efficiency have – at a local level – led to real term declines in earnings for clinicians, as well as serious deficiencies in GP recruitment. These problems, mixed with the strain of an aging population, have bred uncertainty for the thousands of businesses that make up our venerable primary care provision. So the question is: how do we pull together to make this work at a local level?

When speaking with practices, they generally acknowledge the business realities that they face. They understand overhead and direct costs of providing patient care, and appreciate what the bottom line must look like in order to support the partnership. Short term decision making is also usually pretty good. The problem is that there seems to be a gap in appreciation over the whys and wherefores that support long term decision making and how one goes about taking these choices.

Universal truths

Every business, whether a GP surgery or a manufacturer, has certain levels of supply and demand that results in an equilibrium of price and quantity demanded. Exogenous or endogenous influences leading to demand side shifts impact all businesses and their equilibrium. For GPs, these include: an aging population, an increase in net patient complexity and increased levels of expectations from patients. These demand side challenges have a combined effect of increasing strain on practices. With other businesses, expenditure can often rise to accommodate these demands. With GPs, expenditure is fixed, or perhaps even diminishing. This deficit is met squarely in the practice’s bottom line.

In response to this, practices can reduce cost and overheads, eat into profit or choose to opt for less expensive – though potentially lower quality – care. For business sustainability, these are all short term solutions. The next time there is a challenge to the practice, another short term approach may compound previous problems and affect their business viability. So the real question is: how do we overcome the shift in demand side so as to affect long term change? There are two answers to this. Firstly, analysing your costs to understand where efficiencies can be made is good daily business management. Secondly, finding factors that shift the supply curve out and produce long term, sustainable change.

Marginal gains

Sir Dave Brailsford quote

Let’s first tackle the easiest approach – reducing the average cost of service delivery. Dave Brailsford, the esteemed coach for Team GB cycling, talks about improving performance through the aggregation of marginal gains. He explains it as “the 1 per cent margin for improvement in everything you do.” In Team GB’s case they looked at – amongst other areas – nutrition, clothing, sleep patterns, dental hygiene and infection control.  If we assume that we can make comparatively little impact on a national scale, we are then left to look at utilising what we can achieve in CCGs, federations and practices to make efficiency gains.

The point is that by making small, 1% changes – whether it’s a telephone provider change, a floorplan redesign to enable better utilisation of buildings, utility changes, better staff health, and so on – these changes all add up to make a leaner, better running organization. Yes, some of these areas may require capital expenditure, but a better run service impacts in many ways. People can go home on time, which can promote better attendance. This in turn can potentially lower locum spend, which leads to lower admin overheads, finally allowing for better utilization of overhead resources. Over time, costs come down and less effort is expended in delivering the same quantity of care. Through these strategies, true efficiency can be achieved.

Matching demand shifts

Secondly, we should look at what economists call ‘supply side shifts’ to counter demand side shifts. Supply side shifts include changes in production costs – like people and costs of sale – changes in technology, changes to tax and regulation, and changes in the prices of alternate products. In our case, we can focus on changes in technology.  The biggest shift our industry has seen is the introduction of digital clinical systems, furthered by hosted clinical systems. This has allowed us to do more with less, more often and with fewer resources (and has eradicated the problem of finding that elusive Lloyd George, thanks to electronic patient records).

However, we can utilise technology even further to allow us to do even more for even less. Effective document management, integrated medical devices, practice WiFi, better patient and care communications, and changes in processes using interoperable systems are all ways that technology can be used to bring about efficiencies.

The further adoption of such technologies will allow the shift in supply curve to parry the inevitable shift in demand, helping the practice to make quality, long term decisions that will meet the increasing demands of patient care. Hopefully this can be achieved without diminishing the quality of care, and can be done at a price that is achievable.

Certainly, technology for the sake of technology is not the answer and as many have seen, the creation of a federation just because it’s the new, done thing is not the answer either. Diligent planning and change that’s embraced by the organisation is needed.

At all times, processes and people need to be seen as the solution, and technology merely as the enabler. But what a fabulous enabler it can be.