For a recent HTN Now panel discussion, HTN welcomed panellists Sabrina Khan, business practice manager at Parson Drove Surgery, and Dr Sheikh Mateen Ellahi (Mateen), GP and practice partner at ELM Tree Surgery and South Stockton Primary Care Network. Mateen shared a case study from his practice, detailing successes including reducing DNA rates, encouraging “substantial growth”, improving patient experience, and implementing a “hub model” to speed-up decision-making.
As a brief introduction, Mateen talked about how his love for business, medicine, and teaching had led him to take on a role as “basically the business lead” at his practice, whilst Sabrina shared her experience with managing practices of all sizes, specialising in crisis management.
Background to the ELM Tree medical centre case study
To begin the session, Mateen presented his case study based on the ELM Tree medical centre, based in the North East of England. He set the scene by noting some of the difficulties experienced by practices in areas including managing the expectations of patients who might not be aware of the contracts that practices need to abide by, staff shortages, and the needs of staff who may be unhappy with their workload.
“We’ve got 12,000 patients, and have seen substantial growth. Currently we have five partners, three of whom are clinical, and on top of that we have three salaried doctors, one advanced practitioner and one paramedic. We also have affiliations with four different local universities, and we have medical students coming in from two of those, as well as four postgraduate trainees.”
Telling us that the practice has grown from 4,715 patients in 2019 to 11,456 patients in 2024, Mateen said the growth rate has “increased drastically” in the last few years, seeing “an uptick of patients organically, truly through word of mouth”.
Focusing on patient experience
Taking a closer look at the practice’s performance based on findings from the 2024 GP Survey, Mateen highlighted results which were “much higher than the national and local ICS average”, including in patient experience of contacting the practice, the helpfulness of reception and administrative staff, experience at last appointment, and awareness of next steps after contacting the practice.
“When access is a problem, you need to find out why access is a problem,” Mateen said, “and one thing you can solve is reducing DNA rates, so we’ve focused quite heavily on reducing those. We’ve gone from 4.6 percent a couple of years ago, to 3.2 percent.”
Another area of focus for Mateen has been on how to measure quality, which he considers is “quite subjective” in primary care. Examples he decided on included QOF, where the practice has scored 100 percent for the last five years, and where Mateen says he is “particularly proud” of the practice’s work on keeping exception reporting to a minimum.
“You could call a patient for asthma review two or three times, then tick a box to say you tried your best, and still get the funding for asking. But we try unlimited times, every couple of weeks, every month, and so on – we want to actually see the patient, we want the patient’s health to be the best it can be, and we’re proud of that approach.”
Other examples of potential quality measurements from Mateen’s presentation included high scores on IIF searches, holding LD reviews twice yearly to “help reduce health inequalities”, over 90 percent of medical appointments being “provided by a GP”, a CQC rating of “Good”, and “exceptional feedback from all medical students and postgraduate doctors in training (GP SPR)”.
The secrets to this success? Collaborating with the local federation, Mateen reveals, to offer extra appointments for the local area, and regularly performing locus shifts for practices who “might be struggling to provide access”.
Sharing that he “often gets asked what the magic pill is” in this regard, Mateen said that “it’s actually about culture, which sometimes isn’t talked about often enough”, also adding having the right systems and processes in place, delegating admin work appropriately, and making sure the practice has “a continuous thirst for wanting to improve”.
Innovations in primary care
Mateen shared with our live audience some of the innovations put in place at ELM Tree, including implementing what he refers to as “a hub model”, which sees all clinical partners and a GP assistant in the same room. This model, he says, “helps us make decisions very quickly, and if there are any concerns about a patient we can discuss them right away, which essentially makes it a triage hub”.
The practice’s appointment model also plays a role in its success, Mateen went on, as it “promotes continuity of care and utilises review slots to support patients in seeing the same clinician if preferred”. Other factors, he said, are room sharing to maximise limited space, and regular staff and 360 feedback, which enables ongoing improvement.
There were some barriers to the changes the practice made, however, and Mateen shared a few of those, including logistics of the hub model and shared space to support patient confidentiality and privacy.
AI integration is an ongoing challenge, Mateen mentioned, following talks with a company looking to integrate AI into the practice’s systems. “Audits still need to be done to ensure clinical safety remains a priority” he clarified, “although we have been helped along by one of the clinical partners who has coding capabilities”. He noted that certain automations of normal lab results has already begun, but that further integrations are planned for the future.
And finally, when it came to achieving the results with DNA rates shared earlier in the presentation, Mateen said that one of the barriers was cost. “We had to hire a member of staff to spend time making sure patients don’t abuse the system, and that patients received a call if they were running late to ensure they attended”.
Taking these learnings forward, Mateen said that the practice is collaborating with the local federation to help local practices, and integrate some of the solutions found to work at ELM Tree into those practices who might be struggling with similar issues. The planned consultancy project will focus on pain points and redesigning processes, implementing continuous quality improvement, with coaching and support offered by Mateen and his team.
Insights on practice improvement
Following Mateen’s presentation, Sabrina took over to talk about some of the projects she has been involved in around practice improvement, and some of the main takeaways from those.
“I worked with a practice that was in special measures and on the brink of closure. As a practice manager I’m looking at things from a non-clinical and administrative perspective, as well as looking at what the clinical issues are. That means working alongside GPs to understand what the issues are, what skillsets are available, and what support is required. A lot of the time it’s finding the right people to fit the role and meet those targets and deadlines.”
Some of the KPIs Sabrina has put in place to help in this process include clinical KPIs, “which I allow the partners to lead on”, and then financial KPIs. “I also do personal KPIs,” said Sabrina, “which is looking at what people are contributing to the practice, where they want to go, and how we can fit that into where the practice is at the moment”.
Mateen added to this list, saying, “one of the biggest things I would encourage everyone to do is regular audits, so looking at the processes and workflows you have in place to see whether they’re actually functioning”.
Taking point from a question that came in from our live audience, Mateen talked about good practice around telephony, saying, “the NHS is promoting a new telephony system which enables staff to get more data about demand, types of query, peak times, and so on. Unfortunately we haven’t got that system yet, although we are hoping to later this year, but we’ve calculated a lot of that data already, and we have a set number of staff at different times of day based on usual demand.”
Sharing that the practice had had 170 “wasted appointments” in the last week, Mateen highlighted the traditionally challenging role of GP receptionists, adding that the practice has made strides in changing that, “so patients ask to see a doctor and we ask them when they would like that appointment”. This, he said, means receptionists “spend about two minutes on the call”, so “having those systems in place, having that data, and actually integrating that, has been vital for us.”
Sabrina agreed on the importance of telephony data, adding the value that it can bring for auditing or identifying needs in terms of training and support. “We also have a callback system,” she said, “which has been so helpful in bringing down complaints”. She shared that having designated slots for online appointments, having an on-call list, and changing the mindset around patients calling the practice at 8am, has also been important in improving access.
In her experience, separating clinical and non-clinical is important when it comes to measuring quality in primary care, Sabrina told us, and “from a clinical perspective it’s also measuring patient outcomes, hospital admissions, types of appointment, and linking that to access, so we can see how we’re performing, whether we have enough appointments, and so on”. From a non-clinical perspective, she continued, “it’s more about patient satisfaction, using surveys, feedback, and allocating a set portion of your diary to go after that feedback allows you to gauge all that and measure where the quality of care is coming from”.
It’s also about ensuring that non-clinical staff understand how to navigate patient care, Sabrina noted, “taking into consideration whether they’ve had the right training, whether they know about the types of patient that might come through, about sending patients to the right services, and what services are available if we’re not able to help them right away”.
Barriers to suppliers and innovation in primary care
On the barriers to suppliers and innovation in primary care, Mateen talked about his personal experience, and how he considered the lack of infrastructure to be one of the biggest challenges for innovators.
“I think there are quite fragmented IT systems between primary care, secondary care, and tertiary care, and the systems are fairly outdated, so it all needs updating. There’s a lack of standardised interface, and a lack of connectivity, as well.”
Mateen also touched upon other challenges for future innovation, such as data storage and security, organisational culture, the cost of educating staff on new technologies or systems, and health information exchange, since “currently there’s limitations on the ability of start-ups to access comprehensive patient data across all platforms”. As an outside supplier, Mateen estimated that it could take anything from 12-18 months to complete all of the integrations with primary care, forming another major barrier to innovating within the NHS.
When it comes to the clinical system market, Sabrina shared her perceptions that NHS England is beginning to become more open to start-ups and new entrants to the market, but also talked about difficulties suppliers may have understanding the challenges within primary care. “If you don’t understand what the challenges are in general practice, you’re not going to get much traction from key stakeholders, because as much as we’d love to support that innovation, we have our own time and funding constraints.”
Sabrina’s main recommendations are to collaborate with practices, leaders, senior teams, and existing suppliers. She noted from her own experience: “when I had to make a decision, I ended up going with a supplier we already used, because it’s about looking at the efficiencies, the training time, and what the quickest way of integrating something is”.
The future of innovation in primary care
Mateen and Sabrina moved on to consider what challenge they would like to see resolved in primary care. Mateen said, “my focus would be on interoperability – if everyone in the NHS could work off one system, that would help massively. Things have improved over the last few years, but we still have issues around sharing patient information between locations, so having access to a patient’s records from anywhere would be a big improvement.”
Sabrina echoed this, adding, “that is the biggest issue that we have, aside from needing more GPs and clinicians. It would make seeing patients and giving them the best care much easier.”
We’d like to thank Mateen and Sabrina for joining us, and for sharing their insights with us around innovation, practice improvement, patient access and patient experience in primary care.
