Dr Geoff Rawes, this year’s Guidelines in Practice Award winner, describes his practice’s project to improve the management of risk factors for CHD and diabetes

Blyth, the largest town in Northumberland, is situated in a former coal mining and shipbuilding area. It has a largely static population with high levels of unemployment. There are high rates of morbidity and mortality from a range of chronic conditions, in particular coronary heart disease and diabetes.

In Blyth, as in other areas of deprivation, medical practices face major problems in attempting to improve the health of the local population.

Our practice decided to adopt a team-based approach to the clinical governance targets set by Blyth Valley PCG (now PCT) as part of our strategy for implementing the National Service Frameworks for CHD and Diabetes.1,2

The patient is encouraged to become part of the team, with the aim of improving the management of risk factors for coronary heart disease and diabetes in our practice population.

How we set about making a difference

In 1997, following the dissolution of a large practice, we set up a single-handed practice. The original staff consisted of a doctor, nurse practitioner, practice manager and a trainee receptionist. From 1998, more administrative staff were employed.

We were keen to avoid the problems that had been encountered in the previous practice such as ‘excessive demand’, ‘always fire-fighting’, ‘never having enough time’ and catering to ‘patients’ wants’ instead of ‘patients’ needs’. So we used the opportunity afforded by a fresh start to try to improve service delivery.

A patient participation group was formed, which met once a month. Structured patient questionnaires were given to patients before and after consultations. One to one patient interviews were carried out by the practice manager and – to prevent bias – members of the patient participation group. Practice staff participated in in-house ‘brain-storming’ sessions to help identify what was needed.

The results told us that everyone wanted "more”.

Patients wanted more:

  • immediate access
  • time with the doctor or nurse
  • knowledgeable staff
  • information about their problem
  • responsibility for their medical condition.

Meanwhile, staff wanted more:

  • available appointments to offer
  • time to complete their duties
  • clinical knowledge
  • job satisfaction.

Making changes

The practice receptionists underwent customer service and information technology training. Their work towards gaining National Vocational Qualifications assisted the practice to achieve the Investors in People Award and a Charter Mark. Both processes significantly changed the culture of the team.

The practice manager already had human resource qualifications and the GP had previously been a GP trainer and had also trained nurse practitioners under a pilot scheme funded by a research grant from the regional health authority.These were also important factors in achieving our aims.

The quality initiatives significantly improved relations with patients, while better IT skills allowed us to produce comprehensive information booklets for patients on our services, including how to use them appropriately.

This led to a reduction in demand and more available staff time, which in turn enabled us to carry out a fundamental review of working practices.

A new approach to chronic disease management

We wanted to approach chronic disease risk factor management in a more positive way. We wanted to empower patients and provide support to enable them to take more responsibility for their own health, and motivate them to make lifestyle changes.

The practice nurses were already stretched by trying to achieve clinical governance and NSF targets, so we looked at how best this could be achieved. The reception staff agreed to take on an extended role and, in December 2001 as part of a pilot project, training was introduced to allow them to take on a number of clinical duties.

The GP and the district and practice nurses provided in-house training in venepuncture and cholesterol and blood pressure monitoring techniques. In other sessions the staff learned about the symptoms of CHD and diabetes, and about screening and medication.

The GP supervises the clinical receptionists and takes responsibility for their work.

The practice obtained more blood pressure, blood glucose and cholesterol monitoring equipment, and decided to fund hepatitis B protection.

Administrative staff then took on the task of undertaking all blood pressure and urine checks, blood glucose and cholesterol monitoring and taking blood specimens. The project was endorsed by the patient participation group and became a permanent arrangement in 2002.

The practice nurses underwent further training in chronic disease management.

One-stop clinics

Many of our patients suffer from more than one chronic disease. The one-stop clinics enable us to carry out all the necessary screening tests for coronary heart disease, hypertension and diabetes (Table 1, below) in a single appointment. Figure 1 (below) shows our patient information leaflet for the CHD clinic.

Figure 1: Practice information leaflet on the one-stop clinic for coronary heart disease


Table 1: Improvements in patient care at 31 March 2003 compared with 31 March 2001. Clinical governance targets set by Blyth Valley PCG (now PCT)
  2001 2003
Patients with CHD
Target Achieved Target Achieved
Taking aspirin in past 12 months (unless contraindicated) 75% 100% 80% 100%
Blood pressure recorded in past 12 months 75% 100% 80% 100%
BMI recorded in past 5 years 60% 97% 80% 100%
Smoking status recorded in past 5 years 70% 100% 80% 100%

Screened for diabetes:
in past year
in past 3 years





Cholesterol recorded in past 12 months 60% 95% 80% 98.8%
Cholesterol <5 mmol/l in past 12 months 25% 25% 50% 81.7%
Patients with hypertension
Blood pressure recorded in past 12 months 85% 99.1% 90% 99.6%
Estimated Framingham risk recorded in past 5 years* 0 92%
Patients with diabetes
HbA1c recorded in past 12 months 75% 100% 90% 100%
Blood pressure recorded in past 12 months 75% 100% 90% 100%
Smoking status recorded in past 5 years* 95% 100%
Albumin:creatinine ratio and use of ACE inhibitors recorded in past 12 months* 99.3%
* = good practice, no target set        

When the patient arrives at the one-stop clinic, the administrative staff carry out routine screening and the results are recorded on a disease management form and passed to the practice nurse.

This allows the nurse to spend more time with patients discussing results, agreeing a treatment plan, reviewing medication and providing education and information to assist patients in managing their condition and reducing their risk factors.

Patients see the GP once each year or more frequently if their disease is poorly controlled.

How successful has our initiative been?

Our figures show a dramatic improvement in the recording and management of chronic disease (see Table 1).

One measure of our success is that in December 2001, 25% of patients under 70 years with CHD whose cholesterol had been measured during the previous 9 months had total cholesterol levels of <5 mmol/l.

In the same period the following year, the percentage rose to 81.7%.

The one-stop clinics not only mean fewer visits to the surgery for patients, but they also enable us to take a holistic approach to patients’ problems.

Patients are now better informed and have more support in making lifestyle changes to improve their health, and no longer depend on symptom management and medication alone.

Patients have a greater rapport with staff and feel more valued and respected. They use our services more appropriately and yet access is easier for them. We believe they feel part of the team.

Our staff have also benefited from this initiative. In addition to improved relationships with patients, their extended roles give them greater job satisfaction and they have more time to carry out their duties.

Rolling out the project

We now ask all patients over 15 years of age visiting the surgery to complete an annual questionnaire. We check their blood pressure, height, weight and body mass index. If the BMI is above 30, we check the patient’s blood glucose level to enable us to detect possible cases of diabetes early and to implement full screening if necessary.

Plans for the future

Now, with training and support, our clinical receptionists are monitoring patients taking medication for certain chronic conditions.

For example, when a patient asks for a repeat prescription for a diuretic or thyroxine the receptionists now advise the patient that he or she needs screening tests.The receptionists carry out the tests, check the results and notify the patients of the result, advising them to speak to the GP or nurse if the result is abnormal.

This process has greatly improved our chronic medication monitoring with only minimal medical or nursing input and we plan to extend the approach to statins and ACE inhibitors soon.

We are training a receptionist to carry out annual medication reviews of the over-65s in a one-to-one consultation, and to record health and social information needed, thus meeting a requirement of the National Service Framework for Older People.3

We believe that all these simple developments could be just as effective in practices of any size that wish to improve patient care.


  1. Department of Health. National Service Framework for Coronary Heart Disease. London: DoH, 1999.
  2. Department of Health. National Service Framework for Diabetes: Standards. London: DoH, 2001.
  3. Department of Health. National Service Framework for Older People. London: DoH, 2001.

Guidelines in Practice, October 2003, Volume 6(10)
© 2003 MGP Ltd
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