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Léa Legraien speaks to Dr Tom Milligan about his work to reduce failure demand and being named Healthcare Leader of the Year at this year’s General Practice Awards.
Tom Milligan is a GP partner at Practice One in Bridlington and the GP primary care lead for East Riding of Yorkshire CCG.
As of 30 November, he is also the 2018 Healthcare Leader of the Year winner. After joining Practice One, located in a deprived area and faced with a GP shortage, Dr Milligan developed innovative ways to help the surgery both survive and flourish.
By using the failure demand model – developed by Professor John Seddon and described as ‘demand caused by a failure to do something or do something right for the customer’ – Dr Milligan implemented a workflow optimisation project to ease pressures at Practice One.
This included making all letters available digitally within hours of arriving at the practice, and filtered by trained admin staff, saving each GP 20 minutes per day. Another innovation is moving patients in East Riding CCG onto oral vitamin B12 supplements next year to help prevent 12,000 unnecessary injections and free up more than 2,000 hours of clinician time.
Described as inspirational by those who know him and praised for his excellent communication skills and ability to drive change, Dr Milligan discusses leadership, GP representation on CCG boards and the state of primary care.
How do you feel about winning
Healthcare Leader of the Year? It’s absolutely fantastic to have been recognised for the work I’ve put into helping my practice and other practices in West Yorkshire.
Why do you think the judges picked you as the winner?
There’s something really important that all of healthcare can learn from. When I joined my practice in Bridlington, it was struggling. We were originally four partners and I joined as the third partner. At the end of my first day, one of the partners said that they were leaving.
As a result, I realised that something about the way we operated needed to drastically change and I became quite interested in failure demand. So we’ve redesigned processes to work better for patients and address failure demand, and have probably made 50 changes.
How did you address failure demand within your practice?
One example is a patient calling our receptionist and asking where their prescription is. If [that’s because] our practice didn’t process the [patient’s] request in a timely manner, this call is additional [and unnecessary, it would i that case be something] created by our delay, as it was our faulty system that generated the work in the first place.
Consequently, we have developed processes to try and fulfil all prescription requests on the same day, where possible. The examples are endless but re-designing the steps for service delivery can make failure demand disappear.
Do you think we need more awards to recognise leadership in the NHS?
Medical leadership should be everywhere, at all levels of all organisations. Recognising the contributions of these individuals locally is the key for me. The downside of national recognition is that it may promote a top-down change culture, [while, in reality] local professionals are the key to making their own services run better.
What motivated you to become GP primary care lead for East Riding of Yorkshire CCG?
I’ve described the difficulties I had in my own practice. Having made changes and [implemented] a structure to improve the situation, I was passionate about how I could work with and help other practices by supporting them to implement bottom-up change.
How have these changes influenced the culture, locally and nationally?
In East Riding, we had a huge amount of support for teaching other practices how to initiate change. It started off with an event for a half-day teaching [session] in conjunction with Hull University Business School, which taught us about systems thinking.
This was further developed as we got support from NHS England on process mapping. We also had additional support from the Quick Start programme via NHS England to get management consultants into 12 practices to help them with bottom-up change.
Why is it important for GPs to be represented on CCG boards?
Having daily contact with a full variety of people of all ages and backgrounds and with different types of illnesses gives GPs a unique perspective on healthcare delivery.
The generalist status allows some appreciation of the population health and the impact of wider determinants of health on healthcare delivery. By doing the work, GPs can show colleagues [in managerial roles] improvements to systems and safety that would be invisible to the leadership otherwise.
The traditional model for change has been top down, including how we do commissioning and procurement and prevent duplication between organisations. But the exciting thing I’ve learned from Hull University is that 50% of all efficiency across the wider system comes from bottom-up change through process redesign.
How are you leading change in primary care?
It started with our own organisation and understanding waste work and failure demand. Once we understood that, we tried to do process redesign to make things neater. The way this happened was by lowering hierarchy and empowering staff to make changes; helping them be involved in those changes and [achieving] effective delegation of whole workstreams.
What do you think constitutes great leadership?
People can only offer values-based leadership if they understand their own values and know what helps others get behind [something] and support them to get their projects implemented.
What does the NHS most needs from its leaders at the moment?
I think NHS leaders should be honest and [work] alongside managers. They should be in a position to empower bottom-up change, which is about supporting workers to make changes to their own working environment that make their jobs easier to do.
We should avoid things such as targets, which often incentivises the wrong type of work. We should also be trying, as leaders, to prevent failure demand created by the system, which makes up 30% of all of the work done in a practice. This isn’t helping patients and if we can redesign processes to make that disappear then patients can get better care and it makes the work of the practice much easier.
How would you describe the current state of primary care?
It’s really sad because primary care feels to me both underfunded and undervalued. The independent contractor model hasn’t yet had full national support and I worry about the increasing financial pressures.
What changes would you like to see in the primary care sector?
I’d like to see finances improved in the future and perhaps a closer look at the division between the work and funding in primary care versus secondary care, which seems to be taking more and more of the budget.