Dee Kyne takes us through the learning one GP practice uncovered in designing services that would free up clinicians’ time and help patients become better at self care.

Three years ago Pathfinder Healthcare Developments Community Interest Company set out to redesign the services delivered at and through Smethwick Medical Centre in Sandwell, an ambitious GP practice with a population of 10,000 in the heart of the West Midlands. 

The focus of this work was to become more patient friendly, provide accessible efficient services and to improve the working day of the clinician. SMC partners recognised that it was time to make change and make working practices more efficient enabling the practice to be ready to meet the changing world and new contracts head on.

A key component of this was a community of committed clinician’s, led by Dr Niti Pall. The outcomes of this work were significant, delivering savings on hospital utilisation, a risk stratified patient population and some replicable, impactful interventions.

To deliver the vision of outstanding excellence in long term conditions management using a population health approach within three years:


  • Reaching into hard to reach communities
  • Enhancing self care and awareness of one’s own health needs
  • Developing innovative ways of accessing services

Measurable outcomes

  • Reduce secondary care use
  • Measuring impact of self managed care
  • Improving patient experience: access; streamlining; self empowerment
  • Proactive screening
  • Value for money

Key learning points

  • Communicate, communicate, communicate and then communicate again!
  • One intervention does not change a system, whole system change needs many interventions
  • Include all in the design efforts and create the buy -in we did and it worked!
  • Work closely with those who think it will never work -if it does they will be your greatest champions!
  • Be rigorous about the before and after results, collect viable realistic and achievable data
  • Be rigorous about money flows understand them to effect where to make change
  • Identify strategic partners collaborate, it extends opportunity
  • Look at other initiatives that are happening around the community in Local Authorities and see what they can bring to your redesign. Many endeavours act in isolation and are rarely joined up.
  • The money can be brought in bit by bit and in fact now there is greater imperative for the’ invest to save initiative’ this impacts significantly the QUIPP agenda proving it is possible to create savings with improved service that is streamlined, giving greater patient service and satisfaction.
  • Remember communities are not hard to reach but many services are

Workforce development

Skilled and motivated workers are essential for providing safe, high quality and efficient healthcare. As part of our redesign programme, we focused on getting staff involved in all aspects of developing services. We used a learning and supervision process and supported staff with their changing roles. We linked staff learning needs and knowledge management systems to performance management so everyone knew there were definite objectives to work towards.

We got support from experts in learning and supervision to help with change management. We also developed a “train the trainer” approach so that staff could be trained to support and mentor others as we went through changes.