We recently had the opportunity to catch up with Dr Rajkumar A Shanmugam (Raj), a general practitioner and head of the practice team at the Eric Moore Partnership in Warrington. Raj is also NHS England’s deputy chief medical information officer and chair of the NHS Clinical Leaders Network.
Raj shared with us his career to date, as well as the journey he has been on in creating the Eric Moore Partnership Medical Practice, which has won multiple accolades including being rated as ‘Outstanding’ by the Care Quality Commission. In addition, Raj has established the Medi-Centre Warrington, described as a “state-of-the-art healthcare premises”, and embraced technologies in support of better patient care.
Raj’s journey into primary care
We first asked Raj whether he could tell us a little bit about his background and his career to date.
“I originally trained in hospital medicine, training at large hospitals across England, but I soon discovered that creating change in large organisations is often more challenging, especially within public sector-led units. As much as I enjoyed clinical medicine, I often looked across at the rapidly-evolving general practise structure in England in the late 90s and recognised that primary care offered significant potential for change and transformation, especially for someone at the early stages of their medical career. As a young junior doctor I was passionate about making a real difference to patients and to their care pathways; I had a healthy dose of visible and youthful enthusiasm for change that must have been visibly evident.”
One of the challenges that he came across at the hospital where he was training was “incredibly long waiting lists for endoscopies, which should usually be between four to six weeks, but at that time had gradually lengthened to over 26 plus weeks.” Raj described how he initiated and helped deliver a project, starting with perusing the available data to look at where the referrals and demand were coming from.
“We found that there was an increased demand from the community, because of an Increased awareness of dyspepsia, its link to gastric and oesophageal cancer and bleeds. Prior to my planned move to general practice, I had an interest and trained in gastroenterology. Having a foot across as a GP trainee in primary care gave me a better understanding of the interface challenges. The upper GI endoscopy lists at that time were originally individualised to each consultant surgeon or physician. Working together with the consultants and a manager from the hospital, we unified the lists across all consultants and also created a direct access gastroscopy service.”
In addition, Raj described how he undertook educational updates at GP practices on the revised NICE guidelines for dyspepsia, around appropriate referrals and better management of patients within primary care with new medication. “This early successful project brought the waiting list down over a period of six months, to just two weeks. It was my first transformation project and gave me a better insight into the workings of the NHS across primary and secondary care divides. It also helped me understand how to get the very best for patients by working differently with colleagues across the primary/secondary interface. The value of having accurate referral and waiting times data helped with this project significantly. I always said that having data alone isn’t sufficient, you need to know what to do with it, how to interpret it and convert it to intelligence.”
Raj enjoyed being able to help in this way. “It gave me a real buzz – as a medic, I loved to make my patients feel better, but being able to create change within a system that benefits wider groups of patients was also an amazing feeling.”
As a young doctor, he added, the move into general practice was transformative.
“I couldn’t believe what general practice could offer at that time – you could create your own space for patients as you deem fit, work in a manner that worked for you and your patients. You could even trial and dabble with different software; you didn’t have to get multiple approvals from boards or external agencies. You could engage with any supplier organisation you wanted to, as long as they were safe, patients were happy, and you had their consent.”
At that time, he said, general practice had just started the funding and utilisation of computers across primary care. However, the reality was that adequate data capture hadn’t quite caught up.
“I moved up to Cheshire from Lincolnshire as a newly-qualified GP – fresh, enthusiastic, wanting a challenge. I was invited by a primary care manager colleague who had worked with me previously in Lincoln, to offer temporary support for a medical centre in Warrington for a week. Little did I know that it was going to become my long-term base for the rest of my career! The Eric Moore Health Centre was highly rated and respected when it was built in the 60s, and for the three decades thence, but by the late 90s, when I came along, the doctors who had worked there for three decades plus were clearly getting exhausted, and many of them were well past the retirement age and just hanging on to help support their much loved patients. When I first entered the practice, I noticed was that there were plastic sheets and covers on these very impressive looking big desktops, and the plastic sheets covering them had even started accumulating dust on them.”
The GPs were still using paper prescriptions and at best were using the computers just to print prescriptions.The local health authority managers and the local GPs within the health centre were delighted when Raj accepted a longer-term role in transforming the health facility, and Raj got what he describes as his “dream job”, not only as a valued GP, but also as the practice executive/transformation lead.
Raj set about implementing a fully-functioning IT system, ensuring that all clinicians and staff utilised IT for all aspects of patient care, including appropriate data input/coding. This helped with clinical searches and audits supporting clear data extractions, and helped with delivering quality and assessing patient safety-related processes including prescribing.
Raj worked on helping his retirement-aged GPs to get used to using the computers, to using templates, protocols and introducing a digital appointment booking system. Raj also began to perform audits on patient data and assessing patient volumes so that the practice could be prepared for demand, which he said was “well ahead of the curve at the time, in the early 00s”. Raj then brought in senior managers and like-minded clinicians to continue transforming the facility.
Raj moved on to talk about how he began working at a national level, alongside his role as a GP.
“In the early 2000s, a US-based company called Revive got to hear about our work in primary care informatics. They asked through the local hospital-appointed ‘booking manager’ if I wanted to work with them on developing and piloting electronic referrals. At that time, referrals were all in paper formats and quite a struggle; they would take easily about two weeks from seeing a patient to being approved by a hospital consultant leading to a referral. We used process mapping exercises with our teams just to explain why it took so long.”
Patient notes would be entered into a computer and a letter would get dictated, then would sit on a tray to be transported to the secretary’s office. “It used to take a day to two days, even though it was only down the corridor,” Raj noted. Then the secretary would type it up, bring it to Raj in paper form to be amended before Raj would then send his amended copy back to the secretary, with the final copy being retyped and collected by the hospital to be sent by “snail mail” a day later. On top of that, he said, the consultants, being as busy as they were, would usually review letters once or twice a week and only then accept the referrals. By the time the patient was allocated an appointment, it usually would have taken a minimum of two to three weeks.
“We used the Revive software, and I liaised with like-minded hospital consultants to ensure that referral letters reached them the same day that they were typed; the consultants then needed to commit to answering the letter within one day. Although this involved a bit of IT software across the primary/secondary care interface, it was mainly clinicians who wanted to see this change to make a difference to patients, that actually made it happen.”
Raj continued: “The national team from the Access and e-booking team from the Modernisation Agency suddenly got really interested. We had an amazing local electronic access manager called Ros, who was equally interested in this – she highlighted the work we’d done nationally, and all of a sudden, we realised that we had made one of the earliest electronic booking systems in England. Unbeknown to us at that time, the government had just launched the multibillion national programme for IT, and one of the key deliverables was electronic booking with the ability to choose, called ‘Choose and Book’. My work in Warrington was highlighted and I ended up presenting and sharing our experiences nationally. I was then appointed into my first proper job in informatics and digital transformation as national clinical lead for Choose and Book as one of the first few clinicians appointed into the ambitious National Programme for IT.”
Raj highlighted that despite him accepting a part-time position nationally, his main passion continued to remain in general practice and clinical practice.
“Making my patients feel happier or satisfied when they left my room or when I left their homes was always my first priority, and I always found that after a really long surgery, as tired as I might have felt, I would always go home happier and satisfied that I had made a real difference to my patients. I have always said that it’s a true privilege to be a GP and also to be in a unique position to make a real long-term difference to patients and their families. It’s never a job; but a role, responsibility, and a truly honourable vocation.”
The revamped practice ended up becoming one of the exemplars for Choose and Book nationally, winning a national award for effective IT implementation.
Raj then moved his attentions to “using every single facet of IT available from the NHS, and from wider sources. I initiated a 10-year practice transformation project – we called it the Eric Moore practice integration project.”
Developing the Eric Moore Medical Practice Integration Project
Raj described how the transformation project came to fruition. A four-phase approach was planned for the group of single-handed GP practices within the Eric Moore Health Centre in Warrington. Phase one focused on connecting everyone in the building with the value of using IT. “We did that really effectively, using the old Microsoft processors, and we supported a continuing training programme for all of our team members,” Raj said. He noted that at the time of his entry to Warrington, the Health Authority was “incredibly helpful”; the centre had rapidly become at risk of closure when GPs started retiring, and among its population were deprived areas where people lived 10 years less on average than people over the river in Cheshire. “It was in the Health Authority’s interest to keep the practice viable and fully supported.”
Through the project, Raj aimed for the practice to become paperless. In 2000, Raj visited Kaiser Permanente, a healthcare provider in California, and was impressed with how they mandated the utilisation of effective IT input across all aspects of care for their patients. This further motivated Raj to make a real difference and transform his practice in Warrington.
Within one year, the practice had become ‘paper-light’.
“I banned patient notes being brought into a doctor’s room, which in turn would force GPs to use the computer to not only access records and data but also to input the same,” Raj shared. “Summarising and making relevant entries of all existing notes was the highest priority, and we pushed data summarisation by bringing in medical students and other trained data entry specialists, who worked late evenings and weekends, and blitzed the paper records.” They identified a storage company to move their notes out to make space, but Raj noticed that when he asked to access any notes, the company would locate them, scan them, and send them in electronically. He approached them and suggested that they scan the notes before they were put into storage. “They agreed, and I balanced the cost against the storage space that we would need. This move started the process of scanning documents across patient records, which over time was done by all practice front office staffers and a routine day-to-day document management process, making us paperless.”
Phase two of the project involved amalgamating all four single-handed practices together into one, which became the new Eric Moore Partnership Medical Practice. Raj explained how working hours, patterns, on call/duty doctor sharing, held joint education and clinical governance meetings were connected between the practices, with an ethos of joint working. By the end of this phase, they had appointed a single practice manager and were amalgamating finances and staff.
Phase three was about converting the integrated practice team into a transformation exemplar across multiple projects, including digital transformation, practice governance, and leadership model transformation. “We brought in patient self check-in screens, we supported patients to access their records – initially we could send them a link to look at the basic reports with full consent, but then we created a records room, where patients could sit in and a receptionist could sit in with them.
Phase three also placed focus on ensuring that they had a multi-professional team. Raj described how they empowered nurses and other non-medical clinicians to join them, and changed the leadership structure from a GP-led model to a multi-professional matrix leadership model with a GP, practice manager and lead nurse. Raj noted that staff have benefitted from the incentivisation model and called it an “amazing journey”. He added: “We are proud to say that we still have the same successful enhanced model today. We had an initial list size of 3,600 when I joined, and now we’ve grown to over 12,600 patients, becoming one of the larger GP practices in Warrington.”
Moving on to phase four of the EMP integration project, Raj explained how the two new buildings have supported his and his practice team’s wider ambitions for patient care, including bringing in an integrated primary care delivery model supported by secondary care specialised services and imaging services.
“Phase four needed a fit for purpose infrastructure, and a key need was to have a world-class, ‘connected’ building. I approached different colleagues with the model for the building and reiterated that it wasn’t just about a building for general practice; rather, we wanted a community facility that would provide the infrastructure for a wider variety of healthcare services. Our aspiration was to have specialist consultants come in and work with us. We wanted to have imaging and scans undertaken in the community, and we wanted the scan reports to be in our own patient systems rather than sitting on somebody else’s.”
There was some pushback initially from the local hospital about doing scans in the community. Raj got a consultant from a different hospital to see if they could get a grant to buy an ultrasound machine, and once they had secured that, they set up a pilot to do ultrasound scans, creating one of the very first community ultrasound services in the country.
“It offered results in the same week, rather than six weeks in the hospital. It was amazing, and all the practices in Warrington said, ‘Raj, can we dip into this service?’ So we floated that offer as a separate entity, which still holds contracts across Cheshire and across Yorkshire and the North West. That has a life of its own now, and we got a consultant radiologist to lead that, along with a great team of people.”
Phase four also involved fitting in diagnostics, X-rays and scans, Raj continued; then they had to provide space for a mobile scanner in the car park, with the right clinicians managing the same. “Having a fully-fledged day case theatre facility in the community was also an aspiration. All of this was successfully built and achieved with the opening of the new Medicentre Warrington as the same site of the previous health centre in 2016 .”
Creating a connected building : the new Medicentre, Warrington
Raj talked us through how he went about creating the kind of “connected building” that he envisaged for the new integrated practice.
“We wanted the building to provide access and support to consultants, where patients can receive most things without having to go in to hospital. We already demonstrated, by bringing in consultants to work with us and work on our systems, that we had better output for patients and we saved the system money by employing consultants within our practice and running it as a day case hospital. We had visits from the national teams to see how that model can work, and at that time there was a big push to move more consultants out into the community. You don’t need to have a dermatologist or rheumatologist sit within a hospital building, but rather to be scattered across the community doing community clinics, which in turn brings them closer to the patient. The build for the facility started with the practice buying the existing health centre site from the NHS at market rates, and a build that delivered what is now possibly the most advanced health facility in the community in Cheshire.”
The Medi-Centre’s unique development of a “community-based day case theatre” was highlighted by Raj as a major achievement.
“It’s got the facility for 25 air changes, which you need for orthopaedic procedures and so on. Normally, GP practices would have a simple 10 air exchange unit attached to the wall, but that needed to be changed and filtered for major procedures. It has wi-fi in every single corner of the building, with a virtual remote receptionist supporting first-floor patients and an MRI docking station in the car park. There are multiple stations for patients to be able to access their records, and self check-in screens. We have a phone system that measures the total number of calls and uses cloud-based web technology, which will show you how many people are waiting and how long they’ve waited. This is becoming commonplace now, but when established it, it was unique from a GP practice perspective. On a daily basis, the practice manager will share a single screenshot to see the average time a patient waited on the phone, and the average time spent by the receptionist on the phone, so everybody is aware of how well they are doing. We ended up answering calls within one minute, and we also streamlined our appointment system so patients could book appointments directly.”
Raj added that they have put iPads in the main play area to encourage children to learn about healthcare content, and they encourage patients to bring in their iPads and connect them to the internal system. They are also working on developing a practice YouTube channel and additional social media channels to help convey messages on health and wellbeing. Every clinician has committed to providing at least one video podcast a year on relevant topics.
If you walk into the practice today, Raj described how you will find “a main reception with two or three receptionists, and then upstairs we have a soft consulting room for patients who have mental health issues who need a quiet space, and when they go upstairs they’re greeted by the remote receptionist from the back office.”
Ultimately, Raj said, “It’s time we brought IT innovation into the NHS.”
Using IT and technology to support better patient outcomes
Raj went on to share some of the work that he and his team have been doing using IT and data effectively. He also spoke about the practice’s ‘CarePlus scheme’ that supported some of the most vulnerable in society and was developed with four main area of focus and calls to action, alongside their patient participation group.
“We had a very poor level of management of diabetes amongst our patients, which worsened over the pandemic, so we started using technology to support us and our patients. Using the continuous glucose monitors, which monitor blood sugar levels and how it reacts to different foods, was a great start. The monitor is available now on the NHS to allow us to prescribe the same. We set up a ‘diabetes action plan’, and we set up a process where patients with very poor control of diabetes are targeted. They are given training on using the app and sent home with the patch that monitors blood glucose. They would give access to our lead diabetes practice nurse, and every day she would check the screen, so she can see live readings of glucose for the list of patients. She could pick the phone up and speak to them if she needed to check anything. It’s amazing to be able to use technology to be able to do that. We also have an automated blood pressure machine and a weight machine in the waiting room, which connects into the system – patients don’t have to make appointments just to get their blood pressure and weight done, they just need to put their name and date of birth in, and it goes straight into the system.”
Another area of focus was cancer care, which Raj noted had become even more challenging over the pandemic. He described how the practice looked into long waiting lists for cancer and noted that patients were struggling as were the health and care system. “We therefore appointed a cancer care coordinator who supports people with a direct line to these individuals through a surgery hotline and email that was monitored every day. Patients are given direct access into a dedicated VoIP (voice over Internet Protocol) number which is manned all day at the practice, and they get priority access, they can send messages, send photographs, and so on. The practice developed its internal audit of cancer care patients, which tells us who has been waiting the longest; which of these patients actually have an established diagnosis of cancer; and what stage they’re at. It’s all managed by a dedicated team who coordinate with the different cancer care teams and McMillan and Hospice teams enhancing and supporting the patients journey. We would like to believe that we have made all efforts to ensure that our patients have a positive experience of the system through what is possibly the most distressing phases of their lives”.
Raj also shared the two other areas of the CarePlus programme – a “physio-cercise scheme” offering specialised weekly exercise classes to its elderly patient population, and the ‘”homeless medical service” for Warrington, supporting people experiencing homelessness from across four sites with. dedicated team of outreach clinicians, and prioritisation for same-day appointments as they are classed as a ‘hard to reach’ population.
Raj touched upon some of the most important things he has learned on how to make change happen.
“I think people always think somebody needs to give a handout to make things happen, and the great thing with primary care is you don’t have to wait for handouts,” he said.
“We are delighted that as a practice team, we have been awarded ‘Outstanding’ in our care of our patients by the Care Quality Commission. Our consistent use of data and technology has helped us improve our access, improve the quality of care, improve the patient’s experience of the practice. One of the key elements to our success is in ensuring that patients are our partners in everything that we do – we have a very active patient participation group.”
Finally, we asked Raj what his priorities are in digital and technology at Eric Moore over the next ten years.
“In the next 10 years, I hope we can look at AI enablement and empowerment of patients – I’d like us to move from where we are currently, i.e. where it’s very dependent on the system; to a model where we can use effective algorithms to direct patients to self-help pathways which can be personalised. The key word here is personalisation of care. And I believe that AI is going to help us offer that for the longer term, in a manner that no single clinician can contemplate delivering. I am not worried or frightened of AI becoming too independent or taking over clinician’s roles. I fully believe that we shall be at the helm, using AI-enabled processes to be able to transform how we deliver care.”
“For instance, I’d like to give all of our patients avatars, so for example, if you are drinking too much, your avatar can show you the inside of your body and demonstrate what your live blood readings for alcohol and its effects are. It will tell you that this is directly related to the amount of alcohol you consumed in the last week. Another example is to have continuous blood glucose and other constituents monitoring. Imagine the learning and the impact on early diagnosis management of conditions that can be initiated by the patient themselves.”
Before retiring, Raj said that he would like to “live in a world where we are supported by technology, where we can actually cure or reverse conditions such as diabetes, using that technology and allowing patients to do it themselves. General practice needs to be at the helm of such processes. We have such an amazing system in general practice in this country, which is unique to the whole world. Across the system, our general practice model is one of the most cost-effective systems in the world. Despite some setbacks in this area caused by the pandemic, I am able to see some incredibly positive signs of recovery – we simply need to steer it to take on continuing transformation around technology and innovation at local levels, that continues to remain cost effective, supported by a national NHS infrastructure that continues to value and support technology and change across health care systems.”
Many thanks to Raj for joining us.