Practice manager Jennie Dock shares advice and tips on managing the ongoing blood tube shortage to ensure you can prioritise patients efficiently and minimise disruption
The powers that be saw how well the NHS was coping with the pandemic and decided to throw a little spanner in the works to poke our complacency.
General practice (and other areas of the NHS) have been mandated by NHS England to delay all but the most urgent of blood tests.
There are a few reasons for the shortage: an increased demand for investigations subsequent to delays caused by the pandemic, a shortage of the raw materials used to make the bottles, staffing challenges for the production and distribution lines, and delays on import caused by border controls.
So we know what we should be doing, but how do we actually do it without causing our already pressured teams to fall over? Here are my tips, as a practice manager of a large practice in Southampton, following the changes we have implemented.
The NHSE guidance helpfully tells us what’s urgent:
However, there are still a lot of judgement calls to be made within these parameters.
Your team will need to have a clinical discussion to decide what your practice policy is. In terms of prescribing, our practice has agreed that INR, DMARDS and denosumab monitoring tests should not be delayed.
Most QOF recalls can be delayed – if we’re only talking 2 weeks, that shouldn’t put us too behind.
Individual clinical decisions will be needed for any tests that have been requested acutely for investigations – ideally for the requestor to decide, but that may not be practical.
Get an admin member to put together a spreadsheet (see an example here) with all the bloods that are currently booked, and why they are booked. They may need to look at the actual blood test request form to find out the reason for the request. They can leave in those tests agreed at practice level – for example the INR, DMARD and Denosumab monitoring, also any 2-week-wait (2ww) blood tests. Other tests should be authorised by a GP.
Give one GP some protected time to complete the assessment of clinical urgency (if the spreadsheet is well completed by the administrator, the GP should need about a minute per patient). Then the administrator will need to code the record, text the patient, and cancel the appointment.
Don’t forget to also stop online booking of phlebotomy appointments, and consider changing all your future blood test appointments to ‘urgent’ blood test slots.
We have taken the decision that, for the time being, we request any tests meeting the NHSE criteria using the ‘urgent’ flag within the blood test request system (ICE in our case). In addition, we are asking clinicians to record in the notes that the test is urgent, so it’s easier for reception to check when the patient is being booked in. For any non-urgent tests, we are asking the clinician to code ‘Laboratory test requested – not done’ so we can search on this to reinvite them at a future date. We are also adding this code to any that we are cancelling. To make it easier, you may be able to create a shortcut on your IT system – in Emis you can use Quick Text to set up a shortcut to this code (ours is called #delay). You could also put these codes into a protocol to make it easier for the clinicians.
Although the future test requests we generate will be graded as urgent or not, there will already be a number of forms in the system which aren’t, and the reception team have the tough job of sorting out what can and can’t be booked. Give them the black and white information regarding the prescribing safety tests and 2ww, and I would recommend anything else is run past a clinician to check.
Patients will obviously be anxious to hear that their blood test is being cancelled, or that they won’t be able to book for a little while. Take every opportunity to reassure them, so that the Reception team aren’t inundated with calls.
Update your website and social media with the information on why you have done this (see an example on our website here). It’s a good idea to let patients know when you made the statement, and when you will next update them – put it in your diary so you don’t forget.
Make sure the whole team is on board, both with requesting new tests in the same way, and with booking future tests.
You might like to use the text we used when we sent the SMS to our patients:
‘You may be aware there is a global shortage of blood test bottles. We have been told to postpone non-urgent tests – see NHS England information here: https://bit.ly/3ByiMF3. A GP has confirmed your test is not urgent, and we have cancelled your blood test appt. We will review this after 17th Sept, and reinvite you when we can. Please see our website for more info.’
Your phlebotomists will still be doing quite a few bloods, but you may be able to reassign them to other work. They could help with the admin side, for example on the spreadsheet described above and also the cancelling of booked appointments. If an HCA or other staff member able to give flu vaccines, you could divert them to support running your flu clinics. Or you may want to encourage them to take some annual leave, if appropriate.
It would be lovely to think that this shortage will only last for a couple of weeks, which we can probably cope with before it starts to impact QOF. But the likelihood is that it will go on for longer. The BMA are currently lobbying NHS England (see here) for income protection for QOF in what has already been an extremely challenging year for meeting targets. Many LMCs are also challenging NHSE on this decision too.
This is one of the reasons that coding is important; if you would normally have sent recalls to patients, make sure to code them as not sent so you can evidence that later in the year if you don’t reach target. As above, in our practice, we have added the coding ‘laboratory test due – not done’ so we can evidence that we have clinically risk assessed this request.
You could consider Near Patient Testing for HbA1c tests, although this includes factoring in the expense of the machine and the consumables – it may be possible to persuade your CCG to supply you with a machine and some consumables in the interests of patient safety.
As well as the potential loss of QOF income, you may have an enhanced service for phlebotomy which is paid ‘per bleed’. Less blood tests will mean less income. Discuss with your commissioner if they will protect your income during this time.
Of course, all of this is additional unfunded work for the clinicians and administrators. Most practices have been allocated ‘Covid fund’ monies – ensure that the funding is allocated towards this, and that in any audit of expenses, your time is accounted for here.
Finally, just a reminder that general practice and your practice specifically is not on their own with this. There should be opportunities to share supplies of bottles with other practices locally or in your PCN, work with your commissioners and collaborate with secondary care to make best use of the resources and provide a robust service to patients.
Jennie Dock is a practice manager in Southampton
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