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9 May 2017
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Are there any simple lessons for practices looking to improve access? Rick Stern worked with over 1,500 individual practices across England in order to find out
Getting an appointment has always mattered; as patients we want to be seen quickly and if we are seen regularly, we probably want to see the same person each time. As practices, it’s the key to managing the increasing workload and the stress on our clinical team. And now it has started to matter to everyone. The NHS has begun to realise that the pressure on hospital beds cannot be managed by a single-minded concentration on the flow of patients through A&E. The steady drip of demand from general practice is now seen as underpinning pressure in the wider health system, to the point where ‘if general practice fails, the NHS fails’.
This is not new. Back in 2009 we produced a report for the Department of Health  that for the first time focused on access in general practice as the single most important issue in managing urgent care and the pressure on the rest of the NHS. It helped shift our collective thinking, placing general practice at the heart of the NHS, rather than on the periphery. It also led to many new offers to practices to rethink their appointment systems and redesign care, varying from rapid quick fix approaches – frequently focussing on converting all contacts to telephone triage – through to extensive modules for practice managers as part of nationally developed programmes.
So are there any simple lessons for practices looking to improve access? From our work with over 1,500 individual practices, or nearly a fifth of all practices across England, there are five main things to bear in mind.
First, understand the problem. All practices are different and there is a real danger of tackling the wrong problem unless you invest some time in understanding exactly what is happening in your practice. We have developed a web-based tool that brings together a lot of different information about the practice – including all the calls into the practice and different types of appointment over a week – alongside the latest feedback from the national patient survey and demographic and workforce data, to prepare a report that compares your practice with all others across the UK. The report highlights how the practice is similar to and different from others, such as whether it is offering more or fewer consultations and if it is likely to be able to keep up with calls throughout the day, and offers a series of practical suggestions for making potential improvements. Crucially, the report is the basis for a broader conversation across the practice team based on real evidence that places its experience alongside those of its peers.
Second, being busy is not always a good thing. We encourage practices to focus on reducing contacts with patients that do little or nothing to sort out their problem. There are many examples of this. One of the most frequent is directing the patient to the wrong clinician. If I have a long-term health condition, continuity of care, or seeing the same person, is likely to be very important to me. And if the appointment system is under pressure it is often tempting to slot people in with the next available GP or nurse. But if I am unhappy with the consultation I will just reschedule another appointment, creating more pressure rather than less. Telephone triage can work well, but in a struggling practice it can just lead to an increasing spiral of activity as more people have multiple appointments, first on the phone and then again face to face. Frequently, the solutions are counter-intuitive; practices that try and save time by scheduling shorter five-minute slots tend to discover that they are ineffective, as either the consultation takes longer and the GP runs late or it drives more repeat visits as not all patients feel they have been properly listened to – and the Royal College of General Practitioners argues that it is bad medicine.
Finally, we often find that there is limited consistency across the clinical team, with some practitioners only inviting patients back for repeat visits in line with NICE guidance while others are allowing patients to visit far more often. These factors, and the differences in consultation styles, lead to more appointments being taken up than necessary. We are generating extra activity while at the same time frustrating too many patients.
Third, there is a risk of making things too complicated. The more pressure we are under, the more work-arounds we introduce and the harder it gets to book an appointment. In one practice, we found 24 different appointment types, which only made sense to the person who had developed them, not to the reception team who had to make sense of them, let alone the patients trying to get seen.
There are also real benefits in making the system as consistent as possible with one script for the whole reception team that steers the best and simplest route through the initial call to the booking. Too often, differences in appointment systems are driven by the clinicians themselves, and the reception team find themselves trying to second-guess the different expectations of the GPs, some of whom stick to an agreed common approach while others collude in letting particular patients work around the system.
Fourth, rapid care is good care. This is particularly the case for the small number of patients who are acutely ill and can potentially prevent unnecessary admissions to hospital. But there is also plenty of evidence that patients perceive rapid care to be good care, whatever happens in the consultation. And sticking to time makes life easier for the practice team and for patients.
We have also gained new insights through our more recent work for NHS England, looking at the increasing workload on practices. Making Time in General Practice  helped underpin the analysis in the General Practice Forward View  and looked at the pressures on general practice in two ways. It looked at the increasing bureaucratic burden on practices, including the fragmentation of the way practices are commissioned and paid for services as well as the vast amount of unnecessary work generated between practices and hospitals. It also looked at the clinical workload, auditing potentially avoidable appointments, suggesting that as many as 27% of all appointments could be managed in other ways – in many cases, depending on extra investment to recruit more staff, or setting up new services that would be better placed to pick up a lot of the non-medical workload.
Potentially, this opens up a whole new front in the battle to free up time in general practice. As we have seen, there is a lot that practices can do for themselves to free up the time of doctors and nurses. Or a lot of small things that, when added together, can have a big impact and transform a struggling practice into a thriving one, where clinicians have time to talk to each other and more time to spend with patients, as well as getting away early enough to maintain healthy relationships with their families and friends.
Beyond this, increasing numbers of practices are taking up the offer from NHS England for free support to all practices across England to audit their own appointments. We now have a tenfold increase in the number of clinicians who have completed the audit and have received a report that feeds back what they have found across the clinical team and compares this with practices across England.
There are also suggestions about the areas that appear to be most important ways in the practice to divert workload away from GPs.
Again, there is no one standard solution. Some practices find that increasing their skill mix, with more practice pharmacists or physiotherapists or other practitioners, would make the biggest difference in sharing the load. Others find that the relationship with community pharmacy is crucial, or that greater opportunity for social prescribing would have the greatest impact. We are also finding that adding up the findings across groups of practices, or in some cases across the whole of an sustainability and transformation plan (STP) area, provides invaluable information for targeting future investment into general practice in the most effective way.
There is also more targeted support for practices than ever before. NHS England’s general practice development programme  has identified 10 high-impact actions to release capacity and is actively working with hundreds of practices on practical steps to free up time and improve patient care. It plans to extend this to all practices over the next five years.
We are working closely with the national programme to ensure we learn the lessons from our recent work. In practical terms, this means we are currently repeating a national survey of general practice to assess the current burden of bureaucracy on practices, and continuing to roll out the appointment audit for all practices in England. We will return to the findings from this work in future issues.
The bottom line
In summary, there are three final learning observations.
First, however difficult the financial climate, the pressure from other parts of the NHS, and the challenge of an ageing population, you are still in control of your destiny. It is often difficult to see the way forward when staff are working long hours and budgets are under pressure, but there are, as we have described, clear things you can do to use your time more efficiently and reduce workload, as long as you start with a clear understanding of the problem you are trying to fix.
Second, we are only just beginning to tap the potential for practices working together. I am a firm believer in the current model of general practice, with independent standalone businesses serving a defined patient list, but there are many things that are better done just once rather than multiple times across a network of local practices. Greater consistency and reviewing variation across practices could open up the way for improving access, not just within but across practices too.
Finally, there is no quick fix or no magic bullet. Improvement in the NHS is invariably built on a series of small steps forward that together can add up to a fundamental shift, from a daily struggle to cope and survive to a collective pride in a job well done.
1. Health Policy Insight: Editorial, Monday 12 September 2016: Andy Cowper Interview with Simon Stevens, chief executive, NHS England
2. ‘Urgent Care in General Practice’, Primary Care Foundation, May 2009, available at primarycarefoundation.co.uk/images/PrimaryCareFoundation/Downloading_Reports/Reports_and_Articles/Urgent_Care_Centres/Urgent_Care_May_09.pdf (accessed 19 April 2017)
3. ‘Making Time in General Practice’, Primary Care Foundation & NHS Alliance, October 2015, england.nhs.uk/gp/gpfv/workload/releasing-pressure/ (accessed 19 April 2017)
4. General Practice Forward View, NHS England, April 2016 england.nhs.uk/gp/gpfv/ (accessed 19 April 2017)
5. NHS England’s General Practice Development Programme england.nhs.uk/gp/gpfv/redesign/gpdp/ (accessed 19 April 2017)