In the second of two articles, Rick Stern and Henry Clay of the Primary Care Foundation discuss the PAAA online tool, which is helping teams to reduce pressure and manage practice workload.
The last 18 months could not have been more challenging for general practice. A rapid transformation from traditional face-to-face appointments to remote access showcased general practice at its finest.
Yet, practices now find themselves being denounced for their failure to see patients face-to-face and are coming to terms with new punitive metrics and CQC regulation. This flies in the face of years of national policy initiatives encouraging greater flexibility in accessing general practice, including more phone appointments for those who need them.
How can practices navigate this increasingly toxic policy environment, supporting weary and beleaguered staff teams and making best use of dwindling resources?
One insight from many years of work with thousands of practices is that solutions tend to be counterintuitive – avoid the temptation to just work harder or see patients as the problem rather than the solution. We offer a few brief reflections on how you might cope with the current pressures.
Give patients a choice
Bear in mind that patient choice in accessing appointments may reduce your workload, not increase it.
Practices should be applauded for the shift on appointments, not demonised. It is not a matter of telephone bad; face-to face good. Complex questions rarely have simple binary answers, even though the media and politicians tend to look for quick fixes.
There are always benefits in being flexible in the way you offer appointments – whether they are same day or booked in advance, a standard 10-minute or an extended slot, an individual or group session, phone, online or face-to-face, nurse or GP or pharmacist, continuity of care or the next available clinician – all of these options meet different needs for different people.
Most of us, as patients, welcome a choice and feel we are best placed to decide what we need. What is often overlooked is that choice may well be the best option for the practice too. Trying to direct patients to options they don’t want is counterproductive as they are likely to make a further appointment – whether it’s with the clinician they want, or in the right format, or at the time that works for them. Giving patients what they want may actually reduce workload, so be good for the practice too. As King Canute well knew, nobody can hold back the tide.
Use the data
Make time to translate the ocean of data in your information system into meaningful intelligence.
Practices have taken great strides in this direction but, for most, there is still a long way to go in making evidence-based decisions on what to change, where to focus or what priorities to have for investment.
Too often we rely on the anecdotal example of a few patients that we remember, so we plan based on the experience of a handful of vulnerable or dysfunctional patients rather than the needs of the many. There are many helpful, and free, tools available to all practices to harness information – try our Potentially Avoidable Appointment Audit (PAAA) or national support from the Time for Care Programme. In this, we have also analysed data for practices over several years, looking at consultation rates by age band and for particular conditions.
But while it is unwise to design your practice around outliers, you have a lot to learn from the few patients who return hundreds of times a year and take up so much of your time. Most practices spend a large part of their working week failing to satisfy the needs of a small handful of patients. Focusing in on the frequent attenders who take up a disproportionate amount of time and resource can lead to more creative solutions.
One of the main findings from other more detailed audits we run with practices is that it is often GPs providing most of the support to those who are most demanding of your time, when other members of the team may be better placed to provide continuing support or meet non-medical needs.
Good management is ‘under-appreciated’
Focus on improving clinical management within the practice team. Good management remains under-appreciated and is as vital in general practice as in any business. Managers are still often denigrated – but managing your resources effectively, which by and large means managing your people, is crucial. In our experience, clinicians are given little support and assistance to help them use their time to meet the most pressing priorities for improving care.
But management is not just about the practice manager, it is about clinical leadership too, so embedding supportive reviews and appraisals as well as clinical review and peer review, will have a profound impact on staff well-being and your bottom line.
Tackling low morale by offering support will help motivate your team. When practices feel under attack, many respond by working harder, but spending even less time with your family and loved ones is rarely the answer.
What motivates people in your team will inevitably vary, but some of the best solutions are simple to set up. Building in a daily 15-minute break at the end of morning surgery so that people can meet up, check in with colleagues and pick each other up, is often one of the best informal indicators of a well-performing practice team.
Working together in partnership with other local practices in PCNs, the local community or the wider health & care system, will continue to offer opportunities for reducing workload and improving care. The pandemic may have cut across some emerging partnerships and accentuated others, such as for the delivery of vaccines, but working together with other practices is still likely to offer the best opportunity for managing workload and influencing the system around you.
Similarly, grab the opportunities that are presented to you.
During the pandemic many practices have learned how to use telephone consultations and will be planning to continue this for many appointments. But what an opportunity it provides to make best use of a wider set of skills.
If patients do need to be seen face-to-face, they can be directed to another clinician type with much more confidence than would ever be possible through providing guidance to reception staff. It provides a more varied mix of cases and more interest to the wider clinical team and there is an opportunity during the telephone consultation to explain to the patient the benefit to them – getting them on side from the start.
By getting this right, these patients feel that not only have they spoken to the doctor, but they have also seen the person best able to deal with their condition so that they become your partners in making the system work better. What a contrast to patients kicking against the suggestion from reception staff that they should see the nurse.
Remember, patients are your allies not a threat – unless you ignore them.
All general practices can access the Potentially Avoidable Appointment Audit at www.pcfaudit.co.uk or find more information at www.primarycarefoundation.co.uk/overview-of-the-audit.html or email us at [email protected] For the Time for Care Programme go to https://www.england.nhs.uk/gp/gpfv/redesign/gpdp/releasing-time/