Rick Stern and Henry Clay of the Primary Care Foundation discuss the PAAA online tool, which is helping teams to look differently at managing practice workload. The first of two articles, more will be shared on this at Management in Practice’s live event in Birmingham on 9 November.
It is always challenging to think about how things might be different. Most of us struggle to picture how the world might look in the future, personally or professionally. In the most testing of times, it is hard enough to just keep things afloat in general practice. No wonder – when staff think about how things might be different – minds tend to drift to thoughts of early retirement, or alternative careers, rather than redesigning care in the practice.
But there are simple tools that can help you start to see the wood from the trees. Six years ago, NHS England commissioned us to review unnecessary bureaucracy and increasing workload in general practice. The subsequent report, Making Time in General Practice, focused in on clinical workload and especially how to tackle the increasing pressure on GPs.
We developed a simple tool for thinking about how work might be managed differently and, after four upgrades to put it online, make it easy to use, improve instant reporting and adding new functionality.
Almost 20% of all practices in England have now signed up.
The Potentially Avoidable Appointment Audit (PAAA) asks clinicians to make a simple choice after each appointment – was this appointment ‘avoidable’ or ‘unavoidable’. And for all appointments that were seen as potentially avoidable, we offer simple options for classifying whether they could have been dealt with by another clinician in the practice, another local service, by another organisation or if it was due to the system not working properly.
Each individual doctor, nurse – and increasingly pharmacists, social prescribers and other members of the clinical team – has a different view on this, depending on their style of clinical practice and their understanding of what else might be available across other services or in the community.
Perceptions vary, but the results of the practice audit offer the basis for a more informed conversation about how to reduce workload. Members of the clinical team seem to vary so much in their views about whether others could pick up some of their workload, yet across the thousands of clinicians who have taken part in this national audit over a five-year period the overall average of appointments that are seen as ‘potentially avoidable’ remains at around 25%.
Put more simply, practice teams reckon that a quarter of appointments could be better managed differently. No-one would suggest that you could catch all these in advance – but there is plenty that can be done. Even if a fraction can be managed differently this will help. A lot.
The PAAA tool is free to use
The PAAA tool is available at www.pcfaudit.co.uk. It is easy to use, at no cost to practices across England. It is frequently deployed as a first line diagnostic for practices that are struggling but are unsure what is making their working lives so difficult – but others use it regularly to monitor the changes that they make.
Automated reports, prepared for each clinician and then for the whole practice team, highlight variation within the practice team, and across the more than 800 practices who have received reports after completing the audit. It also points to the changes that might have the most impact on managing workload in the practice.
For many, they see the answer as extending the skill mix within the practice team, so bringing in nurse practitioners or pharmacists may offer the best way of reducing pressure on overstretched GPs. For others, better social prescribing or improved access to mental health support may be the answer.
Reflection questions, asked before each clinician completes their part of the audit, point to other steps that might reduce pressure on the practice. These include exploring how the practices can help direct patients towards the right practitioner, or how to reduce patients coming for appointments when the practice can add no value. This part of the audit tends to work best across groups of practices where there are larger numbers of responses and can help shape commissioning intentions across the wider healthcare system.
New improvements to the PAAA allow practices to learn more from the audit. It is now easy to set up audits across groups of practices, such as PCNs, so that there is an additional level of learning, comparing results across practices who are increasingly working together and offering the basis for a development session identifying priorities across the practice network.
We have also made it much easier to develop an action plan from the results. The new ‘action planning tool’ is built into the online audit, with potential actions already identified, so that the practice can pin down who will do what by when. We have also built in a survey to identify what impact the audit has had on reducing workload in the practice. It is too early to share results but, in time, this will help identify what aspects of the audit practices feel has had the greatest impact and led to tangible improvements.
Finally, the audit now records how patients are seen, so has helped track the big shift to telephone and online appointments during the pandemic and whether patients need follow up visits. Although the political rhetoric damns practices for reducing face-to-face appointments, this flies in the face of policy initiatives encouraging greater flexibility in accessing general practice, including more phone appointments for those who need them. The key here is giving patients the care that meets their needs and the incredible transformation at the start of the pandemic should be celebrated.
The audit offers a way of tracking changes in appointments and seeing them as an opportunity for reducing workload and improving patient care.
Most practices have reported that the results are discussed in the practice and lead to practical changes including recruiting new staff, improving care navigation, introducing different types of appointment, and building stronger relationships with community pharmacists. Others have emphasised the importance of having a different conversation within the team, or as one GP put it: ‘At a time when we are drowning in work, we need to look at things differently and that’s what made the audit so useful.’
The PAAA has been developed, maintained and improved by the Primary Care Foundation working with Methods Analytics. It has been commissioned and fully funded by NHS England. All general practices can access the audit at www.pcfaudit.co.uk or find more information at www.primarycarefoundation.co.uk/overview-of-the-audit.html or email us at firstname.lastname@example.org
To take part in Management in Practice’s next live events in Birmingham (9 November) and Newcastle (30 November) book your place at managementinpractice-events.co.uk