Releasing Capacity Roadshow - GPC/NHSE
Bristol March 9th March
There was an extraordinary hiatus at the beginning of this meeting whilst we fiddled with our mobile devices so we could vote online. Surprisingly most people present were optimistic about the future of general practice. Dr Robert Varnum pointed out how poor the data was about what most concerned GPs about their working days.
There were video recordings from Chaand Nagpaul and the new director of primary care at NHSE Dr Arvind Madan. Dr Nagpaul pointed out the vast number of unnecessary appointments and in particular those made solely to sort out a missed hospital appointment. Practices had the freedom to change their own ways of working.
Dr Madan a GP of 20 years' standing admitted the problems of workload, paperwork and funding. There was no “silver bullet” but NHSE, CCGs as well as practices all had roles to ensure the success of the Five Year Forward View. Practices were not “helpless observers” and could take initiatives to improve services and reduce workload at the same time. He remained optimistic that by working together we could make a brighter future.
The Making Time in General Practice study was next presented by Rick Stern from the Primary Care Foundation. The key messages included in it had been welcomed by Jeremy Hunt and Simon Stevens. Practices felt under unprecedented strain for reasons well known to us all. Working hours were longer and the share of NHS budget had reduced. Getting paid by NHSE and CCGs (by far the most burdensome), processing hospital information, keeping up to date with changes in emails and bulletins, reporting information to NHSE and tight timescales and supporting patients to navigate other parts of the NHS were the biggest bugbears. Some 75% of GP appointments were judged unavoidable but others could take on the rest.
The key messages were to for NHSE to simplify payment systems, repair the fractured relationships with hospitals and the need for practices to share learning from others and to work together. This would require funding to free up time. Practices varied enormously from one another with a few coping very well. The Secretary of State had decreed that patients would not need to see a GP to rebook a hospital appointment. How this would work in reality was unclear. Unlocking the potential of the whole community to, e.g. to better support the lonely, would require funding across groups of practices. There was a wide range of aids in development including apps.
An audit appointment tool on appropriateness would soon be available and should only take a few seconds per patient. The demonstration did indeed make the process look easy. There would be comparators to compare practitioners, practices and the national averages. Early interest can be registered at firstname.lastname@example.org.
NHSE recognised the need for increased investment, reducing burdens, workforce development, support for struggling practices, premises and IT development and practice development (centred on increasing access) and what had happened so far was presented in a rosy glow. Jeremy Hunt’s much vaunted package to “support primary care” was now delayed to the early summer (it had been hinted that we might have heard about it today). In answer to exasperated questioning about the time being taken Dr Varney said that primary care really was at the top of the NHSE agenda. Apparently adjustment to trust contracts had already been made to forbid a blanket policy of referring patients who had missed appointments back to their GP. This was greeted with outrage: had anyone told the trusts? The minimal changes made to QOF nationally this year and the “Somerset experience” was being watched closely at the centre. MCPs would not have to take part in QOF. Disappointingly our speaker seemed to believe in the “5000 new GPs” perhaps being contractually obliged to do so but accepted that even they as well as other workforce initiatives might be too late to help crises in some areas, paradoxically perhaps those not yet in extremis who were not receiving immediate first aid. There was no white knight coming to save us. It was therefore up to practices to do what they could now.
Hence there were 10 high impact changes already being made in some practices. These were
1. Active signposting by receptionists to other providers perhaps via online resources.
2. New types of consultation such as phone and email by NOT bolting on more work but replacing other types of consultations.
3. Reduce DNAs by making cancellation earlier, text reminders, 4. Team development including the famous pharmacists, more filing of routine letters without GPs seeing them.
5. Productive work flows with efficient processes, fostering productive environments and matching capacity with demand.
6. Personal productivity with resilience, computer competence, touch typing and speed reading.
7. Partnership working between practices and other services.
8. Social prescribing to external services and so avoiding being “patients’ friends” (this is already working in Wells and Mendip).
9. Systematic self care advice.
10. Developing Quality Improving expertise - NOT by working faster, harder and longer.
We were promised to be able to look at case studies in these fields later but first Mark Robinson a pharmacy adviser with the NHS Alliance spoke of his experience with improving prescribing in a practice 20 years ago with focus on changes contained in discharge summaries, leading on to poly pharmacy reviews, reviewing the whole prescribing system including repeat prescribing which generates a number of niggles every day in most practices taking up time. He went on to run clinics based on strict filtering leading to long term condition management in conjunction with practice nurses. Working group clinics with 10 patients at a time worked well. He also looked at anticoagulation, QOFs and DESs taking some of the burdens from GPs. It was “relatively easy” for practices to take on a pharmacist on either shared care or wholly employed basis. Community pharmacists had been giving minor ailment advice for decades but locally funded schemes were being wound up and there would be no nationally funded schemes. Therefore, sadly, the return of patients eligible for free prescribing to GPs to get an FP10 would not end.
Dr Mike Taylor from Brisdoc and the One Care Consortium spoke next. This latter is managing the PMCF in Bristol and the surrounding areas. A platform to test schemes for collaborative working. EMIS was developing a system to allow access to multiple lists, Artemis was an intranet to help spread best practice and a new telephone, Cloud-based system was being developed. Data sharing in OOH and between practices, additional services including mental health, physiotherapy and phlebotomy.
The ability to see GP records out of hours represented a quantum leap in care. Data sharing agreements had been signed by over 100 practices allowing some 85% of patient records to be accessed OOH. Individual patient consent was still sought on each occasion. This was still “read only” at this stage however. Connecting Care had improved communication and had reduced the number of doors being kicked down by police when the patient was in fact sitting in A&E. All of this would assist in making the government's seven day access imperative agenda more palatable at the least.
I attended the productive work flow small group hosted by an NHSE manager where we looked at some case studies. We were invited to feedback to the central team. Inevitably we had to look at the patient pathway starting with difficulties in encouraging patients not to use the telephone. It was agreed that online systems were not flexible enough. Experiences of Advanced Access were shared but some had found auditing of “emergency appointments” useful to match demand to capacity. Constant vigilance was required as demand changed. Patients needed to understand that resources were not limitless. There were admissions that GPs were part of the problem wanting to be all things to all men, anxious about missing things but recognising that true continuity of care was key to efficiency but that “continuity of care” for HMG now means being able to see the medical record. Not signing (electronically or in person) dictated letters, “keeping GPs away from QOF” and better coding of incoming mail (not by GPs) to allow GPs to see fewer letters that do not need to be seen before the patient's next contact. A script collection register to prevent time wasted by pharmacists blaming practices for scripts they have lost had saved much time for a Bristol practice.
The personal productivity table was next. It was poorly attended. There were eight principles described (from the Australian Medical Association).
1. Making home a sanctuary
2. Value strong relationships
3. Have an annual health assessment oneself 4. Control stress and not people 5. Recognise conflict/distress/upset as an opportunity 6. Manage bullying assertively 7. Use peer support 8. Create a legacy - remember why you are there.
A proficient touch typist can type 65 words a minute and do not need to look at the keyboard. There is a free App. Speed reading can double reading speed. Some GPS are not confident using their clinical systems, others have developed extraordinary levels of “muscle memory” of processes.
A healthy team is alert to risks, creates a compassionate and open culture, has regular managed time outs to discuss problems, shares responsibility for stressors and acts collectively with a culture of support, has external networks, trains mindfulness, involves the whole team in CPD and ensures staff are registered with a GP.
Somerset’s SUCCESS scheme and the Benevolent Fund were hailed as outstanding examples of good practice.
My third session was concerning new consultation types and reducing DNAs. Your correspondent depressed everyone by pointing out that the standard of medical care demanded by the court is that achieved when can see and examine a patient in person. The concept of telephone triage as the second best option when there are no appointments was discussed and roundly rejected. Offering booked telephone consultations as an active choice, especially for follow ups, was suggested as a way of reducing risk especially when coupled with good continuity of care. These have to limited to a certain number and interwoven with face-to-face consultations rather than as “bolt-on extras.” The One Care Consortium was piloting a web based system, “Web GP,” which is a simple “yes or no” set of questions which promises a follow up contact within a certain time. Slots can be then devoted to doctors reviewing these and appropriate actions recommended. Some 10-15% of responses are said to result in avoiding an appointment. The drawback was that, “silver surfers” aside, this might be of more interest to a population that rarely needs primary care. Group consultations could be a good way (pilots are underway) to encourage peer support and can be run by a practitioner not necessarily a doctor as an alternative to repeating the same information 10-20 times in individual consultations.
In the summary it was agreed that working in groups of practices was vital to avoid “re-inventing the wheel” and that the current problems in general practice had added impetus to this process. On the other hand, continual pressure of work and the difficulty in getting time away to study was a problem. A woodman, struggling to saw through a tree trunk, might consider himself too busy to stop to sharpen his saw and so make the job easier. Just doing the “same old same old” would not work. Not every problem was outside our control. However, as co-working proceeded, new challenges would undoubtedly be uncovered. Small steps worked best and the wider experience was disseminated the better.