What we have learned: Five key lessons about access for GP practices
So are there any simple lessons? 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 for practices looking to improve access …
1. 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.
2. 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.
3. 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.
4. 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.
5. Free up GP time – review avoidable appointments
There are 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. 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.
In summary, there are three final learning observations:
- 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.
- 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.