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What do we mean by avoidable appointment

A blog by Rick Stern from March 2018 ‘If only …’ explores the idea of avoidable appointments, what practices have gained from the audit, and what might be possible with further investment in general practice. It has also been published in Health Care Leader.

If only ...

Just over two years ago we were finalising a report for NHS England looking at workload pressure in general practice called ‘Making Time in General Practice’. I remember a tense discussion about how to present the headline issues from the report. A senior figure in NHS England wanted to say that ‘more than a quarter of all GP appointments are avoidable’. While this was one way of looking at our work, we wanted to emphasise that appointments were potentially avoidable, only if other services were put in place first. If only there is investment in other members of the practice team, in improving communication with hospital services, new resources for social prescribing. If only.

We did moderate the message. We also were supported to develop the key tool at the heart of this debate – an audit of potentially avoidable appointments – and 270 practice reports later, we have now been asked by NHS England to develop a simple to use, automated, free to use audit tool, for all practices across England.

To get this right, we have been surveying practices who have used the audit so far. Amongst a lot of positive feedback was a concern from one GP that he was unclear whether the audit was intended as a way of measuring what GPs can avoid doing now, or what might be possible with further investment. This gets to the heart of what ‘avoidable’ might mean. Avoidable is a subjective term. Each clinician will have a different perspective on their own role, what others can do, the importance of continuity for different groups, what patients can do for themselves, and what other organisations could pick up for the practice.

The key here, is to get people to talk. By talking it through together, the practice team can collectively develop a better understanding what has to be done by the GP, or what could be picked up by a nurse, the practice pharmacist or GP associate. Or even what might be directed to others outside the practice.

We are actively encouraging practices to complete the audit based on how general practice could be –– not just how it is now. So, if you had more colleagues in the team, a different skill mix, better links with local pharmacies, better information sharing with local hospitals – what could be done by others?

We also found out that more than half the practices that got back to us had made immediate changes after looking at the results of the audit. Practices were improving signposting to get patients to the right person in the team, offering more telephone appointments, using care navigators, advanced nurse practitioners and clinical pharmacists more, or making arrangements with the local pharmacy to deal with minor ailments.

This is impressive. But what might this look like if the investment from the GP Forward View, when it finally finds its way to general practices, was spent on the things that really matter to practices? Some STP areas have already been looking at the results of the audit in this way. Not just as a way of individual practices focussing on redistributing their over-stretched resources now, but whole health communities investing in general practice as a sustainable way of building the NHS for the future. Now that would really be something.

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The Primary Care Foundation supports the development of best practice in primary and urgent care. We apply our work shaping national policy to support local change. We use information to create understanding, driving improvements in care, reducing unnecessary variation across organisations and between clinicians and developing practical tools for front-line staff in general practice and urgent care.