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The latest blog by Rick Stern ‘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 is available here and will also be 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.

If you want to know more about how to use this free audit tool, either for your practice, a group of practices, or across your CCG or STP, go to www.primarycarefoundation.co.uk or email Rick Stern at This email address is being protected from spambots. You need JavaScript enabled to view it.  


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I want to share a few thoughts as I hand over the baton to a new generation of leaders in NHS Alliance and return back to the Primary Care Foundation. The best example of offering advice to a new generation is the one and only no.1 hit with a clear and unambiguous public health message – Baz Luhrmann’s 1999 ‘Sunscreen Song’ – which highlights that the only advice he can offer, which is genuinely based on evidence is ‘use sunscreen’.

For my part, I would like to take a fresh look at how we make decisions in the NHS and the importance of something economists and psychologists refer to as action bias. Put simply, action bias is the idea that when faced with difficult situations we tend to get the feeling that we need to take some action regardless of whether this is a good idea or not. It follows that we would make better decisions if we had an awareness of the unconscious psychological processes that drives our decision making at times of stress.

I recently noticed a link to a great 7-minute video that focusses on what happens in a goalkeeper’s head when they try to save a penalty. Now this is all pretty close to home for me – as some of you may know my son started a career as a professional goalkeeper and has since managed to turn his passion for football into a career as a goalkeeper coach.

As my son always tells me, goalkeepers love penalties. They can’t lose. The striker is expected to score but if he saves a penalty he is a hero. Interestingly, when he was still playing in goal he took this a stage further and decided that he should do everything he could to distract the striker as he prepared to take the penalty. He would walk out of the goal and move the ball, argue with the referee and tell the striker where he was about to hit the ball. It was a nice theory, but it was at best unproven – the only certain thing was that he got booked a lot and created a name for himself with referees.

So what did the video have to say? Academics, with nothing better to do, spent a lot of time reviewing thousands of penalties and they found out something very interesting. They discovered that goalkeepers would save more penalties if they did nothing, or just stood still.  But, this isn’t what goalkeepers are trained to do and a heroic, if pointless gesture, feels much more satisfying than remaining rooted to the spot. This is where action bias comes in, we feel better doing something and there is plenty of evidence that doing less has better outcomes in other fields too. Traders on the floor of the stock market are primed to do things and make rapid decisions, but the research shows that those who trade less are actually more successful.

In healthcare, there are many examples of action bias. GPs opt to prescribe antibiotics even when they know it will have no impact and contributes to broader harm. And, politicians and policy makers exhort general practices to offer more appointments, doing more and working harder, when we know there is greater patient satisfaction in practices who offer fewer appointment slots. Or put another way, general practices that struggle most are those that respond to the increasing pressure they are under by doing more – offering more appointments rather than standing still for a bit and thinking.

So, I offer three reflections to the new leadership team.

First, the answers to problems are often counter intuitive. So, put simply, doing something – anything – especially when you have no evidence that it is the right thing to do, may not be smart. You may just be digging a deeper hole.

Second, productivity is not just about doing more – headline figures for productivity invariably rise at a time of austerity or financial crisis – but being genuinely productive, so improving how effective we are rather than just being more efficient, takes careful thought and reflection.

And finally, I would encourage everyone to spend more time following up random links and videos as they may just trigger a new way of looking at the same intractable problems. If we are serious about transforming general practice and primary care, rather than just doing more of the same, we need to give people the ‘headspace’ to come up with creative solutions.

Rick Stern

Outgoing Chief Executive, NHS Alliance

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It has been an extraordinary privilege to lead NHS Alliance alongside Michael Dixon. I had no plans to become a Chief Executive again but Michael is a difficult man to say no to, and the opportunity to work alongside him and the extended family of the NHS Alliance was impossible to resist. So as we hand over to aq new leadership team, I would like to offer a few quick reflections on how far we have come over the last 4 years. I came in at a difficult point when the Alliance was facing an uncertain future. So what did we do?

First, we successfully shifted the focus from clinical commissioning to primary care provision. The NHS Alliance has always enjoyed taking the moral high ground – and giving away our core membership to help create NHS Clinical Commissioners was the right thing to do but raised serious questions about the purpose and future of NHS Alliance. It was increasingly clear to us that how providers work together - including how general practice works at scale and works with the rest of the wider community - would be central to our future mission.

Second, to support this we needed to overhaul the way we worked. Today is a key milestone in this journey, but NHS alliance has already become increasingly virtual, without an office base. We also took steps to reduce our costs, establishing new partnerships and build on our strengths – bringing together leaders across primary care who are passionate about using their experience and expertise to make a difference, connecting what happens on the front line with policy making in Whitehall.

Third, we needed to be clear about who we were and what we believed in. We have published two major statements of our values and aspirations - our Manifesto for Primary Care 'Breaking Boundaries' and towards the end of last year, just before the FYFV, our own 'Think Big, Act Now: Creating Communities of Care.' and we continue to produce ground breaking work, including ‘Pharmacists & General Practice’ that has shaped the rapid growth of practice pharmacists, our work on tackling the current recruitment crisis by creating a new role for practice pharmacists, working with Pharmacy Voice on ‘We are Primary Care’, bridging the gap between health and housing including ‘Housing: Just what the doctor ordered’ and most recently our work 'Making Time in General Practice' leveraging significant changes from the secretary of State.

Finally, we have built and developed a new team to lead NHS Alliance, bringing together a new generation of leaders for primary care. We have welcomed not just bright new stars from general practice but leaders from across the breath of primary care and the wider community; from housing, fire and rescue, community development and the police. And today is the culmination of this process, making way for a new leadership team. T

his is also an opportunity to remind ourselves of what is so special about NHS Alliance. In the end, it is always the people, the connections and the relationships. We manage to achieve a lot together and I have no doubt that the future will be every bit as impressive in the hands of the new leadership team. Personally, I am looking forward to shifting back to being part of the team, as before, rather than leading it as we continue to make the case for health and well being across our communities.

Rick Stern

10th December 2015

Outgoing Chief Executive, NHS Alliance

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b2ap3_thumbnail_Rick.jpg  b2ap3_thumbnail_David.jpgSummary

This week saw the publication of a paper in the Lancet ‘Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial)’ by Professor John Campbell and colleagues.  We welcome this first multi-site trial across nearly 21,ooo patient consultations in 42 practices comparing the effectiveness of telephone triage by GPs or nurses in general practice with usual care for patients seeking same-day consultations in primary care.  To be clear, this research looks at telephone triage – returning all calls and then deciding how to deal with them – not more focused use of telephone consultations, where patients who want to consult with a doctor or nurse over the phone can take up this option as an alternative to a face to face appointment.

The headlines (Phone consultations 'do not cut GP surgery pressures', BBC, 4th August 2014) suggested that telephone triage needs to be treated with caution rather than heralded as a one-stop solution for transforming access in general practice.  GP triage was associated with a 33% increase in the mean number of contacts per person over 28 days, and nurse triage with a 48% increase, compared with usual care. The report concludes that while “Telephone triage might be useful in aiding the delivery of primary care” … “The whole-system implications should be assessed when introduction of such a system is considered”.

The Primary care Foundation has been working with practices on access and urgent care for over five years since our report to the Department of Health ‘Access and Urgent care in General Practice’ in 2009.  We developed a web based tool, that takes a look at one week in the life of a practice, and makes comparisons with other practices and potential suggestions for making life easier in the practice and improving patient care. We have now worked with over 30 CCGs and PCTs and supported over 1,200 practices, so we thought it might be helpful to reflect on our experience. Below is a summary of some of the key factors we have found that practices tend to find useful when responding to demand an activity.

Reflections on improving access in general practice

Money is important, but it doesn’t explain everything

There is a great deal written about increasing demand and lack of resources and both of these are relevant across many parts of primary care.  However the resourcing is an issue that has a longer-term cycle and resolution and is beyond the short-term direct control of the practice team.  We may have seen some evidence of higher demand in areas of high disease prevalence possibly linked to deprivation, the age of the patient population, language or ethnicity.  In most places we see a spread of practices - some managing well with less activity and some struggling with higher than expected consultation rates.  We frequently see practices with matched resources and populations in the same street or health centre with very different activity profiles.  One practice has high activity (and perceived high demand) while the other has a lower than expected rate of activity.  When we cross reference the patient satisfaction we frequently find that the practice with the lower activity has higher levels of patient satisfaction.

The single most important factor remains good continuity of care 

So what is driving the difference?  In a word, continuity.  Many people, especially elderly people with more complex conditions, want an appointment with their ‘own’ doctor or nurse within the next 5 working days.  The perception that everyone wants a same day urgent appointment is often driven by what is available – increasingly, the choice in too many practices is an ‘urgent’ appointment today, or nothing for at least a week.

So the practice that can routinely offer an appointment or a call with the patients doctor of choice within the 5 working days tend to have lower activity levels as they don’t have patients making repeat contacts to try and get their own clinician.

It’s the system, not the patients

Access is of course in the first instance via a phone call to the practice.  The most common reasons for poor phone access are the way reception staff are organised or a lack of phone lines.  Patients are often seen as the problem – calling too often for unnecessary appointments and then failing to show up – whereas, in reality, the system set up by the practice is often the main source of the problem.  As pressure builds, practices try and set up more barriers to protect limited appointments – appointments available when the surgery opens, appointments ‘embargoed’ until later in the day, patients told to call back later – all of which drives us into more desperate behavior to get limited appointment slots.  So in an attempt to manage the pressure for appointments, the system becomes increasingly complex and patients become experts at ‘gaming’ the system that has been put in place to make life easier.  Practices which have a system generating high demand inevitably have higher phone volumes and often fare less well on phone access.  On rare occasions we do find lack of resources an issue but, in our experience, this tends to be an exception.

Phone or face to face?

We are great supporters of telephone consultations as an effective route of access to the practice.  Its time effective for both the patient and doctor and also expands the options for patients to choose what type of access would suit them.  Again continuity is a key factor so the patient must be able to get their own clinician.  The important factor is choice - the more routes in to get an appointment, the more choice patients have and the more likely they are to choose the most effective route for themselves and the practice.  The trick the practice has to pull off is to ensure each route of access has adequate capacity for the demand and delivers true choice.

Restricting patients to one form of access, such as exclusively through same day appointments, telephone triage, or through a duty doctor clinic, tends to lead to a bottleneck as different people will seek different solutions.  Young men, mothers with young children, working adults, people whose first language in not English, and the frail elderly will want to access care in different ways.  So multiple routes, including face to face care and telephone consultations, as well as booking appointments on line and increasingly email advice, will all have a part to play.  The more as patients we understand there is a choice, the less pressure there tends to be first thing in the morning. So, a simple question early on in the phone call to book an appointment “would you like to see the doctor or nurse face to face, or would you like them to call you back?” could go a long way to help.

A 'silver bullet'?

We don’t have a model or template that solves all the problems but a set of analytical tools that helps the practice make choices and review how they do things while benchmarking their activity locally.  There is no ‘silver bullet’ or one system that will work well in every practice.  No matter how the practice uses its resources putting access to the clinician of choice at the center of their design will deliver benefits.

If you want to find out more about how we can work with your practice or CCG, please contact us at This email address is being protected from spambots. You need JavaScript enabled to view it. or call Rick Stern on 07709 746771 or David Carson on 07703 025775.

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About Us

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.