4 things your practice can do RIGHT NOW to improve things

General Practice is under pressure like never before. Four things your practice can do right now to improve things:

  1. Cut out patient confusion

  2. Challenge your efficiency

  3. Make the most of what you’ve already got

  4. Get started at doing something different

Read on to find out more detail

Context: Of course, your practice basics need to be in place (clear roles and responsibilities; accountability of staff; whole team meetings) but here are some immediate actions around efficiency and freeing up appointments. Consider these pointers against your current practice ways of working. If you already do some of this, check how reliably it is being done. The actual ways of working, when under pressure, are often very different from how we imagine them.Once in place, then consider the deeper issues faced. Such as the medicalisation of social need, inequalities of service provision (creating failure demand) and working with your community as assets.

1. Cut out any patient confusion

The work that presents to you each day is often not fresh new work. Tied up in the daily demand is work caused by patient confusion and anxiety about next steps, especially in a time of long waiting lists. This causes avoidable phone calls and often ends up with avoidable GP consults. Consider:

  • Automated SMS immediately post diagnostics – in particular for bloods. SMS that explains the results communication process, including expected wait times etc.

  • Ensure consistent messaging on diagnostic result timelines and processes across all staff groups – GPs included.

  • Consider SMS or app-based communication of results normal or borderline abnormal. But include next steps advice as to any uncertainty. Even if the patient is well things will often result in them contacting the practice.

  • Set up standard text templates for common next steps, including who to go to for updates and safety netting. For sending out post-consultation for things like referrals to specialist settings.

Outcome: lower patient anxiety, clearer communication, freed-up capacity

2. Challenge your efficiency

Pressure on general practice is rising, but our own patterns of work compound the issue as well – creating avoidable work, inefficient use and lots of it:

  • Skew 1 – Who are we not seeing? We concentrate our resources on a very narrow band of our list each year. Classic 80/20 rule. This means there are many people who don’t get in or now don’t try to get in to seek help. Because we go to where the noise is (the 20% of pts taking up 80% of the resource), other patients decline in their wellbeing and become more complex – creating more work for practices. What to do: get help to find the people turning up frequently over 3 years

  • Skew 2 – Find your true long-term regular attenders. There have been repeated efforts to reduce the burden of frequent attenders and most of them struggle to make any difference. This is because for most current high attenders their attendance is episodic. They will not be high attenders next year . The trick is to expand the timeframe and look at your regular attenders over a number of at least three years. The patients that regularly attend over that period are your long-term attenders – well worth spending time in a “win-win” approach to improving their healthcare with continuity, clinician ownership of their care, AND freeing up large amounts of practice capacity, 1,000s of appointments in fact. What to do: (a) find those patients (b) allocate them to a named GP (c) proactively put in regular appointments (d) introduce them to another member of staff who could be their first point of contact if you think this would help.

  • Reduce variation between clinicians. We know that upwards of 25% all of consults end with the patient being asked to come back again. This varies by clinician, even within the same professional group. Some of this looping is for good reason, some is driven by defensive practice and some is less readily explained. If clinicians can talk openly about this and reduce this looping they are in control of safely, even by a %, the impact is significant. What to do: Pick a week and look at who you have asked back. Peer review a group of these with one other clinician and see if you can reduce the call back.

Outcome: significant freed up capacity, practice consistency

3. Make the most of what you have got

While the shortage of clinicians, especially GPs, is a crisis that many saw coming (frustratingly for years), it won’t be solved quickly. Thus, practices need to make the most of each and every staff group. This includes:

  • Making the most of the new ARRS roles. For example, Social Prescribers: Send them the right work and make sure everyone understands the role. They may be less effective with patients with extremely complex social needs and also those with clear dominant health needs – such as those affecting mobility. They are more effective with patients where the social needs are just emerging – acting proactively.

    • So, sending them the ‘Top 20’ super-attenders that GPs have been struggling with for years is likely to only create extra activity – not reduce demand

    • However, rather than generating their own new parallel list of patients, a focus on long-term regular attending patients IS a very suitable target for a different, wider approach to support and will also have knock-on benefits for free up capacity as well

    • What to do: Review with your Social prescriber, who they are seeing and check that they are not adding another lane on the motorway. Talk with them about who best to send to them

  • Avoid inappropriate appointments. Spend time ensuring there is a consistency of view on what work can be done by who. What to do: ensure that (a) reception decision protocols are up to date with this information; (b) they are supported in their navigation; and not an unconnected outpost of the practice.

  • Use your secretaries to their full potential. Ensure your workflow is clear (regarding task) and that patients contact secretaries, rather than GPs, for ‘status of’ queries on things like referrals to specialists. Taking work from reception in this way allows reception to concentrate on better signposting conversations. What do to: Ensure patients know how to contact secretaries for the issues that they can answer (website information etc)

  • Provide daily support to junior clinicians. Whether nurses or new GPs, the less experienced you are, the more likely you are to ‘do more’ for your patient (practice defensively). What to do: Provide scheduled and protected time, with proper feedback, to build skills and competencies. This could be as simple as a team ‘huddle’ once a day.

  • Employ who you can. General Practice is undermanaged. Management is less than 1% of cost, whereas in the country as a whole business run at 9% and NHS Trusts at around 2% [1]. You might not need clinical staff, you might need people who can staff phonelines, ring people up to check in (like in the crisis of the pandemic where many of your reception staff just checked in on people sheltering, which made a real difference), help with your admin, do data searches for you. Be creative- there are people in your community needing work and you have work needing to be done.  

Outcome: freed up capacity, practice efficiency, a happier workplace

4. Do something different & let go if you need to

All of this is within reach for most practices, but it still requires consistent leadership from senior clinicians, especially partners. For some, given the workload, constant rhetoric, and general fatigue, this is something that they cannot give, causing some senior clinicians to withdraw and concentrate on today’s work rather than leadership duties. We constantly hear “Things need to change. But we haven’t got the time”

This is understandable, but:

  • There are people who do have the headspace to step up – let them. Across the land, there are lots of partners and PCN CDs who are struggling to introduce the new models of care general practice is screaming out for – not because they’re the wrong ideas, but because of lack of engagement from their colleagues and fellow partners/members.

  • Blocking work passively by not engaging is hugely damaging. So, reflect upon whether you have the energy to be at the front and if not, support others who do. It is a huge sign of humility and respect.

The second factor that often paralyses change is the drive for perfection. Leaders often tie themselves in knots trying to work out the perfect solution before starting. Getting into ever-deepening levels of detail with the expectation that the new way of working must work perfectly from the start. It won’t.

  • This is a fallacy in complex human systems. There is never a ‘correct’ answer. Take continuity of care for example. For a practice that currently struggles to give continuity to anyone (many practices) the best way forward is to learn by doing - ensuring GP continuity to some priority groups and learning from that experience.

  • The way forward is to learn by doing in iterative cycles – which is fantastically liberating and brings hope.

Outcome: The start of a learning improvement process.

 What we do to help you

We can WORK WITH YOU directly on any of the things above, either hand-on to provide energy and support you and your practice towards rapid change or just in a LIGHT TOUCH advisory role.

 contact@pcnacademy.org.uk

Footnotes:

[1] In NHS hospital trusts, even a small increase in the proportion of managers employed, from 2% to 3% of the workforce, led to a marginal improvement of 1% in patient satisfaction scores, a 5% improvement in hospital efficiency, and a 15% reduction in infection rates. Prof Ian Kirkpatrick, Chair, York University

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