Can GPs control their workload?

GPC guidance offers practices advice on how to manage workload and stand up to unreasonable demands. Neil Roberts reports.

Encourage self-care
Encourage self-care

The GPC has published a new handbook of practical guidance for practices to manage escalating workload, with advice on pushing back against inappropriate and unresourced work, list management, federation, patient self-care advice and more.

The 42-page Quality first: Managing workload to deliver safe patient care is not a 'flash in the pan' policy document, says GPC chairman Dr Chaand Nagpaul, but a handbook that GPs should work through as a practice, and a tool to help empower GPs to regain control of workload to protect safe, quality core services.

One of the biggest complaints the GPC hears from practices, says Dr Nagpaul, is about unresourced workload.

Mid Mersey LMC medical secretary Dr Ivan Camphor gives a current example of pressure on GPs to prescribe antiviral flu medicines, creating additional and largely unresourced work for practices.

It is time for GPs to 'be brave', says Dr Camphor, to 'stand up and say we cannot do any more'.

The handbook provides significant practical advice to practices on how to refuse inappropriately referred and unresourced work.

Highlighting inappropriate workload demand from secondary, community and social care as a drain on GP appointment time, the handbook says: 'In the interests of patient care, practices should not carry out work that has been inappropriately referred.'

Referrals

Practices are advised to contact the source of the inappropriate referral and require local commissioners to address the problem. A template is provided for practices asking commissioners to reassess service specifications for parts of the health service responsible for transferring work into general practice that should have been carried out elsewhere.

A list of enhanced services is included, and practices are reminded these are provided at their discretion and advised to decline work shifted from secondary or community care which is not funded by an enhanced service or similar mechanism.

PMS practices are advised to assess which additional services are no longer being funded after local reviews have cut funding.

'If the CCG or area team decides not to commission (and hence resource) the service, the practice is entitled to give notice to cease the service,' it states.

The guidance advises practices on federations, non-NHS work, empowering patients in self-care, and new ways of working, such as using online services, and skill mix.

Wessex LMCs chief executive Dr Nigel Watson says there is a risk the guidance could be interpreted wrongly as using patients in GPs' battle with commissioners. 'What we want to do is enable things to happen, not use it as a battle tool to go in to fight everybody, because that won't be productive,' he says.

GPs need to ensure that pushing back against unfunded work does not mean using the 'patient as a battleground' over individuals' care, he warns. 'But we do need to recognise general practice is not going to be able to work if more and more work is just pushed over and practices aren't able to deliver it.'

Dr Nagpaul is clear the handbook is not about restricting services. The focus from the GPC is on helping practices to provide safe, quality, core general practice.

In line with his intention to make greater use of partnerships with patients, Dr Nagpaul says this guidance is in the very best interests of patients as well as GPs. 'No patients want their GPs providing services beyond capacity,' he says.

Bureaucracy

Patients would rather have their doctor providing GP appointments for sick patients, not tied up with bureaucracy and inappropriately transferred hospital work, he adds.

'None of the services practices may need to consider reviewing is actually a service patients expect their GP to provide,' he argues. In fact, he says, the guidance helps GPs ensure they do not breach Francis recommendations or professional duties by working beyond safe capacity.

Dr Watson agrees that getting 'patients on board' is critical to the success of attempts to manage workload. 'If we don't keep patients onside, we have no hope,' he says.

Elsewhere, the handbook has resources for empowering patients to take more control of their care.

Ultimately, says Dr Nagpaul, where patients do want a wider range of additional services provided by GP practices, they do not want them provided at the expense of core general practice. The clear and simple message to politicians and commissioners is, if you believe patients want additional services, you must resource them.

Commissioners

'The additional capacity to provide care coming out of hospital is the commissioners' responsibility,' Dr Nagpaul says. 'We need to look at other sectors of the NHS. Hospitals are clear about providing care according to their contract. You are not going to find hospitals providing a procedure without being commissioned. This is about making sure additional capacity is resourced.'

The new guidance comes just months before about 90% of CCGs will take on new primary care commissioning roles, with fully delegated responsibilities, shared responsibility with the area team, or greater influence over commissioning.

The guidance encourages practices to make full use of their CCG membership to insist commissioners use the levers at their disposal to set service specifications, making the scope of provision clear, and to support GP practices.

'We are reminding practices they do have the power to influence their CCG,' says Dr Nagpaul. He says there have been examples where practices have 'taken CCG boards to task' and they have backed down and changed decisions. On occasion, CCG boards have even been replaced in response to member practices' dissatisfaction.

'GPs having the power to influence local policies,' he says. 'That is what this handbook is about. After several years of GPs feeling browbeaten, beleaguered and disempowered, this handbook is to help practices take some control, feel empowered and recognise they have the tools to make changes locally, which will make a difference to their workload.'

The GPC, says Dr Nagpaul, has influence over the national GP contract, but much of the problematic workload is outside the contract and beyond the control of the negotiators. 'That's why as a national body, we are providing practices with these tools.'

The GPC is writing to all CCGs highlighting the guidance and asking them to have GP workload pressures as a standing agenda item.

Lancashire Coastal LMC and GPC member Dr David Wrigley says this sends an important message to CCGs that they need to support practices. But he warns that despite co- commissioning, CCGs remain under pressure to balance the books. 'It's not so much GP-led commissioning as accountant-led commissioning,' he says.

CCG involvement

Dr Wrigley, who until last month was a CCG board member, said it was 'up to GPs and practices to ensure the document is discussed at CCG board level'.

GPs should feel more empowered, he adds, and realise that the CCG is supposed to be there to support general practice.

Co-commissioning, he says, will make this guidance even more important, and it will be more important for GPs on the ground to step up and make CCGs support them.

To date, says Dr Watson, CCGs have been largely responding to the secondary care agenda. But with aspirations outlined in NHS England's Five Year Forward View document to shape more care around out-of-hospital services, commissioners will need to pay more attention to ensuring that GPs can properly manage their workloads.

The guidance, says Dr Watson, is 'a starting point' that can help practices manage local issues.

'Fundamentally,' says Dr Nagpaul, 'the government must address the deep financial and capacity problems at the root of the crisis in general practice.'

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