General practice has been under huge pressure for a number of years. Demand is rising at the same time the profession is facing a recruitment crisis. Latest figures from NHS Digital show that almost 1,300 full-time equivalent (FTE) GPs have been lost from the NHS workforce over the past two years.
The government remains committed to recruiting an additional 5,000 FTE GPs by 2020 compared with 2014, however the latest workforce figures suggest that reaching that target is further away that ever.
Last month, the DH announced plans to increase the incentives available to encourage doctors to train as GPs. Meanwhile, NHS England is also looking abroad in an attempt to boost GP numbers. It is hoping to recruit 600 overseas GPs by April 2018 and possibly up to 3,000 international GPs by the 2020 deadline.
However, NHS England also wants practices to look at how they can work differently and also manage demand in order to make their practices more sustainable and help mitigate the impact of the GP shortage.
What are the 10 High Impact Actions?
To this end, NHS England has developed its 10 High Impact Actions. The actions are all aimed at helping to free up GP time to enable them to deliver more clinical care. They form part of NHS England’s General Practice Development Programme, which has developed out of the GP Forward View and is headed up by Manchester GP Dr Robert Varnam.
Dr Varnam explains that these actions are a ‘quick route’ into how practices can make improvements and make themselves mores sustainable. They are all based on real-life successes and one of the aims of the initiative is to highlight and spread innovations so practices can learn from what has worked elsewhere.
- Active signposting – Providing patients with a first point of contact that directs them to the most appropriate source of help. Web and app-based portals can also be used for this.
- New consultation types – Introducing phone and email consultations, for example, to help improve continuity and convenience for the patient, and reducing clinical contact time
- Reduce DNAs
- Develop the team – Broaden the workforce in order to reduce demand for GP time and connect the patient directly with the most appropriate professional.
- Productive work flows – Introduce new ways of working which enable staff to work smarter, not harder.
- Personal productivity – Support staff to develop their personal resilience and learn skills that enable them to work in the most efficient way possible.
- Partnership working – Create partnerships and collaborations with other practices and providers in the local health and social care system.
- Social prescribing – Use referral and signposting to non-medical services in the community that increase wellbeing and independence.
- Support self care – Take every opportunity to support people to play a greater role in their own health and care.
- Develop quality improvement expertise – Develop a specialist team of facilitators to support service redesign and continuous quality improvement.
What support is available for practices?
To support these actions, NHS England has developed an online forum where practices can access case studies and examples of how each of the actions can work in real life and the results they can achieve (see below for link).
According to Dr Varnam by March 2017 nearly 40% of CCGs had expressed an interest in obtaining help from NHS England to implement one or more of the actions.
There is central funding from the GP Forward View available to support some of this work, which in most cases needs to be accessed by CCGs. Earlier this month NHS England invited CCGs to bid for their share of a £45m fund, first announced as part of the GP Forward View, to roll out online consultations to practices (which relates to the 'new types of consultation' high impact action).
There is also £45m of GP Forward View funding for training reception staff to ‘active signpost’ and training clerical staff to manage clinical correspondence (‘productive workflows’). Meanwhile, £100m of funding has been allocated to recruit 1,500 pharmacists to work in general practices by 2021, which supports the idea of developing the primary care team.
Some CCGs are also making use of NHS England's Productive General Practice programme, funded from the £30m 'Releasing Time for Patients' programme announced in the GP Forward View, to look at how they can change workflows in order to free up more GP time.
Do the actions work?
Dr Varnam believes the actions can make a big difference to practices. ‘We’re seeing that every single one of the actions has an impact,’ he says. ‘It varies between about 5% of GP time up to about 15% or maybe more.’
Some of the case studies on NHS England's forum have also shown impressive results. Use of active signposting across six surgeries in West Wakefield saved 1,685 GP appointments across a seven-month period in 2016. Meanwhile, practices in Bury, Greater Manchester are estimated to have saved more than 1,700 GP hours and 5,459 admin hours a year through using the productive general practice (PGP) programme.
However there has been some scepticism about whether some of these steps are the best use of additional primary care funding. For example, a study published in the BJGP last month suggested that online consultations may not improve efficiency and could even increase workload.
GPs have also been critical that extra funding for general practice has been attached to specific uses, rather than practices being able to use the money as they see fit.
Where should you start?
But, if practices are interested in trying the actions, where should they begin?
‘The first thing I say is to try and get yourself some quick wins,’ Dr Varnam says. ‘And often only you will know your circumstances well enough to choose the best quick win.
‘The second good idea is not starting from scratch, but building on what you’ve already got. So sometimes people say we’ve tried a little bit of that before but looking at some of the case studies I can see we could get an awful lot more out of this idea.
‘The third one is to not despise the small things if that’s where you can get rapid movement. It’s really easy to assume that every solution has got to be really big but frankly most days if I had one or two fewer appointments the day would feel better and I’d do a better job.
‘For some GPs if you save 20 or 30 minutes a day all sorts of other things can become feasible. So I often say to people, that might guide your choice of where to start.’
Dr Varnam also says working with your neighbours or across a federation is the key to making change happen more quickly and seeing a better result. He says that this can be particularly important if you are looking at developing the practice team and introducing new roles into general practice.
‘As soon as you bring a group of practices together and start to measure the work they’re doing – how many people see a GP and how many people could have been seen better by someone else – practices themselves are coming up with figures between 15% and 45% of GP appointments that could have been dealt with differently,’ he says.
‘And they’re coming to the conclusion that if they did things together they could share a physio, or two or three pharmacists, or train their receptionists in actively signposting.’
He believes it is essential that practices start looking at new ways of working. ‘If we don’t work differently we will be overwhelmed by workload. It’s right that the system is doing all it can to reduce inappropriate transfer of work from hospitals. But it is also right that the system is doing all it can to help people manage their work differently, because just carrying on doing the same doesn’t work for anyone – not for patients, GPs or the rest of the practice.’