Robert Varnam: Releasing capacity in primary care - just another pipe dream?

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  • Posted:Wednesday 02 December 2015

Robert Varnam shares the results of NHS England's study of workload issues in general practice and offers solutions for addressing pressures in primary care.

This presentation was given at The King's Fund event Pressure points: how can we support primary care to cope with growing demand? on 24 November 2015.


Hello, good afternoon. I’m going to do three things, if it’s alright, I’d like to share some of the results of our recent study into workload issues in general practice, to share our thoughts about what we can do nationally as a system, and the things that we’re working with the profession on that we think practices can do to help themselves.

The background is fairly obvious to NHS England’s interest in this and it actually is the background to me; I’m a GP, I’ve spent a lot of time working in system leadership and leadership for quality improvement and I was asked to join NHS England a couple of years ago in order to work on our call to action on general practice, to answer a lot of the yes, but how questions.

And one of the things you heard straight away is yes, primary care could rise to new challenges, yes there’s a lot of untapped potential or unfulfilled potential right now and one of the reasons is that general practice feels and looks a lot like this. It is too constrained, its feeling constrained, there are lots of obvious reasons for that and also it feels too peripheral.

The forward view has helped, I think, in making a very big re-emphasis of the role of primary care and the centrality of primary care at the heart of the future for the country and the NHS, but it hasn’t yet done very much of the detail right across the board. So we’ve started some things in the new deal for general practice and things, and new investment, new workforce development, new premises development and that’s good, but some of those things take a very long time to come on-stream and benefit patients by releasing pressure.

But, when you talk to people about what the pressures are right now, for a long time we’ve had anecdotal lists and I’ve contributed to some of the anecdotal lists that have been circulated by the BMA and the NAPC and others over the years. But as you look at it you’re left asking well, where should we most direct our efforts and quantifying some of that has been unmet need.

So, last year I commissioned some work from the Primary Care Foundation supported by the NHS Alliance and a steering group of some of the great and the good from primary care to answer the question where are the biggest issues? Let’s try and quantify it and then talk about some solutions.

If you’ve not had a chance to see the study so far it can be downloaded from there and I will put that link up again at the end.

And I think it’s already been really helpful and you may have seen some of it quoted by the Prime Minister or the Secretary of State so far. Here’s what was in the study; some quantitative work working with practice managers and GPs to understand the most prevalent and burdensome externally generated bits of bureaucracy, particularly for the practice manager. And then for GPs, and this is just about GPs at the moment, what the most prevalent issues are, highest incidence of potentially avoidable GP demand.

That quantitative work was then checked out, some qualitative stuff and reviewed by a steering group, like I say, some of the great and the good from the world of primary care, and the two areas of big headline figures are as follows: the first is the areas of bureaucracy, some pretty big chunky ones in terms of issues that are burdening practices at the moment from an administrative perspective. And I think some of these are quite new. Some of them are age old and some of them are new.  The most obvious one being top of the list; getting paid, has become much more problematic because general practice is now serving multiple commissioners and they each do things differently, on every dimension of what the thing looks like, it’s done differently.

And some of those are big chunky conceptual strategic things and some of them are as tricky as working out what the remittance notice means and reconciling it against the bank account is phenomenally time consuming in many cases. There are some patches where it is better, but when you’ve got the NHS and CCJ and local authority commissioning multiple different services using completely different contracts and payments and reconciliation systems, the burden for practices is big and it’s quite recent.

And some recent improvements have been an improvement, it seems, according to practices, but not nearly enough.

Other things are more age old, they are more of the kind of things that we’ve been hearing for a long time, but it’s helpful seeing what sort of relative proportions they come in for practices themselves.

A lot more information in the report along with lots of quotes about the detail of that.

Then secondly we looked at potentially avoidables. So this is an audit from about just over 5,000 GP consultations where the GP themselves rated afterwards whether it was potentially avoidable or redirectable, could have been handled differently and then if so, how. And here are the answers.

So, 26% of consultations, for a high volume specialty that’s a phenomenal number of consultations could potentially have been handled differently according to these GPs, through a variety of means and I’ve classified them a little like this.

The things in green are ways in which the practice themselves could have reordered care, redesigned flow or had a different set of services and/or skill mix and avoided that consultation ending up with the GP, who’s the most expensive member of the team and currently where it’s very, very hard to build the workforce.

The things in orange are areas where the system may help. And it’s worth explaining some of those because someone else in the practice, fairly obvious, self care or pharmacy, fairly obvious, outpatients 3% so about 15 million appointments could have been avoided if outpatients went differently.

Three categories in there; one of them is patient fails to attend appointment and is referred back straight back to the GP, no questions asked. Second one is where a prescription is issued in outpatients but not actually given to the patient, they are told to go and see the GP practice, needing a GP consultation. And then the third is where ongoing investigations are deferred or referred back to the GP, rather than being handled by the outpatient clinic. That accounts for about 3%.

So you’ll see that a lot of the things that you’ve heard about already today, it’s good news, are actually scratching where it’s itching. These are not just peripheral issues, interesting opportunities that you’ve been hearing about today. These are things which could address some massive pressures at the moment in primary care, particularly when it comes to the things that practices could do themselves.

And so we are now working on things that we can do. We’ve moved in to the action phase and we’re doing it in a phased approach. So you may already have heard the Secretary of State announce the change about outpatient DNAs, but here’s the next lot of things that we’re working on.

They fall in to four areas and let’s look at each of those four areas in a bit more detail.

Streamlining of information; some of this is to do with contractual information. So the getting paid challenges at the moment. We think there is room for improvements particularly through piloting, not just redesigning and assuming but actually piloting some changes to the CQRS payment system. Making it work better, making it more accessible to more commissioners, have a more simplified approach to commissioning.

Secondly, we’re soon going to publish a concordat between NHS England, the GMC and the CQC on ways in which we are collaboratively going to reduce the burden of reporting for CQC registration and personal revalidation. A lot of duplication right now, and some work has been done already, but it’s not been nearly enough.

And then thirdly we think there are things we can do, kind of e-mail stream that bombards many practices we think can be streamlined. We want to be working with NHS Clinical Commissioners, NHS England Local Teams and GP practices to understand where the big wins would be, and then we’ve got people ready to implement new data streams and searchable websites and things so that you can actually find some of that information.

Next in the outpatient standards, one of them has been announced already which is that there will no longer be allowable for any Hospital Trust to have a blanket policy wherein the patient who DNAs for the first time has to be referred. That’s been rewritten in October, we’re in the process now of reminding all Trusts that’s been done, the NHS Standard Contract is going to be updated to reflect that and we’re going to support CCGs in forcing some of that or tracking some of that, probably in collaboration with the BMA.

But then secondly, going a bit further, about those other two categories in outpatient issues; we want first for the professions to describe what good looks like. The recent Academy of Medical Royal Colleges report on accountability and co-ordination, what does it mean if you are under the care of outpatients? Can we get a professional standard that says what you should expect to receive in the outpatient clinic, handled entirely by them and co-ordinated properly without patients having to bounce backwards and forwards.

And once we’ve got that professional description, probably led by the Royal Colleges with others describing those standards, we’re going to put them into the NHS Standard Contract. We’re hoping to get that done for next October’s refresh, so we’ve already got that space in next October’s refresh for that one as well. Large amount of working being done on paper free and largely this working is going to be done by CCGs and their Trusts, but some of the benefits will be felt by GP practices.

So, first part of that is that all discharge letters will be coming electronically to the GP practice. After that, then those discharge letters will be coded so that they can, if the practice wishes, go straight into the notes. And then we’re looking at outpatient standards and making those electronic and making them coded as well.

So a lot of work to be done by other people which will benefit GP practices and we’re hoping to spend very, very large amounts of money on making that happen quite quickly. We’re hoping to half the timescale for that after the spending review.

And then lastly, we think we can continue doing more on wider workforce. So, we’re already doing stuff on 5,000 more GPs and 5,000 others in general practice. I think doubling of the investment in the clinical pharmacist pilot helps that, that’s now covering 7 million patients with this extra money that we’ve just put into that.

But then also we want to do more to help every CCG, ensuring patients have access to a minor ailments scheme and we think there’s a huge gap in the capacity of people to do care navigation. Awareness of the model is rising, that’s great, willingness and eagerness of the voluntary sector to be providing services; is great. One of the biggest challenges actually lies in joining up the GP practice and that big resource, so we want to be seeing what we could do at a national level to promote that, to get good standards in it, to fund it, to encourage others to be funding it. Still exploration, but we’re really committed to spreading that as much as we can.

But, we’re really mindful that actually there are only some things that can be done nationally, only some things that are meaningful. So, together with the BMA and others, we’ve been working up a list of best practice ideas that could be done at a CCG or a Federation or an individual practice level where the profession helping themselves is how the BMA talk about it.

I personally think this is really necessary and encouraging. I think it’s particularly encouraging because you’ve already heard people describing the fact that many of these things are happening right now. In fact, I think there are examples already of everything, so I’ll go very quickly through what some of this looks like.

A lot of the examples of this are actually coming out of what we used to call the Prime Minister’s Challenge Fund, we now call the GP Access Fund, but it’s the Challenge Fund that these 2,500 practices are already doing virtually all of this right now, so it’s no longer hypothetical, we can start gathering the case studies and helping people be confident in them.

Active front end is the variety of ways in which people are saying if you contact us, we will not just passively book you with an appointment with a GP, we’ll actually ask what the problem is, signpost you where appropriate, stream you to the most appropriate source of help, add value through that first contact process, whether that’s by phone, in person or on-line. A lot of work that lots of practices have done, but many have not done anything on to help reduce DNAs, to make the most of the capacity in the appointments that exist.

A lot of the new contact modes, so working by phone or e-consultations, they are not just nice because they are more convenient for patients, they’re nice because they help GPs deal with peoples’ problems in a short time slot, and that helps to add value all round. And we want to help more people get hold of those.

Developing the workforce; big deal, it’s partly about skills for people we have already, in particular things like health coaching skills, but also about diversifying the skill mix in practices. Incredible seeing what’s been done, for example with pharmacists, with advanced nurses and with physios in lots of the Challenge Fund schemes. Go directly go to physio, brilliant ideas.

A lot of work to do to improve productivity of other work flows within the practice. Lots of the NHS has been able to do amazing things over recent years because they’ve had people with expertise in LEAN and in general practice we’ve done amazing things just by working harder or faster or staying later or putting more work in on a Saturday. Actually there’s a lot you can do by redesigning with a LEAN mindset and toolkit.

Some of that is personal, so a lot of people are growing in their interests in very simple things like helping clinicians learn to speed read and to touch type, and I was speaking to a group of practices recently where they reckon they’ve saved between 20 and 40 seconds per ten minute consultation by teaching their GPs to touch type. Now, as a GP I can save 20 seconds per consultation is a heck of a lot of time, that’s amazing.

So some very simple things there.

Partnership working isn’t just a means to protect oneself from the cold wind of commercial reality. Actually collaborating in federations, collaborating with community pharmacy, with the social sector, with housing and others, we think is necessary to help on a variety of levels and one of them is would it help release capacity in primary care?

So would social prescribing, not going to say anymore about that, you’ve heard about that already, and also supporting self care, systematically providing the knowledge, the skills, the confidence for patients and carers to play a greater part in their own management. Not self care as a blame and we’re getting some of that in the medical profession at the moment. General practice needs to protect itself from these awful patients who should just look after themselves. That’s not going to cut it.  But there are some fantastic ways of supporting genuine partnership working and self management which we want to promote.

And all of that is going to need some pretty broad based support and I’m hoping we’re going to get some money for it and it will be lovely to see what comes out from the detail about the spending review, because we’re talking about a sector that has received almost no investment in leadership development, in management development, in business support and business infrastructure, in QI and actually I think that’s going to be necessary right across the board to make any of this a reality.

So we’re committed, in the New Year, probably February, diaries permitting, myself and Chaand Nagpaul from the BMA, we’re going to be doing a bit of a road show around the country taking these ideas out with some case studies, some resources for people about how they could make it a reality locally. We’re going to look at how we could support people who are interested in doing this locally and would like some kind of support. We want to ask people what kind of support would you need or value if you were to take some of these and implement them locally.

And like I say, hopefully some development funding nationally as well as the things people all already doing locally to invest in that.

That’s a whistle stop tour through current plans.

It is very much the start, I think, of something. So we’re not thinking that this is job done. We’re thinking this is the first tranch of things that we’ve identified so far that could be done. So we’re spending a lot of time now asking people well, how would you make use of this?  How would you collaborate?  What else could be done?

So, I’d encourage you, if you’re interested, not just to download the study and see the results, but actually to connect with us on what the solutions could look like in the programme over the next few years, hence me putting my e-mail address up there.

I hope that’s been helpful. Looking forward to some discussion as we move on, but thank you for listening.


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