How can GPs provide rapid access alongside long-term continuity of care?

A year ago I wrote a blog that started with the sentence ‘It seems that hardly a week goes by without a new story in the press about general practice under pressure’. A year on, and this still holds true.

And yet, GPs are still being asked to do more. In recent weeks GPs have been blamed for the crisis in A&E because, it’s claimed, they’re not open for enough hours. This is despite evidence showing that the pressures in A&E are primarily due to patients who need hospital admission, most of whom could not have been managed in general practice. The government promised an additional 5,000 GPs by 2020 but latest figures suggest that the number of GPs is not growing and is, at best, static.

Last year the Fund carried out detailed research to see if we could get a better picture of what was actually happening in general practice. We found that GPs were under huge pressure for a variety of reasons, including activity rising faster than investment and workforce numbers; the increasing complexity of patients whose care is now managed in general practice; new services and clinical advances; and complex relationships with the wider health and care system, where pressures in one part lead to pressures on another.

One challenge we identified was the difficulty GPs face in providing both rapid access and long-term continuity of care. We found that if a high proportion of appointments need to be put aside to deal with on-the-day demand, waits for routine appointments can become very long. And when patients who might have accepted a week's wait for a routine appointment find they can’t get one for a month, they are then more likely to book an urgent appointment – which both adds to the pressure on practices and reduces continuity of care for those patients.

If a hospital ran its outpatients and A&E departments as a single department with the same staff, we probably wouldn’t be surprised that in order to run on time there would need to be plenty of excess capacity to cope with the peaks and troughs of emergency demand. And yet GPs are managing urgent, on-the-day demand at the same time as they are providing ongoing health care for people with multiple and complex long-term health conditions. A recent study from The Health Foundation observed that continuity of care was linked to keeping people out of hospital, and yet it has been very difficult for GPs to provide both continuity of care and rapid access.

We still don’t really understand why demand in general practice is rising, and there is unlikely to be a single cause. However, it is clear to me that if general practice is to meet the demands placed on it, it needs both investment and a change in the way it delivers services so that it can better address the dual demands of urgent care and long-term conditions management. As ever in health care, there isn’t a single model that will work. Some practices have already had great success with using telephone triage to segment work; others have used a team approach with different professionals (paramedics, pharmacists and nurses) able to free up GPs to manage the most complex cases. New models are being tested in the Primary Care Home programme, the vanguard programmes and by some federations and individual practices.

What most approaches have in common is that they start by implementing some basic service improvement activities, such as really understanding capacity and demand data, clearly mapping processes and evaluating any changes. When general practice is under pressure, it is extremely hard for clinical staff and practice managers to give themselves the space and time to do this kind of work – firefighting is all that can be done. But in addition to investment in capacity, general practice needs access to service improvement support if it’s going to be able to meet the growing and changing demands placed on it.

We will continue our work to monitor activity in general practice this year, publishing further analysis of new data and the results of our regular survey of GPs. A new approach to general practice is likely to need to look beyond general practice in isolation, and in our upcoming work on community health services we hope to begin to identify potential models of care that can bring community services, general practice and others to support people to live in their own communities for as long as possible.

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#548960 Harry Longman
Chief Executive
GP Access Ltd

The demand led model where GPs respond to all demand as it arrives deals with the alleged problems of access and continuity at the same time. Access is within minutes, and choice of clinician is provided every day so there is no waiting for a named GP. I've been publishing material on how this works for five years. The comment, "Some practices have already had great success with using telephone triage to segment work" may be referring to our work, but it is the opposite of what happens. The demand led system specifically does NOT segment work (such binary distinctions as on the day vs routine are wrong and counterproductive). The system treats each patient as an individual and enables GPs to provide the appropriate individual help, with continuity if required, and reduces workload at the same time.

#548961 George Cook
General practitioner
Grassendale Medical Practice

We have 6 doctors, 2 male and 4 female. Two are on maternity leave and in June there will be three for a 4 week spell before one returns on a shortened week.
Locums are hard to get and do not offer continuity of service.
The planners seem to ignore the fact that women have babies and tend to work part-time and quote numbers of GP's rather than whole time equivalents.
I have no suggestion as to the cure other than a drastic increase in medical students.
The present system favours brains rather than aptitude and maybe enrolling more students and allowing large numbers of drop-outs who are rewarded with a degree which will qualify them for para medical and nursing occupations would ensure that those who pass their finals are committed to medicine rather than dropping out altogether as many do.

#548963 Maxine Jones
Primary care development adviser
International Futures Forum

Any system will work so long as it's adequately staffed and resourced. The Alaskan Nuka system, which offers continuity through small integrated team working, fully staffed teams, floating team cover, a range of extended services (available on site and in real time), care & support planning approaches to support holistic need, looking after relatively low patient numbers per GP wte (1400), has delivered great results. I have found that introducing individual features, such as small co-located team working, or GP led-triage, or care & support planning, or extended primary care services have had limited impact on their own and, in fact, may increase demand and strain on the service. Therefore, in order to pack a punch and achieve quick access, continuity, effectiveness and lower demand, patient numbers per GP wte/team need to be low and the service needs to be designed around a whole-system which supports holistic need. Needless to say, this requires considerable investment and is likely to be achieved best where there are opportunities for economies of scale. Fortunately, some primary care organisations out there are working with the bigger picture.

#549045 Esmat Merali Ka...

Words like holistic needs and approach have become institutional words with no specificity.
Public self responsibility is a big factor.

#549296 Maxine Jones
Primary care development adviser

Esmat, I agree. I guess that some words are intended to capture a number of concepts, but you're right, they are jargonistic. The bottom line is how do we create capacity to optimise the value of the therapeutic relationship in supporting people with issues to do with health AND wellness, so that we're dealing with the substance as well as the symptoms. The new models are basically about creating capacity for good conversations and relationships which, in the process, help people take more responsibility for themselves - current levels of demand suggest that folk need support with this.

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