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Discussion

1) It is clear from our findings on the scope and scale of bureaucracy in general practice that a substantial amount of time in many practices is spent on tasks that could potentially be done in other ways.  It is possible to free up time that could be used to help implement local improvements. Rapid changes would also begin to address a deep sense of frustration that the system adds to the burden in practices rather than offering support.

2) Similarly, there is considerable scope for using GP time in different ways that could reduce the current workload and offer better support to patients. Our evidence is based on an audit carried out with a comparatively small number of 56 GPs and we look forward to building on this base by opening up the audit to all practices across the Country so that they can compare their use of appointments with others. The audit highlights that there are a range of opportunities for sharing and redirecting the current workload. No one practice can hope to address all of these areas but by focussing on specific types of avoidable appointment, practices could make incremental improvements reducing pressure on GPs.

3) The ability to implement common systems has been complicated by the NHS’s poor record on developing integrated information systems, with policy veering from centralist solutions to local diversity. Neither has served general practice well. Much of the duplication and confusion, and the inability of clinicians across different parts of the healthcare system to talk to each other and share important patient information, stem from this failing. Increasingly, patients will demand a greater role in accessing their own notes and sharing this information with everyone involved in their care across organisational and professional boundaries. We make further recommendations about central and local responsibilities in this area and see it as a fundamental route to reducing unnecessary workload and speeding up care across the NHS.

4) We were struck by how far the links and connections between clinicians working within a health community have been frayed and broken. Traditionally, individual professional groups benefited from a common training that was supported and maintained by continuing learning and professional development.  So GPs and consultants would meet up together for educational sessions and other shared events, all helping to foster what many referred to as a ‘sense of place’. Many clinicians felt this common sense of purpose, collectively serving their local community, had been eroded, replaced by an often divisive loyalty to individual NHS organisations. At times of pressure and austerity, there is a danger that investment in time for clinical colleagues to talk and learn together is reduced or removed altogether, and time spent together is where local health communities can make the connections that will reduce workload on all sides.  We forget that health services are always underpinned by human relationships, between clinical colleagues as well as between clinicians and patients, at our peril.

5) There are around 8,000 practices across England, many offering effective, personalised care, based on shared decision making between clinicians and patients, reflecting the needs of their local community.  But too often we confuse the need for personal care with the unhelpful idea that each general practice should personalise its own business systems and processes.  Each meeting between a patient and their GP or nurse should be personal and distinctive. But it is more difficult to justify each appointment system, telephone system, payment system and information system, being different. It is unacceptable that within each CCG there are such wide variations in access that have little to do with patient need but rather are  more likely to be driven by the variation in approach, operational model and staffing levels across practices.  The strength of British general practice is its personal response to a dedicated patient list; its weakness is its failure to develop consistent systems that free up time and resources to devote on improving care for patients. The current shift towards groups of practices working together offers a major opportunity to tackle the frustrations that so many people feel in accessing care in general practice.  This report offers a series of suggestions for how emerging practice groups and federations can create more efficient systems and free up clinical time, for example, by reducing the need for repeat visits rather than creating yet more activity in an over-heating system.

6) Many of us greatly value the contact we have we a GP, preferably someone we have known for years and understands what matters to us as we manage our health. This is particularly important to those with long term illness or who are increasingly frail who particularly benefit from continuity of care with an individual clinician who co-ordinates their care – and of much less value to those who last attended the practice several years ago for a different condition.  But there are many other members of the practice team who could work in new and different ways. A large part of this is about how practices extend and develop their clinical team in a way that reduces the pressure and frequently intolerable workload, on GPs. We know that there will be pressure on recruiting GPs and practice nurses in many parts of the Country for some years to come. At the same time, new roles, including practice pharmacists, GP Assistants, Physician Assistants and Health Co-ordinators, may be able to pick up current workload in a more effective way because of their specific training or professional background, while other tasks previously seen as the responsibility of GPs can be picked up just as well by others. We recommend that NHS England should offer financial incentives to extend the practice team and that practices should be given more support to understand how different roles can lighten their load and improve care to patients.

7) This report also highlights the opportunities in looking beyond the practice to the range of support and goodwill that exists in the wider community. This is hard to do when the day-to- day pressures are so high and GPs are working increasingly long days, as well as being asked to extend their care throughout a 7-day week. The investment in time in building relationships with services outside traditional healthcare, frequently more central to promoting health in our communities, including carers and volunteers, services in the third sector, housing services and many others, is crucial. Again, it may be difficult for each practice to build these separate links, but working together as groups or federations, it may become easier to connect to others who can do more to support patients with long-term needs and tackle loneliness and isolation.  We list a number of examples of what is often called ‘social prescribing’, using the power and influence of the practice to improve health and well being rather than tackle illness.

8) There will also be an increasing need to support patients to help themselves. This is much more than redirecting patients around a complex and fragmented system. The NHS is responsible for making it easier to access care and services and should avoid the temptation to blame patients for its own shortcomings. But new technology offers a remarkable array of opportunities for managing our own health, through websites and Apps, patients accessing their own records, or near patient testing. Both clinicians and patients have a lot to gain, but will need to understand both the potential benefits and risks, with clinicians learning to value informed and empowered patients rather than seeing them as a threat to their authority.  Again, this report reviews some of the latest innovations and explores how working together, it is possible to improve care and reduce workload in the practice.

This report highlights a lot of excellent innovation that could helpfully be adapted and replicated in many other practices across the Country. The ‘Summary of new approaches’ describes the work carried out to explore some of the opportunities to work in new and different ways and provides links to further sections in the Appendix of the report.