Causes of bureaucracy in general practice
A survey, designed with front line practice managers and GPs as well as national stakeholders, was widely circulated to practices to identify the amount of time spent on bureaucratic tasks. The on-line questionnaire was completed by 267 practice managers between December 2014 and March 2015. Full results can be found at (link).
The chief sources of bureaucracy in general practice were as follows:
- Getting paid
- Processing information from hospitals and other providers
- Keeping up to date with changes
- Reporting other information
- Supporting patients to navigate the NHS
The survey results as well as interviews with practice managers have indicated that ‘getting paid’ has become a much bigger burden since CCGs and local authorities have been commissioning services from practices, and that the use of different systems for reporting, claiming and reconciliation has exacerbated this. They also highlighted ways in which the CQRS system for automated processing could be improved to reduce manual workload. We also asked practice managers about the most time consuming aspect of bureaucracy and ‘getting paid’ was clearly the single biggest issue, with 45% of all respondents identifying this area.
The next biggest bureaucratic burden, almost on a par with getting paid, related to processing information from hospitals and other providers. Managers reported this has increased in recent years.
Keeping up to date with incoming information from commissioners and other bodies, particularly at a national level, was also significant areas of burden for practices. Managers reported that this was particularly problematic when later trying to retrieve information sent by email, letter or bulletin.
Figure 1 Sources of bureaucracy in general practice
The fourth most burdensome issue was reporting for contract monitoring or regulation. Here, interviews revealed frustration caused by multiple requests for similar information, sometimes from different teams in the same organisation (particularly NHS England), often at very short notice (eg 24 or 48 hours), and often formulated in ways which differed from how the information was stored. NHS England and CQC were described as frequently asking for information about the same aspect of the practice, but in different ways, at different times, and in a series of requests rather than a single one.
Finally, supporting patients to navigate the health and care system was also an area where practice workload was increasing.
Causes of potentially avoidable GP consultations
Figure 2 Causes of potentially avoidable consultations
An audit tool was developed, again with the support of front line GPs and national stakeholders, to explore how many GP appointments are potentially avoidable, either because other practitioners, within or beyond the practice, could have met their needs, or patients could have sought support in other ways. It was completed by 56 GPs between January and June 2015, reviewing a total of 5,128 appointments.
Overall, 27% of GP appointments were judged by respondents to have been potentially avoidable, with changes to the system around them. The most common potentially avoidable consultations were amendable to action by the practice, often with the support of the CCG. The biggest three categories were where the patient would have been better served by being directed to someone else in the wider primary care team, either within the practice, in the pharmacy or a so-called ‘wellbeing worker’ (e.g. care navigator, peer coach, health trainer or befriender). Together, these three, which could be improved by more active signposting and new support services, accounted for 16% of GP appointments. An additional 1% were to inform a patient that their test result was normal and no further action was needed. A further 1% of appointments would not have been necessary if continuity of care or a clear management plan had been established.
The second most common type of issue lay within the control of hospitals. Demand created by hospitals accounted for a total of 4.5% of appointments. The largest category, creating 2.5% of appointment, comprised problems with outpatient booking (either a lapse in the outpatient booking process, such as failure to send a follow-up appointment), or a patient failing to attend an appointment, necessitating an entirely new GP referral. The other, creating 2%, was the result of hospital staff instructing the patient to contact the GP for a prescription or other intervention which was part of their hospital care.