The idea

Bring practice teams together across the STP footprint to learn quality improvement tools and techniques and share learning and experience to strengthen active signposting.

Lack of appointments versus too many inappropriate appointments

The CCGs initially piloted Learning in Action with 1 cohort of 17 practices who wished to take part.  Some of the practices had previously undertaken other elements of the Time for Care programme, including Productive General Practice Quick Start and Fundamentals of Change and Improvement, so had started to build a foundation for quality improvement.

Practice teams chose active signposting as the High Impact Action they wanted to work on as this was creating one of the biggest issues for staff.  Most were experiencing problems with not enough GP appointments versus high numbers of GP appointments being used inappropriately.

Over 7 months the practices came together to attend Learning in Action workshops where they were introduced to quality improvement tools and techniques, shared learning and experiences, that would help progress active signposting in their practice. The second cohort of 11 new practices built on the first cohort, and equally ran for another 6 – 7 months, culminating in a final shared celebration workshop of 17 practices presenting their progress to date in September 2018.

Representatives from all three CCGs along with practice manager representative, pharmacy, Public Health, Local Authority and Leicestershire Health Informatics (the GP IT delivery partner), also attended the workshops to coordinate feedback from participants and note any common learning/themes they needed to take away and action.  For example, how to market and communicate the changes in a consistent way and agreeing the most meaningful metrics to use.

Working together to find solutions to problems

There was genuine understanding between the practices that it would be easier to make changes if they worked together.  Learning from each other’s experiences and ideas helped tackle practice specific issues but also issues that were common to all.

When practices from Leicester City CCG were experiencing issues with signposting options on Systm 1, their Strategy and Implementation Manager, negotiated free support from local IT to set up an auto-consultation function on the system to allow staff to add other non-medical signposting options.  Once this function was operational practices added to their own menu list and shared their new services to signpost to (e.g. knitting groups, coffee morning sessions) with other practices so they could add the same to their menu list.  This was used as an interim solution whilst a directory of service was developed.

North West Leicestershire GP Federation hoped to identify trends around appropriate/inappropriate appointments.  However, when trying to establish a baseline it found the data size in some practices was too small to draw any trends.  The five practices in the programme addressed this by agreeing to collaborate and share their data so trends could be identified across all five.

Providing support in between programme workshops

Some groups of practices met in between the monthly Learning in Action workshops to keep the momentum going and drive changes at practice level.

Practices from Leicester City CCG met two weeks after every programme workshop.  These meetings were used to recap what they had done at the last workshop and discuss in more detail how it could be localised e.g. discuss further techniques on engaging with patient groups and staff,  revisit measurement tools again to get a better understanding of how to use them.

Practice managers from North West Leicestershire GP Federation opted for a similar approach, where they brought their group of practices together in between workshops.  The federation tagged on time to their regular practice manager meetings to discuss what they had done at the last workshop and what actions needed to be progressed.

Strengthening relationships with local partners

Teams made links to wider pieces of work including primary care networks, community pharmacists and Patient Participation Groups, PRISM (Pathway and Referral Implementation SysteM) and social prescribing resources. Key was also strengthening relationships with local partners.

Practices from East and West Leicestershire CCGs re-launched First Contact Plus, an online tool provided by a local partner to help adults find information on a range of services such as housing, health and independent living. Work had previously been done with this partner on a strategic level. However, through the programme it enabled teams to see how the tool could be used for signposting.

More practices now use the tool which has increased confidence amongst reception staff to ask patients questions that will improve signposting activity.  In turn First Contact Plus has achieved its aim to increase GP referrals and utilisation of the tool.

Champions helping to engage future cohort of practices

The CCGs recognised that to roll the programme out to further cohorts, strong engagement with staff who had not already participated would be important.

A number of programme champions emerged from the first cohort including a GP, Strategy and Implementation Manager from a CCG and a federation practice manager.  The champions shared their successes at future cohort meetings, presenting the impact the programme had made in releasing GP time, delivering more appropriate appointments and strengthening local relationships.  This was hugely powerful coming from colleagues practices knew and trusted, and in turn helped bring more teams onto future cohorts.

Impact

• The programme has equipped staff with quality improvement skills and techniques to take forward change, and make future improvements in their practices to new and different High Impact Action areas.
• There has been greater collaboration between practices, improvements have happened at a greater pace than had practices worked alone. This has been hugely valuable and puts practices in good stead for working as Primary Care Networks.
• Across practices in East and West Leicestershire CCGs referrals to First Contact Plus have increased by 68%, helping more patients to be directed to appropriate services and GPs to deal with those patients that need their help.

Improvements individual practices/groups of practices have made include the following.

Three neighbouring practices in North West Leicester GP Federation

• Achieved their aim of collectively reducing avoidable appointments by 50% per week, equating to 2.5 days of GP time.
• Strengthened relations with local pharmacies and patient participation groups who were supportive of the work.
• Improved their collaborative working to provide equality of services for patients.

The Assist Practice

• 5 GP hours have been released a month through the implementation of active signposting, helping to reduce unnecessary GP workload.
• The practice team has gained more confidence in signposting their patients to the correct service.
• Patients have been educated about other services that may be available to them and to help them achieve a healthier lifestyle.

Whitwick Road Surgery

• Reduced inappropriate appointments by 12%, equating to 194 inappropriate appointments. The freed-up appointments have given GPs more time to focus on those patients that need their time.
• Patients can get an appointment with the appropriate person quicker than they used to. Previously all appointments were gone by 8.20am whereas now some appointments are still available at 10.30am on most days.
• The practice is making better use of other healthcare professionals including its Advanced Nurse Practitioner. Working relationships have also improved with its closest chemist e.g. patients who previously made an appointment with a GP for items such as hay fever medications or simple creams are now signposted to the chemist who will deal with them.

Measham Medical Unit

• Reduced inappropriate appointments from its urgent care clinic by 22%, equating to over 160 inappropriate appointments.
• Patients who need urgent appointments are now able to access them easier.
• Team working has improved, the practice has regular and open discussions about problems which has been a positive change.
• One part time GP was inspired to go beyond the strengthening of active signposting and implement social prescribing from the practice to enable the community to be reconnected. They started with a walking group which led to the forming of other groups with themes such as walking football, singing for dementia, carers clinic and art therapy.

Implementation tips for success

• You must have commitment from practices to consistently attend workshops.
• Ensure clinical and managerial buy-in from practices.
• Demonstrate the benefits of taking part to practices.
• Ensure support for practices from the CCG or federations during and after the programme.
• Maximise success through collaborative working and shared learning.

“We all worked together to share ideas and resources, support each other to make changes. Using other local practices as sounding boards helped a lot, everybody who participated made a contribution” Lynne Keeling, Practice Manager, Manor House Surgery

“Our practices have worked together before but never done anything like Learning in Action. It’s been absolutely brilliant, would recommend it become mandatory for every practice to participate. Working on active signposting has made the patient journey so much simpler and better.” Mayur Patel, Strategy & Implementation Manager, Leicester City CCG

“Groups of practices owning and doing the work is the only way you can make a success of it. We’ve seen a positive change in practices where patients can access the right type of services quicker and easier, and GPs are not having to waste time on unnecessary appointments” Ian Potter, Director of Primary Care, West Leicestershire CCG

If you would like to find out more about participating in the Learning in Action programme, along with details on how to apply, visit our web page.