Reducing pressure in general practice

We recognise that general practices are under considerable pressure. We therefore commissioned a study to quantify the sources of bureaucracy and potentially avoidable GP demand.

The Making Time In General Practice study by the Primary Care Foundation with the NHS Alliance was commissioned as part of the work NHS England is doing with its partners to implement the NHS Five Year Forward View, and expand and strengthen GP services and primary care across England. The report was overseen by a steering group including the Royal College of General Practitioners (RCGP) and the British Medical Association (BMA) General Practitioners Committee.

The report was published in October 2015 and an easy to use web based resource has since been produced to make it as easy as possible for practices to look at the findings of the report, its recommendations and related good practice. The web tool can be found on the NHS Alliance website.

Areas to release pressure overview

The main results of the report, gathered from surveys with 250 practice managers, audits of 5,128 consultations and a series of interviews and focus groups, are summarised in the following table.

Most burdensome area for practice

Cause of externally generated bureaucracy Percentage
Getting paid 27%
Processing information from hospitals 26%
Keeping up to date with changes 21%
Reporting other information 18%
Supporting patients dealing with the NHS 7%

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 Command and Query Responsibility Segregation (CQRS) system for automated processing could be improved to reduce manual workload.

The next biggest burden related to processing incoming information from hospitals. Here, the use of paper based communication in a wide variety of different formats was reported to place a burden on practices, where structured electronic medical records are used.

The third issue was keeping up to date with changes in the health and care system. Here, interviews indicated this relates chiefly to information sent by national bodies, especially NHS England, and that there are particular challenges in later trying to retrieve information sent by email, letter or via a bulletin.

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, 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 Care Quality Commission (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.

Processing information from other providers comprised a significant proportion of administrative time, and managers reported this has increased in recent years. Supporting patients to navigate the health and care system was also an area where practice workload was increasing.

Causes of potentially avoidable GP consultations

Cause Percentage
Unavoidable 74%
Other in practice 7%
Self care/pharmacy 6%
Outpatients 3%
Sick notes/appeals 3%
Other 3%
Care navigation 3%
Organisation in practice 2%

Data submitted by 56 GPs for over 5,128 consultations are summarised above. In total, 27 per cent of appointments were judged to have been appropriate for diversion or handled differently.

The most common potentially avoidable consultations were amendable to action by the practice, often with the support of the clinical commissioning group (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 per cent of GP appointments. An additional 1 per cent were to inform a patient that their test result was normal and no further action was needed. A further 1 per cent of appointments would not have been necessary if continuity of care or a clear management plan had been established.

The second most common issue lay within the control of hospitals. Demand created by hospitals accounted for a total of 4.5 per cent of appointments. The largest category, creating 2.5 per cent 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 per cent, 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.

Actions at national and practice level

We are  committed to taking action to address the issues identified in this landmark study. We are working on a suite of measures to be at national level which will reduce workload. Find out more about the actions we are planning to take.

Releasing capacity in general practice roadshows

We co-hosted a series of free workshops in partnership with the BMA from February 2016. This was an opportunity for GPs and local commissioners to hear from primary care leaders, learn about the national programme to release pressure. Delegates heard about successful innovations at practice level and identified actions they could take themselves.