Liz Spice, Cross Sector lead, Primary Care Transformation, NHS England North-East and Yorkshire, recalls how working collectively with Integrated Care Board (ICB) colleagues across the region led to a trailblazing new approach for understanding pressure in general practice.

General Practice is acknowledged as the bedrock of the NHS but historically it’s been hard to demonstrate accurately the pressure felt on the front-line.

Three years ago, as we entered the beginning of the winter pressures period for 2021-22, it was clear that both primary and secondary care were still feeling the impact of the pandemic. Secondary care colleagues could evidence this with some powerful statistics.

We quickly came to realise colleagues working in general practice, although struggling with similar levels of demand, couldn’t demonstrate the growing workload in a similar way and as a result were not receiving the same levels of support and resources to stabilise demand.

It was a very tough time. Colleagues were delivering COVID-19 vaccinations as well as seeing patient demand beginning to go through the roof. All the seasonal trends that we could usually prepare for were completely out of sync. There were also a lot of negative headlines around the lack of access to general practice for the public which was fuelling the fire and morale was at an all-time low across the profession.

There was a lack of understanding and transparency of the very real pressures they were facing – for example our urgent and emergency colleagues couldn’t grasp why quite so many low acuity patients that could be dealt with outside of hospital, were turning up at their doors.

“The purpose of identifying pressure is to alleviate it, protecting both the continuity of patient care and the GP practice team.”

Scoping work

First of all, we realised we needed to quickly define and agree what pressure within general practice looked and felt like first to allow us to prove the reality on the ground.  We called out to our 4 systems across the region to ask if anyone had something in place already that could accurately reflect the current issues general practice colleagues were experiencing, which could potentially be used to scale up across the region.

Encouragingly there were already pockets of best practice across the region, and it was colleagues in Tees Valley who stepped forward with a framework already developed, similar to that already well-established across Acute Trusts, which was known as the OPEL framework. It included Operational Pressure Escalation Levels (OPEL) which is an operational measure to show the level of pressure within the organisation.

It goes from level 1 to 4, with 1 being business as usual and 4 experiencing significant unexpected pressure causing increased pressure to patient flow at a level that compromises provision / patient safety.

Practices in Tees Valley had been reporting OPEL levels since 2020 but it was identified early on that defining and experiencing pressure in practice was highly subjective and to support an appropriate resilience response, a framework was established to guide the identification and articulation of the pressure.

This framework was then co-developed with practices, local medical committee and GP federations and was subsequently updated with additional collaboration with Directory of Services (DoS), ambulance provider and EPRR representatives and rolled out across the North East and North Cumbria ICB.

We recognised the familiarity of the framework could be a plus from an engagement perspective, however we knew it would be tricky to shoehorn a known acute process into general practice at scale. We would need a different approach.

Our collective approach to scaling up

We knew that a critical success factor in adopting and mobilising a GP OPEL framework would be buy-in from our Primary Care leaders within our 4 systems across the region.

They too were feeling colleague’s frustrations and saw the benefits in tackling this at scale across the region. This being the case, we were given the green light to proceed with implementing the GP OPEL framework at scale.

It was a real partnership piece working alongside nominated leads in each system, where we quickly stood up a task and finish group, to share learning and to support with mobilisation at a local level.

It was clear there were four natural stages to this work:

1. Define pressure
2. Log pressure
3. Mitigate pressure
4. Enable support

“A clinical director at the time told me the only measure she had of things being seriously pressured was the number of staff members in tears. This needed to change “

1. Defining pressure

The first stage was in some respects the easiest. The Tees Valley OPEL framework already provided a fantastic overview of some of the core escalation areas that would add to pressure within a practice, for example reduced staffing, increased demand, insufficient supplies, IT outages. The response to the OPEL levels was of course different as all local services are set up differently, and therefore systems tailored the framework to reflect this but kept the core components in.

Initially we were very focused on the metrics, and how we quantify when a practice hits the higher OPEL levels but the anecdotes we received when drawing in colleagues’ thoughts on pressure, brought home exactly why this work was so important. A clinical director at the time told me the only measure she had of things being seriously pressured was the number of staff members in tears.

This needed to change, and with initial challenges resolved and positive feedback received, our initial refined GP OPEL framework was provided to practices in the region via our ICBs as a means to log and understand their pressure and where they were on the scale.

2.Logging pressure

 ICBs started to send through their OPEL levels weekly into the regional team once engagement locally had been undertaken. Engagement has been a thread throughout this work and continues to be an ongoing area of this work locally.

We did receive some initial challenges from colleagues in South Yorkshire concerned that additional reporting would increase pressure on practices who were already under strain. However, they came to the realisation that recognition of the issues was the means of getting the necessary support and in providing transparency of general practice pressure to national colleagues alongside pressure within acute hospitals. This system now has one of the highest submission rates because they appreciate the value of this work.

 The very first weekly pressure report produced was in January 2022 and 16% of practices submitted their OPEL level. It was a start and a positive step towards recognising general practice pressure in our region.

3.Mitigating pressure

The purpose of identifying pressure is to alleviate it, protecting both the continuity of patient care and the GP practice team. For example in some areas, if a practice reports an OPEL 3, their ICB ‘place’ colleagues might call them to ask questions around problems and try and work out a solution if it is outside the norm – for instance if the fridge has broken down with all the medicines in it or there is no capacity that day due to staff illness, colleagues can coordinate support from the local area.

4.Enabling support

If you’ve reached OPEL 4, this is classed as an operational emergency, and it is at this point the ICB team will try to provide more hands-on support and often make commissioning decisions to alleviate demand. For example, patients could be diverted to other services or neighbouring practices. There are many mitigations that can be made, even temporarily pausing the normal referral pathways from 111 into practices to allow time for the situation to stabilise.

Continuing our work

The need to capture pressure in general practice has since been officially recognised, with mentions in the May 2023 Fuller report around clarity on capacity and demand to manage surges in demand. Subsequent winter letters and plans have called it out specifically as an approach to monitor pressure in primary care settings.

Monitoring and reporting pressure is more important than ever in this time of increased turbulence in primary care, and one of this year’s aims is to increase the number of submissions further to ensure we are gathering a full picture of pressure across the region.

Another aim is to reduce subjectivity. One staff member’s ‘cannot function’ may be within another person’s comfort levels. Our South Yorkshire system have developed a series of online multiple-choice questions with additional weighting which once completed automatically calculates their OPEL score. This is then uploaded and monitored by the ICB and acted upon if needed. They achieved this through extensive face-to-face user-engagement sessions with practices. Our other 3 ICBs are very interested in this approach, which we will explore the expansion on this year.

Making it easier and quicker for practices to submit linking to wider operational pressure is also a key aim. Many of our practices now submit digitally via the RAIDR app, currently used by System Coordination Centres who monitor and respond to all surges across their system. It allows colleagues to see and recognise the impact on the system in real time. This enables a swift and effective response to any changes in OPEL level.

Our next goal is to do something similar for Community Pharmacy. At present we only report on community pharmacy temporary closures – which isn’t the best indicator of pressure but at present is all we have. So, watch this space!

Roll out of OPEL levels

At a national level OPEL levels are here to stay. The Acute Trust OPEL framework has recently been updated, Community and Mental Health Trusts versions are underway. There is good, widespread understanding of OPEL levels i.e. OPEL 1 – usual demand and managing, OPEL 4 – very high levels of demand and needing help.

As a result of our regional work and over 3 years of intelligence now gathered, we are feeding into the development of a national GP OPEL framework. Although we are still on a journey, we continue to lead the way on this. Raising awareness of pressure and supporting practices and patients during challenging times remains at the heart of our work.

For more information about reporting pressures in primary care please contact england.ney.pctransformation@nhs.net

Cross Sector lead Liz Spice