The RCGP/Nuffield Trust GPs at-scale survey for 2017 has revealed a continued trend towards larger GP organisations. Organisations are growing in both size and maturity and are beginning to implement new ways of working.
But 40 per cent of respondents reported that staff shortages are presenting challenges in achieving their goals. It seems that the workforce reality in general practice – fewer entrants, early retirement, an uneven distribution of trainees and changing behaviours of newly qualified GPs – is beginning to have a real impact on progress.
Although workforce shortages can feel like a barrier to change, my own GP collaboration has found the challenges to be a powerful motivator to invest and innovate.
Operating at scale has enabled us to take a creative approach to the workforce. Through creating a diverse, multi-professional workforce that enables sustainable working conditions for all clinicians working in primary care, we hope to produce a more attractive offer for all clinicians making choices about their future career.
A changing and supportive workforce
As I travel around the country delivering regional events discussing at-scale working as part of the RCGP’s programme, I’ve found that others are also seeking to turn the workforce challenge into an opportunity.
There was a practice in Norfolk that lost five GPs in quick succession, which they were unable to replace. Their solution was to create a team of nurse practitioners to manage urgent care and home visits, as well as substitute roles and shift workload away from GPs while continuing to provide responsive, quality care for patients.
There were practices in the north west – where there was a serious recruitment challenge that threatened the very existence of general practice in that area – coming together and developing innovative services with pharmacists, paramedics and mental health workers. In a short time, those practices have managed to turn the situation around – providing sustainable, innovative, quality care and even increasing the numbers of GPs applying to work there.
The story in my patch
My own practice cares for 50,000 patients across two cities. We are involved in collaborations with other practices, which has added a further dimension to the scale we offer. In recent years, we have found ourselves working harder and harder in a way that has begun to feel unsustainable. In response, we have taken a decision to invest in our workforce and work in a different way – potentially reducing our earnings in the process.
The new approach focuses on creating a sustainable workload for our GPs while maintaining the level of service we offer patients. From our perspective, this move towards sustainable general practice is a move towards quality not quantity – evolving the role of GPs to focus on complexity (with ample time to do it) and become supervisors of a multi-professional team of clinicians.
Scale has been a huge enabler – it has allowed us to focus on the governance required and has allowed testbeds to be created within the organisation before wider implementation. Scale has allowed lower risk investment, pooling of resources, the creation of devolved management structures that support high-quality governance (HR, finance and business intelligence functions) and release of clinical leadership time to drive and oversee change.
We now employ a range of clinicians – pharmacists (eight), paramedics (eight), nurse practitioners (five) and a physiotherapist (one) – and have highlighted role substitution opportunities in a safe environment focused on, and supported by, a quality improvement culture. Many traditional GP roles, such as prescription management, urgent care, home visits, as well as reviewing letters and results, have been transferred to other professionals. The development of competency frameworks and a proactive approach to support and mentorship has been key to progress.
Going the right way
The graph above shows the changes that have occurred in our urgent care system at two sites caring for 13,000 patients. In August 2016 all urgent care patients were seen by GPs. Now very few are. Instead, other professionals in the team see those patients. The graph below is another example that illuminates this change – instead of GPs carrying out home visits, we have enabled paramedics to do more of this.
GPs are available to discuss or review patients, and mentorship and oversight have become important GP roles. Both quality and patient satisfaction remain high. We have carried out patient surveys along the way, as well as using patient participation groups and social media to keep patients close to developments.
The result is certainly not utopia and it is still early days, but it feels like a step in the right direction. GPs now have 15 minutes for routine appointments, which enables them to focus on the quality of the interaction with patients.
Doing fewer home visits and other innovations, meaning a significant reduction in administrative workload, has also relieved a lot of the pressure. The other, perhaps unexpected, result has been that these changes have allowed GPs to develop as clinical leaders with headspace to tackle other ‘at-scale’ aims. The approach we have taken is iteration based on quality improvement cycles – learning fast and changing as we go along.
The decision to focus on sustainability and not profit was not a difficult one to take. We decided to prioritise delivering a happier workplace while responding to the challenges of a world with fewer doctors. Although we have evolved out of necessity, we have turned what could have been a barrier into an opportunity to create new and more sustainable ways of working.
My practice is not alone here – this is happening all over the country and is a demonstration of the resilience we have come to expect from a profession dedicated to providing patient-centred care.
Dr Mike Holmes is a RCGP clinical lead (GP at scale and QI ready) and a partner at Haxby Group in the cities of York and Hull.
Please note that views expressed in guest blogs on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.
Holmes, M. (2017) "Investing in a sustainable workforce" Nuffield Trust comment www.nuffieldtrust.org.uk/news-item/investing-in-a-sustainable-workforce