GP Practice: Discussing Key Issues Facing Urgent and Emergency Care

Dr Agnelo shares his thoughts on managing workload and the key challenges facing urgent and emergency care services. He shares his experiences from working and managing a multi award winning GP Practice.

Parchmore Medical Centre has been shortlisted and won many awards including: Winner of the Managing Workload & Improving Access General Practice Awards 2018, Highly Commended in the Innovation in Primary Care Healthcare Transformation Awards 2019. 

1.What do you think are the biggest challenges facing urgent and emergency care services?

It’s important to outline that from my experience the major challenge facing urgent and emergency care (UEC) services is not increased demand or acuity of the case mix, it is not even the elderly or funding. All of these are predictable, and can be planned for, however, are too easy to misreport or to form part of the narrative used to justify poor performance and poor patient experience in some UEC services. Strategic, operational and clinical leadership in some UEC services fail to be held to account where standards are consistently not met.

The biggest challenges facing UEC services in my view are the (a) workforce and (b) productivity.

(a) Workforce:

• Enough staff may be available but choose not to work as permanent staff in the NHS.
• The current NHS staffing system allows the workforce to choose not to prioritise their commitment to a publically funded NHS, but to perverse market incentives.
• Those increasingly working as locums in UEC services can work a few days in a month and be paid the same amount as full time staff. The NHS is increasingly seen as a cash cow.
• The NHS has become an employee based sellers’ market which is increasingly unaffordable.
• The NHS staffing system has been allowed to be broken and must therefore change.
• We need to make the NHS a permanent employer again

In order to change, there are two things that could be done centrally:

1. Firstly, anyone qualifying to work as a locum or interim should also have to have a permanent job in any part of the NHS for at least two days a week and be able to regularly provide a confirmatory employers certificate to this effect, similar to the mandatory safeguarding or life support training evidence.
2. Secondly, introducing pay ranges or bands for locum work reflecting experience making permanent work more attractive.

(b) Productivity:

• Low clinician productivity is the second major challenge in some UEC services.
• The lowest productivity often being in the most expensive parts of the UEC system which is not good value for the use of public funds.
• There is either denial or a culture that fails to recognise this or the competencies to address.
• Mitigating the risks of reducing the available locum or permanent workforce if they are challenged on performance in a sellers’ market requires strong strategic, operational and clinical leadership.

2.What top tips do you have for managing workload in the GP environment?

(a) Firstly some home truths to accept to get over the managing workload challenge:

• Need strong and committed strategic, operational and clinical leadership for success
• Leadership needs to promote the values of the organisation for excellent care
• Staff need to be valued, and that working as a GP is a vocation not just a job.
• Need a plan including that invest to save is often business efficient.
• Accept that demand is predictable and that you need to map capacity to demand.
• You will have a GP-light workforce given the unaffordable sellers’ market for GP’s
• Recruit a different and varied workforce e.g. Pharmacists, Physicians Associates, Nurse Practitioners, Nurses, HCA’s, Medical Assistants with appropriate support structures
• Map patient flows and avoid duplication of workforce utilisation, recognising where the unique abilities of GPs to manage risk are best placed, for safety, improving quality and continuity of care.
• Recognise that workforce productivity needs to be optimised to make best use of resources
• Understand the UEC services and pathways in your area and in your practice.
• Self evident to reduce use of GP locums and escalating costs for sustainability.
• To be financially viable to manage workload effectively that you make best use of resources.

(b) Doing things differently:

• Workflow optimisation is key to reduce the administrative burden on clinicians with non-clinical workload being prioritised to appropriately trained and supported non-clinical staff.
• Segment scheduled from same day urgent unscheduled work using workforce creatively.
• Use a multidisciplinary team approach to deal with same day urgent care demand
• Develop a responsive practice UEC system that can flex with demand on the telephone, online, face or home visit requests, capable of increasing capacity and productivity twice or three times that planned if required.
• Create daily touch point for clinicians for referrals peer review, case discussion and peer support.
• Use proactive approaches to keep people well and take ownership of their own health e.g. shared decision making with patients, promoting self care and self management, and group consultations.
• Engage with your Patient Participation Group to support plans to manage workload
• See people as part of communities and the need to mobilise the community to support individuals through social prescribing community activities.
• Create staff opportunities for volunteering to cement the sense of community and the reason why they came to work in the caring professions

3.How do you think we can improve the recruitment and retention of GPs?

As a GP Senior Partner and a GP trainer I have a lot of experience in recruitment and retention. The recruitment of doctors needs to be reset:

• We need caring, competent and confident doctors but also doctors that are committed to the NHS.
• Being a doctor is a vocation not just a job, so it’s crucial that we are getting the right people. However, we need to be aware that the junior doctor contract has reinforced the employment as a job, eroding the concept of vocation even more.
• Unfortunately there is the lure by the perverse incentives of the sellers’ market, for recent GP graduates to expect very high payments, for less work, and working only a few days a week as a locum, or even working a few hours from home for the same pay.
• The NHS system has allowed these conditions of employment and perverse incentives and needs to change as discussed previously to incentivise permanent employment for even a minimum time period if that is a condition of being eligible to work as a locum, and with locum pay rates depending on experience.
• With an ever increasing number different UEC services needing GP’s, candidates are spoilt for choice, and lucrative high paying services with less work advertised through social media, is beginning to have an effect.. This reduces the GP workforce that is available and affordable to GP practices and many UEC services.

We need to rebalance our approach to GP recruitment. Currently we have gone too far the other way, with a focus on the needs, and more often the wants of the individuals of the workforce, rather than the needs or requirements of the GP practices or the NHS:

• There needs to be a change from a sellers’ market with hugely inflated and unaffordable costs to a realistic buyers’ market.
• This is only possible through diversifying the workforce, reducing the need to employ a GP, and being prepared to not employ a GP or a GP locum just because they are available, but who have the wrong ethos or unrealistic expectations on pay and conditions.
• GP’s will price themselves out of the employment market as the move to more cost effective workforce diversification reduces the needs to employ as many GPs, unless steps are taken to change the NHS system to mandate minimum permanent NHS working for eligibility to work as a locum and incentivise permanent employment by creating pay bands for locums based on experience.
• Recruitment must be a continual exercise as there will always be a turnover of GPs due to circumstances beyond anyone’s control.GP practices and UEC services need to develop “herd immunity” to the inflated demands of GP locums or employed GPs propagated via WhatsApp or other social media being used as comparisons sites.
• Otherwise whether in Primary Care Networks or not more GP practices will become financially and operationally unviable regardless of working at scale strategies resulting in more surgery closures.

We need to develop the right ethos for GP’s and other staff through work in the community:

• Being involved in volunteering and community projects through GP practices or UEC services helps remind doctors and other staff why they came into the caring professions.
• To support the NHS as a publically funded service for all, not just as a cash cow for the few.
• The GP workforce needs to be valued, appropriately paid, supported and developed, to prevent burnout, and this means changing the working environment and creating variety and reducing the avoidable workload.
• If you can get this right the best people will be satisfied, more fulfilled, stay and work longer, and more effectively with improved productivity.

Unfortunately the pensions issue, unless resolved will force many senior GPs out of the employment market which will create a vacuum, not only of experience, but also the available hands on deck to manage the workload. Hence a very different approach is required, while changing the sellers’ market to make the NHS more sustainable. With already increased resources to the NHS which are continually wasted, we need to avoid the creeping need for privatisation and marketization of the NHS to raise funding due to inflated costs created by the lucrative and flourishing sellers’ market available to the clinical workforce.

4.At Parchmore Medical Centre what is the key to delivering such effective care?

After losing baseline funding following contractual reviews, and losing disillusioned GP partners, there was a big motivation just to survive, continue and improve the work of the Medical Centre.

• Due to the precarious financial situation GP Partners had to introduce tens of thousands of pounds of capital from their individual savings to maintain the practice and avoid staff redundancies.
• It was important to reinforce some core values to all staff, including being sustainable, providing excellent care, being innovative, successful and being the family practice of choice.
• In order to make Parchmore Medical Centre the family practice of choice there needed to be a personal element of care and continuity, which the use of locums prevented.
• We involved our patient participation group, who led with mobilising the social prescribing revolution, with support from our local community, Counsellors and MP.
• We had good strategic, operational and clinical leadership with distributive leadership to lead on specific elements of the practice rescue plan.
• The key was accepting that we would have a GP-light permanent workforce.
• There was also an increasingly available, but unaffordable GP locum workforce, which also set limits to what they would do, resulting in others in the practice having to pick up the extra work. Some available GPs, therefore, had priced themselves out of the sellers’ market as we decided not to employ them.

Diversifying the workforce from being a GP based system was a necessity. Reducing the administrative workload for the remaining GPs with workflow optimisation, was an early green shoot, that galvanised developing the other aspects of the recovery plan.

• This led to the reduction of avoidable emergency admissions, reduction of unnecessary outpatient referrals, even reduction in A&E attendances, and creating longer appointments for those complex cases and improvements in the quality of care markers
• The personal stake in the work meant doctors and staff were doing the best they could, and if you’re doing the right things then the money will follow, with the rewards of improving access, of managing the workload, improving the quality of care, a focus on prevention and keeping people well, and reducing the need for to use unaffordable GP locums..
• Hospitals can create deficits due to overspends contributed to by the increasing staffing costs in a sellers’ market with eventual central bail out, however, GP practices do not have this luxury of being rewarded for failure - we just have to hand the contract back and close down, as we got so close to having to do as a practice.
• In our case when the going got tough the tough got going to avoid practice closure.

5.What principles from your experience in general practice for managing workload could be applied to other UEC settings e.g. UTC, ED, IUC, Ambulance?

All the core ideas I mentioned previously can be applied to other UEC settings from A&E to IUC, and on the telephone, online or face to face.

• This includes accepting that demand is predictable and matching capacity to demand while increasing productivity cost effectively - the core of sound operational management.
• The cultural change needed with behaviours and beliefs among clinicians and all staff, that have become custom and practice leading to poor productivity, require strong strategic, operational and more importantly clinical leadership to change.
• Diversifying the workforce is essential to deal with the lack of available GPs, A&E doctors, nursing and other clinicians.
• Understanding the recruitment challenge with the current clinical workforce in a sellers’ market with inflating costs to NHS services.
• Just trying to fill repeatedly vacant shifts makes no sense. Rather asking what could be done differently and by whom to manage the workload differently with better productivity and better outcomes with re-designed pathways, processes and patient flows.
• What is wrong with seeing senior decision makers as leaders of multidisciplinary teams working together differently and performance managed to maximise productivity as a team?
• Being able to see that there is a queue of waiting people, increasing productivity by all clinicians, and managing the workload by flexing to the demand for better clinical outcomes and certainly better patient experience with reduced unnecessary waiting.
• Every organisation should have a realistic and sensible recruitment strategy to solve today’s workforce problems to increase their permanent staff and reduce use of increasingly costly often unreliable locum staff in the sellers’ market.
• Use of digital and agile working needs to be explored, however, need to be ever mindful of the sellers’ market and escalating costs. Therefore the importance prioritising permanent staff to explore new ways of working rather than temporary staff.
• Ensuring workflow optimisation, to remove the unnecessary administrative burden of clinicians creating more time to care.
• Understanding what different UEC services are, and what they do to integrate flows, processes and pathways between services for fewer handoffs, to reduce waiting, and for improving patient experience while achieving the standards and targets expected