At HTN Digital Primary Care, we welcomed Dr Minal Bakhai, GP and director for primary care transformation at NHS England, for a discussion on modern general practice, the use of digital tools to improve experiences for patients and staff and the national general practice improvement programme.
Background to modern general practice and the national general practice improvement programme
Minal began by highlighting how this work is particularly important to her because of her role as a GP in Brent, North West London, an area with one of highest levels of socioeconomic deprivation and health and care need with a significantly high prevalence of conditions such as diabetes, cardiovascular disease, cancers and mental health problems. She shared the challenges of rising workload, complexity coupled with difficulties in attracting staff to the area, noting a “crisis” point a few years ago where staff and patient satisfaction was at an all-time low. She said staff were struggling to deal with the increasing pressure, appointment waiting times were rising, a first come first served approach wasn’t equitable and “this way of working was taking a personal toll on everybody. For me personally I was missing out on seeing my young children most evenings, it felt unsustainable.”
This led to the practice changing its way of working, moving to “modern general practice”, which as a GP, she would “never ever go back” from. Minal credits the new model with reducing waiting times from an average of six weeks to two days; significantly improving continuity levels; reducing patient complaints; and helping staff feel more in control of their day.
“Importantly, we’re picking up urgent presentations that may have typically waited weeks in a first-come-first-served model on the same day now. Our working lives are much more sustainable and, while it’s not a magic bullet, it does feel like we’ve finally got our heads back above water and we can start to explore the opportunities ahead of us.”
One of the hardest things about making change whilst at “crisis point”, Minal explained, was doing it “without any support, funding or shared resources. We didn’t know what the answer was, we used a lot of our energy in trying to find out, trying out different tools and approaches, and this is why the national general practice programme is really important to me.”
“As a primary care transformation team, we lead the national general practice improvement programme. We are a clinically-led team that is deeply rooted in general practice; we have a faculty of GPs, practice managers, nurses and other clinicians who have extensive experience in improvement. We work with delivery partners who have delivered over 40,000 improvement sessions with general practice, and we are evidence-driven. We take a ground-up approach, working with practices and PCNs, those closest to the problems, who are best placed to find the solutions. As a practice we are not alone in facing these challenges. These are shared problems.
“We have developed a programme of structured support to share that learning, help other practices and PCNs use that knowledge and adapt it to their local circumstances, making the process of change easier, and enable realisation of the biggest benefits in the shortest time; essentially, de-risking change. At the heart of our support is shared learning, collaboration and a whole-system approach to transformation and improvement.”
The modern general practice model
Minal went on to offer deeper insight into what modern general practice looks like and how it works.
She described the model as “being developed by practices and PCNs to address some of the most pressing challenges in general practice, that should be adapted to local circumstances.” There isn’t a one-size-fits-all solution, she stressed, but there are key areas of focus; a framework that can be adapted.
Minal added that the model is supported by a wider system approach, meaning that it’s “trying to align a broader range of enablers to support general practice with the changes.”
Moving on to explain the benefits of the model in more detail, Minal noted that it works in “helping us better align capacity with need, improve the working environment and reduce pressure on our teams and to improve our patients experience of access.”
When considering the problems that the new model seeks to solve, Minal stated: “The current model of general practice as we know it isn’t working for most patients or most staff, and this is almost universal. Patient experience of access has fallen across the majority of practices and on average, the number of clinical consultations have increased by at least 15%, the number of experienced GPs has fallen, and practices are managing 17 percent more patients than they were eight years ago. Essentially we have a growing demand and capacity gap.”
Despite these challenges, Minal noted, “patients still rate their experience of care delivery from general practice highly, and I think our workforce and my colleagues need to be commended on achieving that despite the challenges.”
Minal pointed to the future and further increasing pressure as a result of increases in major illness and multimorbidity from an ageing population, there is no single solution to the challenges we’re facing, we need continued focus on recruitment and retention, greater investment in primary and community care and we also need to transform our ways of working to optimise use of our workforce, skills and wider services and have a model that supports us to prioritise care safely and equitably based on need and be more sustainable.
The key features of the modern general practice model
Minal noted that although many practices are doing some or all elements already, it’s about making each of the steps in the model more rigorous so that we can get the most benefit out of them, and knitting all of the elements together for biggest impact with the right support.”
Minal went on to describe modern general practice as a way of organising work that enables practices to: see all patient need, by providing inclusive, straightforward online and telephone access including the ability to self-serve where appropriate; understand all need through structured information gathering to understand what is being asked of the service; having a great care navigation model so that we have a more efficient way of getting patients to the right person, or the right service, in the right time frame, prioritise and allocate need safely and equitably (including continuity of care), and make best use of other primary care services and the multi-professional team; and improve the efficiency of processes and reduce duplication. Further enhancing these benefits through the use of high quality integrated digital tools, training for staff and iteration using our data. Alongside the changes, the aim is to build capability within the team to sustain and continually improve, which is critical to seeing the benefits. Some of the key benefits seen from practices are improvements in staff experience; releasing GP time to focus on more complex patients; giving staff more flexibility; improved patient satisfaction; and a more inclusive model of access.
She highlighted evidence looking at 10.5 million patient contacts across practices implementing modern general practice, demonstrating practices were tailoring care based on need, with patients at the extremes of age, with new presentations, more complex (continuity) needs or those unfamiliar to the practice prioritised and more likely to receive care face to face. Minal presented evidence that patient satisfaction had also improved, with patient satisfaction scores 6 percentage points higher than the national average.” Minal drew our attention to more statistics: “Where patients had a good experience of going online, they were much more likely to go online again. 72 percent of their contacts had channel shifted from telephone to online.” For practices implementing cloud-based telephony had also had a positive benefit, she noted, as “70 percent of staff found that it made it easier to manage their workload and 60% reporting complaints had reduced.”
A system wide approach to supporting general practice
“Really importantly, this model connects to a wider system plan,” Minal emphasised. “It connects to the ambitions of the long-term workforce plan, particularly around increasing the recruitment and retention of GPs and our wider workforce. It also expands the clinical role of community pharmacy. There’s been a large investment in community pharmacy, which will include management for low acuity but high-volume conditions such as earache, sore throat and sinusitis. Priority actions for ICBs to support improvements at the primary care-secondary care interface. It also includes a public communications campaign to explain the new model and to help take the public with us. This is coupled with funding and aligned incentives.”
Talking about investment in digital tools and processes, Minal noted the £90 million being invested in supporting practices to move from analogue to cloud-based telephony systems as well as £71 million being invested in improved online consultation, messaging and appointment booking tools. Minal explained “there is a real focus on having highly usable and accessible digital pathways for patients and having the right integrated functionality for staff.” She described the right digital tools can enable bigger and faster benefits, and also pointed to optimising the user interface within the NHS app along with improving practice websites “we know that about 60% of patients come to the practice website as a point of contact.” She said: “There will be a new digital framework that uplifts the usability of digital tools for patients and the functionality for practice staff” building on extensive user research she has been leading to develop a deep understanding of user needs particularly focusing on the least digitally confident users. She reiterated to get the benefits you have to have the process changes in place. The tools themselves are not the solution they are however an incredibly helpful enabler.
Minal went into more depth about the types of funding available to practices and PCNs to support them in making the changes to move to modern general practice, noting the significant challenge of time and headspace and funding available “to be used to support backfill including a more phased approach to modern general practice; for example, when practices need additional capacity to introduce different aspects of the model.”
Practical support for practices and PCNs
Minal reiterated the support available from the national general practice improvement programme to support practices and PCNs implement modern general practice and realise benefits quickly. The objectives of the programme are to help practices and PCNs to better align their capacity with demand, improve the working environment for staff, improve patient experience of access and build capability to sustain improvement. The programme is nationally funded and offers practical hands-on, data driven support to practices and PCNs tailored to their needs and starting point.
Concluding her session, Minal encouraged viewers and readers to visit the national General Practice Improvement Programme (GPIP) website to find out more and sign up for the available support.
Many thanks to Minal for taking the time to join us.