Identifying and overcoming barriers for change in your GP Practice

When it comes to the burning questions of what’s keeping GP practice managers up at night, we turned to Becky Malby, Professor of Health Systems Innovation, London South Bank University. Becky discusses the perception of barriers to change within the NHS, and practical ways to identify the opportunity to overcome such hurdles. In this blog she’ll address three important areas of debate:

1. Understanding general practice
2. Communities
3. How do we organise clinical decision making

Becky specialises in systems innovation, co-production, leading networks, organisational change and leadership development in the UK and internationally.

An interview with Becky Malby, Health Systems Innovation, London South Bank University:

Often, when GP practices are asked what problems they face, there is a general set of views about what is going on. At the first stage, those views too often hamper the ability to change. These assumptions are generalised as such:

• There is too much demand out there; we can’t manage to meet it with our current resourcing
• That demand primarily consists of older people and chronic disease
• We are seeing everyone that wants to see us; however, it’s exhausting and doesn’t give staff headroom
• There’s nothing we can do about it; we’re working as fast as we can

If we operate solely on these assumptions we’ll never be able to get to the root cause; or identify what the catalysts are for change. The team at London South Bank University start by using data to find out what’s really going on in practices. They work with practices to identify if the assumptions are true or not and often uncover that there are additional assumptions that come into to play once they dig a bit deeper, which are also problematic.

For example:

1. There is a misconception that everyone in the Practice agrees on what constitutes a GP appointment; the reality is that there is massive variation
2. Overall, 40% of what comes into the GP consultation room isn’t GP work, and it’s best if professionals work to the top of their license; this can include social needs, referrals, reception questions, and others that do not require medical competence
3. Approximately 18% of people that call in or try to get an appointment on the day don't get anything (i.e. no phone answer, no appointments available, turned away); the Practice may have capacity that they don't realise (capacity available on the wrong day, or they don't use triage effectively)  

“There is too much demand out there; we can’t manage to meet it with our current resourcing”

To address the initial set of challenges, the focus needs to be centred around the front of house. Some Practices aren’t using data to understand how many appointments they are currently offering, and whether it's enough for their list size, and whether it’s on the days needed; often relying on random or historical data.

Here are some questions to ask:

• Who is turning up? (i.e. socio-demographics, purpose)
• How many do we turn away? Why?
• What day/time of day do we see the least/most?

By answering these questions you can see the pattern of your demand and therefore what skills you need in advance. As your population health doesn't change that dramatically in a year, this will allow you to do a rota for a year in advance to get the right staff in the right places, liberating significant amounts of time (and headroom).

“That demand primarily consists of older people and chronic disease”

It’s important to firstly understand why people are coming in multiple times a month. Many patients who come in multiple times a month don’t have multiple chronic diseases, and they aren’t necessarily elderly. Is it because of something going on clinically? Or could it have something to do with the ability to cope because of external factors (life issues, family issues, social needs, poverty)? Often patients seek out GP support with a need because no support network is offered elsewhere. How does your Practice deal with appointments outside of clinical needs and is there an opportunity to provide integrated care?

• Listen to the ‘need’ rather than the clinical ‘condition’
• Uncover if it’s something anybody else can help with
• Try and secure a multidisciplinary team review and care plan
• Turn to your community to identify opportunities to bring well being and not just health into the system

For example, Altogether Better work to help practices partner with communities, through local Community Health Champions who lead the community in improving the health and well being. They canvas the local population to ask for volunteers who can help with the health and well being of the local community. They typically find that 50-100 people from the local community volunteer to help those with non-clinical needs. These volunteers are regular people from the community collectively helping to make lives better.

It can take up to 10 months to implement, to the extent that it starts reducing demand by supporting isolated individuals to be well. This asset-based model alleviates the need for a GP to ‘socially prescribe’ services provided by other sectors, creating dependence on other sectors; rather it helps communities help themselves. Even people who are time-strapped can get involved. Volunteering is a fabulous way to build personal confidence, be effective and learn new skills so everyone benefits.

“We are seeing everyone that wants to see us; however it’s exhausting and doesn’t give staff headroom”

The elephant in the room is, what do we do about urgent care in general practice? Some clinicians are great at 5-minute appointments, others are great at 30-minute appointments. The reality is, some are better than others, and when you don’t play to people’s strengths and weaknesses the system falls over.

Do an audit of your current skill sets:

• What nature of work is required?
• Who’s best placed to do it?
• Do we need different resources? (i.e. paramedic, pharmacist, nurse, GP)
• What’s the right combination of resources (people and appointment models)

Once the population knows that they can ring on any day and their needs will be addressed, it takes pressure off of the whole practice as well as the population. The 8.30 am scramble to get to the phone subsides, and calls spread throughout the day.

“There’s nothing we can do about it; we’re working as fast as we can”

Before you get started, go into the project with an inquiry, not a solution. Use data to understand what your demand is, what capacity you’ve got, and how to facilitate it better. Liberate the masses! It’s important that this is a holistic project. Start collectively designing the project, and work as a whole practice. This will dramatically improve relationships as well.

Becky Malby, Professor of Health Systems Innovation, London South Bank University