Case studies

Throughout the vision document we profile practices that are implementing or have implemented innovative responses to the challenges General Practice faces in 2019. Below we highlight those further and include additional examples of good practice. This list will expand as we move towards 2030.

Longer consultations - The Haxby Group

Haxby Group serves a population of 60,000 patients across York and Hull from 11 sites with approximately 30 GPs and 60 other primary care clinicians. The practice aims are to improve the experience of care, address the increasingly complex needs of its population and to have a focus on improving the experience of delivery of care – the latter has enabled GPs to provide longer consultations with 15 minutes as standard.

The redesign of the service began 2 years ago, from piloting in smaller sites to roll-out across the wider group and is ongoing. The practice identified which tasks could be safely handed over from GPs to members of the wider team. The multiprofessional team consists of advanced nurse practitioners, physiotherapists, physician associates and paramedics, and is supported and supervised by GPs who are available to discuss and review patients. Further support comes from the practice nurse and healthcare assistant team. Competency frameworks have been developed to support the development of these teams and to support their introduction into the practice.

Patient engagement was essential as this was implemented and progress was gauged by a quality improvement team looking a wide range of parameters including patient and staff experience with an analysis of the impact of the team on patient outcomes.

As the teams have become established GPs have been able to extend the length of routine consultations to 15 minutes. The changes have resulted in an improvement in staff morale
as workload has become more manageable. Patients have been happy to see members of the wider team, and GPs feel that they are better placed to address the complex needs of their patients. The result is a sense that the attractiveness and sustainability of a career in general practice is improving.

Continuity of care and remote consulting – Pier Health

Pier Health is one of five projects funded by the Health Foundation to test new approaches to increasing continuity of care. The group of practices in North Somerset is looking to use an online tool – 'Ask my GP' – alongside matching patients to GPs to improve continuity between the patient and their preferred clinician. The project also aims to reduce GP workload and improve the service and experience for GPs and patients.

Patients will access care through an online tool and are asked to describe their problem, what they would like done and how best to contact them. Non-GP problems can be quickly identified and resolved by the practice team. Of the rest, it is estimated that only one third of patients need to see their GP face-to-face, with a third managed by email and the remainder over the phone.

In participating practices, a patient-GP matching process is taking place to distribute patients fairly between GPs and ensure all patients have a named usual GP. The online tool highlights the usual GP and will enable higher levels of relational continuity to be delivered.

By reducing the overuse of face-to-face appointments, managing more patients by online messaging and phone, and maximising continuity of care, the team at Pier Health expect to reduce GP workload by 10–20%.

Smarter workload management – Harford Health Centre

The Quality Improvement Team at Harford Health Centre in Tower Hamlets noticed they were dealing with a very high volume of documents including unnecessary correspondence. The practice identified that this was due to a lack of formal process and workflow, variation in who dealt with the correspondence, and inconsistent standards of training. To address the problem, the practice undertook a quality improvement initiative that aimed to reduce the volume of correspondence handled by GPs by 50% over a six month period.

After collecting baseline data, the practice created a categorisation list to help administrative staff identify what type of letter should go to which clinician, implemented scanning protocols, provided training for the reception team, including teaching them how to code diagnoses and introduced new safety processes.

They met their target within three months and have now managed to reduce the amount of correspondence being routed to GPs by 70%. The practice plans to demonstrate cost savings in time spent by locums managing correspondence, as well as increased appointment capacity – meaning the initiative is better for patients as well as practice staff.

Deep End GP Pioneer Scheme – Glasgow

The Deep End GP Pioneer scheme was set up in 2016, with funding from the Scottish Government, to address longstanding workforce challenges in the most deprived urban areas.

The scheme aimed to recruit younger GPs and retain experienced GPs in six practices in Glasgow. Posts were designed to attract younger GPs, for example, by including protected time for personal development, and were advertised through various channels including social media.

The recruitment of six Deep End Fellows provided additional capacity to the host practices which, in turn, gave more experienced GPs protected time to focus on issues facing deprived communities, such as low take-up of cervical screening.

Now in its third year, the scheme has given the practices involved a significant lift, with reduced stress levels. GPs who had been considering early retirement reported a renewed enthusiasm for their work. Four of the first five fellows recruited to the scheme have taken up salaried or partner positions within the Deep End practices.

Social prescribing – Healthier Fleetwood

Fleetwood is a small town on the Lancashire coast with a population of around 30,000. Life expectancy rates are much lower than the England average and the prevalence rates for all long-term conditions are at least twice the national average.

Between 2014–2016, eight GPs retired or left the town and only three could be recruited. In response, practices decided to work in partnership with other health and care providers
and local residents, and the Fleetwood Primary Care Home was created. As well as managing illness – both acute and long-term – there has also been a focus on wellness and resident empowerment through the ‘Healthier Fleetwood’ movement, which has seen a wide variety of activities and social groups set up by residents.

Healthier Fleetwood aims to improve and maintain the mental and physical health of local people, boosting their confidence by encouraging them to take control of their own health and wellbeing, instead of relying on professionals to manage it for them. This is done by connecting residents to the many activities on offer as part of the social prescribing path now being developed in the town. These include arts and crafts, fitness and sports, friendship groups and much more with activities run by partner organisations or often the residents themselves.

Healthier Fleetwood provides practical support and advice in areas such as funding, promotion and administration without taking the lead, so the groups develop naturally and become sustainable for the long-term benefit of the community.

Integrated Care - Health 1000

The Health 1000 pilot aimed to show that a co-located multidisciplinary team, with GPs in the driving seat, could have a significant, positive impact on patient outcomes. The three-year project was targeted at patients from across Barking and Dagenham, Havering and Redbridge, with five or more long-term conditions and complex needs.

A team of healthcare professionals including GPs, a consultant geriatrician, physiotherapists,occupational therapists, social workers and pharmacists, worked together in a health and social care practice based at King George Hospital.

The team delivered integrated, personalised care seven days a week to over 700 patients, each of whom had a named personal care co-ordinator. Care plans were co-created with patients, helping them to manage their health, stay out of hospital and maintain their independence for as long as possible. Clinicians also worked with Age UK to develop wellbeing services, and with local care homes to support and train staff.

The pilot was shown to have had a positive impact on the working experience of staff as well as reducing emergency admissions and the number of bed days. There were also reductions in A&E attendance.

Micro-teams and continuity of care – One Care

In 2018, the Health Foundation launched a programme to test innovative ways of increasing continuity of care in general practice. Two of the five projects are being supported in their delivery by One Care, a GP Federation in Bristol, North Somerset and South Gloucestershire.

One Care aims to strengthen continuity of care in a general practice environment, characterised by an increase in part-time and portfolio working, and at scale delivery. The programme helps practices to identify their most vulnerable patients. It upskills receptionists and other administration staff who, as the first point of contact with patients, are integral to ensuring relational continuity.

Micro-teams will be established, comprising clinicians (GPs, ANPs, nurses, healthcare assistants and clinical pharmacists), receptionists and administrative staff. Patients will be made aware of who is ultimately responsible for their care, even if they do not see their named GP at every appointment.

GP-led teams - Ty Doctor, North Wales

Several retirements left Dr Arfon Williams the ‘last partner standing’ in his practice in Nefyn, North Wales. Rather than close the practice and further reduce access to healthcare in the area, the team made radical changes to the skill mix in the practice, optimising workloads, triaging and signposting all phone calls and upskilling every member of staff.

Extra training was provided to all staff, arrangements for cross cover were made and an advanced nurse practitioner (ANP) was employed. Locating the practitioners in adjacent rooms allows the ANP to ask for advice when needed. Receptionists received additional training, enabling them to confidently direct patients to the appropriate member of the wider practice team, which included, amongst others, a physiotherapist, an audiologist and a social worker.

In addition to this, the practice offers onward referrals, for example to a minor injury unit or local pharmacist. Access to the wider practice team was ensured through the practice’s enrolment in relevant pilot schemes run by the health board.

Regular communication was provided to patients, who have received the changes positively and are satisfied that they can be seen by a suitably qualified clinician in a prompt manner through pre-booked or on-the-day appointments. Staff morale has improved, patients have enjoyed improved access and, on average, the GPs and ANP have 14% spare capacity.

Online access – Blithehale health centre

Increased demand from patients had increased the reception’s workload to the point that it was unsustainable. The practice launched a project to increase patient use of online services by 50% over a six month period, with the ultimate aim of reducing the number of telephone calls and lowering staff stress levels.

Through promotion of its online services, the practice encouraged patients to take responsibility for booking and cancelling appointments and ordering scripts. They advertised these services within the practice, developed a new patient information leaflet and promoted e-consult services and access to online records. All staff – including clinicians – got involved to bring about the culture shift, talking to patients about online access and encouraging them to register.

This activity resulted in a 38% increase in active online users, an increase a 20% increase in the use of the electronic prescription service, and an overall saving of 13 appointments per week.

Locum pooling at scale - Newry and District Federation of Family Practices

Newry and District (N&D) Federation of Family Practices in Northern Ireland is comprised of 31 practices and serves 150,000 patients. Some practices have had exceptional difficulty obtaining locum cover, as a result of which GPs were unable to take holidays for over two years.

The Federation obtained pump prime funding to establish a new locum pool. Locum posts were funded for two sessions a week, including maternity pay, sick pay and superannuation. Practices now pay for the service and this money is reinvested back into the Federation.

Initially, 10 GPs were recruited providing 15 days’ cover in total. Although the Federation was aiming to recruit GPs who had just completed their specialty training, the pool now has a diverse mix of experienced GPs and new recruits. The scheme has worked well to date but, understandably, meeting demand from practices has been challenging. The locums have some choice over which the practice they work in, but they also understand that, where possible, services must be shared equitably.

There have been unexpected benefits of this initiative. One newly qualified GP now represents her area on the Local Medical Committee (LMC) and two of the experienced GPs, who had been considering leaving general practice altogether, have, as a result of the scheme, taken up permanent posts. The locum pool model has also been replicated in the establishment of a central Practice Improvement and Crisis Response Team, which provides specialist support, advice and locum cover to struggling practices.

Use of data to improve population health – Newham LTBI screening

Newham CCG in East London had the highest tuberculosis (TB) rate in England. In 2014, they worked with GP practices to launch an innovative programme to raise awareness of latent TB infection (LTBI) among the local community, and to screen and treat patients in primary instead of secondary care.

The programme targets people aged 16–35 from high-risk countries who have been in the UK for under five years. When they register with a GP, they are offered a blood test to check for LTBI. If they test positive, they are given a chest X-ray, blood tests and a three-month course of treatment, mainly provided through local pharmacies.

The approach is part of a three-year trial designed to identify whether a primary care model for LTBI screening and treatment is more effective than secondary care. Since 2014 over 10,000 patients have been screened and over 400 people treated for LTBI in primary care. Newham now has one of the fastest reducing rates of TB in the country – dropping from 77 per 100,000 to 48 per 100,000 in 2017/18.

Next: Realising the vision >

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