Major challenges in general practice include insufficient core practice funding, increasing demand, and inadequate resources to cover staff salaries and workload. These issues create significant pressure on practices and impact staff retention and recruitment.

The average number of patients per GP has increased from 1,800 in 1965 to 2,300 currently, despite the growing complexity of healthcare needs. We have also seen the loss over 1300 practices since 2015. 

Practices are seeing increasing workload transfer from secondary care, adding additional pressure on already stretched resources.

This should be led by the needs of the patients and practice, acknowledging that different areas (e.g., urban vs. rural) have different requirements. The focus should be on sustainable, realistic and deliverable systems within the finite resource available rather than arbitrary targets that don’t take local contexts into account.

Yes, our survey data shows a high potential for attrition among practice managers and clinicians, with a significant percentage planning to leave within the next few years. This indicates a serious issue in retaining skilled personnel.

The BMA offers a workload control toolkit, updated safe working guidance, template letters for communicating with patients, and videos to help implement these practices.

These are crucial for preventing burnout and fatigue among healthcare workers, ensuring a sense of control and well-being within the workforce. They also help with planning, monitoring and adjustments as and when required to help with demand.

Practices can re-organise services, engage in collective action, and as well as looking at practice list closures. We advise engaging with their local LMC for support and advice.

We used RAG-rated action plans to prioritise tasks, focusing first on team well-being. Daily debriefs helped adjust strategies as needed.

NHS Lothian’s excellent Primary Care Workload Control toolkit outlines an approach which involves mapping out workload over a few days, including various types of queries and interactions, to understand and manage workload better. This helps in designing, monitoring and refining processes, helping to understand the impact of any changes.

We are advising that it is 25 consultations per day. Interactions that would require speaking or engaging with a patient, for example face-to-face or by telephone etc. Administrative, medication and urgent queries need to be built into clinics, so that the time spent on direct and indirect patient care is properly accounted for. Significant tasks like reviewing complex investigations and medical record reviews require proper acknowledgment and time. The duty on-call role should have time to focus on true emergencies and queries, to help support safe working.

Practices should map out patient contacts and work backwards from their capacity. Use triaging and all available resources to manage patient flow effectively. Adjust the approach based on practice capacity and patient needs to ensure high-quality care.

The transition can gradual. Practices should make incremental adjustments, like slightly reducing appointments at a time, and consider strategies to make daily work easier. These changes will all be unique and individual the practice and population. It will be a journey, not a destination, and can vary with changing needs and context.

We must emphasise that safe working is essential for patient safety and quality care, which ultimately reduces system demand. The recommendations in the safe working guidance are all permissible within the terms of your GMS/PMS contract. If you have any concerns, please contact your LMC for support and advice. Engage with your PPG, community, health groups early and local politicians to explain and support the changes early on.

Practices should consider extending appointment times where necessary, incorporating and accounting for administrative time, and utilising triage systems. Regular workload assessments and prioritisation (using methods like RAG ratings) can also help.

Historically, DNAs have been used as a catch-up mechanism by many clinicians due to high pressures in clinic. With safe working guidance, there will be time to manage patient appointments better, tailoring it to the needs of the patient and clinician. Strategies include sending reminders via text, phone calls, or appointment cards. Offering self-booking options and adjusting clinic schedules to meet patient needs can also reduce DNAs. Ensuring flexibility and reminding patients of the importance of their appointments can help manage this issue effectively.

We share DNA statistics with patients, including the associated costs, in our newsletters and waiting area. This transparency helps patients understand the impact of missed appointments and encourages better attendance.

Offering longer appointments which allow for opportunistic holistic health interventions, to allow more than one issue per visit helps to reduce the need for repeat appointments at the practice and is also more convenient for the patients.

Through patient communication, and explanation around alternative appropriate services. Having signposting and triage available through clinical and non-clinical roles helps support this. 

Focus on safety netting and clear communication with patients. Ensure that you utilise all resources to manage capacity and prioritise patients based on urgency and clinical needs. Implement systems that allow for flexibility and timely updates to manage waiting lists effectively. Remember that there are a variety of alternative services that patients can also access and be signposted to.

Implementing a waiting list should be based on clinical prioritisation. Triage patients into categories: urgent, those that can wait a bit longer, and routine cases. Ensure that you communicate with patients about their status and provide safety netting instructions if their condition changes. Utilise all available resources and services to manage capacity effectively.

General practice is not an emergency service and should not be used as such. Anything within an hour is considered an emergency and so should be directed to A&E for assessment. It is important to direct patients to the right service and manage their expectations.  In situations where cases have been signposted to the practice, by other providers for example NHS 111 toward the end of the day, out with of clinical capacity and opening hours, these should be redirected to appropriate alternative services.

Use triaging to categorise patients based on clinical need, urgency and available capacity. Ensure that patients are informed about their status and provide instructions for seeking immediate help if their condition worsens. The triaging and signposting approach should be adapted to the practice's setup and resources. For example, digital literacy and poverty, language barriers, reasonable adjustments etc.

We transitioned from having receptionists handle triage to establishing a Care Navigation Hub staffed by Advanced Nurse Practitioners (ANPs). This change improved patient experience by reducing wait times and provided training opportunities for care navigators.

Our reception teams oversee all types of patient inquiries, including online, telephone, and face-to-face interactions. They are trained to manage these inquiries effectively throughout the day, ensuring that patients receive appropriate assistance and support.

Addressing social determinants of health is key, as they significantly impact health outcomes. Solutions need a holistic approach, including national systems and preventive measures. Comprehensive, system-wide strategies are necessary for effective demand management in helping to address primary and secondary prevention in addition to the social well-being of patients and communities.

Continuity of care is supported by safe working guidance, as it allows for longer appointments, which can address multiple issues in one visit. This reduces the need for frequent return visits. Safe working guidance also supports signposting to appropriate services for non-clinical issues. While broader prevention measures are wider and include the social determinants of health, our safe working guidance helps manage patient load more effectively.

While access is important, continuity of care has significant benefits, including reducing demand. Access improvements should stem from positive structures rather than punitive measures. Continuity of care supports better patient outcomes and experience, yielding system wide benefits.