This guidance is intended to support reflection rather than be directive. Its purpose is not to create additional processes or reporting requirements, but to help practices develop a more realistic understanding of how work is currently organised and support practices in moving to models that are more sustainable.

For some practices, the guidance may simply validate arrangements that are already working well. For the majority, however, it should prompt discussion about hidden workload, role distribution, partnership expectations or areas where current ways of working depend too heavily on goodwill.

Useful questions may include:

• Which parts of our work are visible and which remain largely unseen?
• Where are we relying on unrecognised effort to keep the practice functioning?
• Is our current distribution of work fair and sustainable?
• Are leadership, supervision and improvement activities adequately recognised?
• Do our working patterns provide sufficient time for safe patient care and professional development?
• Which aspects of our model are strengthening sustainability and which may be undermining it?

The aim is not to create anxiety or bureaucracy, but to support more open conversations about what modern general practice requires and how that work can be organised sustainably.

Understanding your current working pattern

Before deciding what needs to change, practices may find it helpful to understand how work is currently being undertaken.

In many practices, the visible timetable tells only part of the story. Appointment books may be clear and measurable, while supervision, leadership, problem-solving, workflow management and follow-up activity occur in less visible ways. Much of the work that sustains safe care will therefore be absent from formal schedules despite occupying significant time and attention.

A useful first step may be a short period of structured reflection or time mapping. This need not be complex. Practices might simply review a typical week and consider:

• How much time is spent in direct patient care?
• How much time is spent on indirect clinical work?
• Which activities regularly occur outside scheduled sessions?
• Where are interruptions most common?
• Which responsibilities are concentrated on a small number of individuals?
• Which tasks have no clearly identified owner?

The BMA’s GP Diary app which is available to BMA members is a straightforward way to carry out this time mapping. Even a relatively simple exercise can reveal hidden workload, duplicated effort, recurrent bottlenecks and responsibilities that have gradually become normalised without ever being formally acknowledged.

Practices may also find it helpful to consider who carries the cognitive load of the organisation. Every practice contains individuals who monitor risk, notice emerging problems, remember unfinished tasks and ensure that issues are followed through when ownership is unclear. These functions are often essential to safety and continuity but rarely appear in formal job plans or timetables.

Understanding the current reality is not an end in itself. It provides a foundation for deciding what changes are needed and where effort is most likely to deliver benefit.

Making change in a manageable way

Recognising the need for change is often easier than implementing it.

Most practices must continue delivering care while adapting to pressure, which means large-scale redesign can feel difficult or risky. For that reason, sustainable change is often most successful when approached incrementally.

Rather than attempting wholesale transformation, practices may benefit from testing small changes, learning from experience and gradually refining their approach. This allows changes to be adapted to local circumstances and reduces the risk of unintended consequences.

Sustainable models rarely emerge fully formed. More often they develop through a series of small adjustments that gradually improve how work is organised and supported.

TURAS provide practical tools to support quality improvement that practice may find useful.

Using small tests of change

One practical approach is to use simple improvement methods such as Plan-Do-Study-Act (PDSA) cycles.

In its simplest form, this involves:

• Identifying a specific problem or pressure point.
• Agreeing a small change to test.
• Predicting what effect the change is expected to have.
• Testing the change for a defined period.
• Reviewing the outcome.
• Whether to adopt, adapt or abandon the change.

The value of this approach is that it allows practices to learn from real-world experience within their own setting rather than committing immediately to large-scale change.

Suitable areas for testing may include:

• Protecting dedicated time for indirect clinical work.
• Clarifying supervision arrangements.
• Making leadership or management time more visible.
• Creating document-management or workflow sessions.
• Redesigning meeting structures.
• Reviewing allocation of incoming correspondence.
• Improving ownership of recurring tasks.
• Reducing interruptions to managerial or supervisory work.

The objective is not to identify a universally correct solution. Different practices will require different approaches. What matters is creating space to test ideas safely and evaluate whether they improve sustainability.

Reviewing change

When reviewing a test of change, practices may wish to consider both quantitative and qualitative measures.

Possible quantitative measures include:

• Appointment availability.
• Workflow backlogs.
• Results-processing times.
• Session overruns.
• Continuity measures.
• Time worked beyond planned sessions.

Equally important are qualitative indicators such as:

• Whether clinicians feel less rushed.
• Whether supervision feels more manageable.
• Whether workload is perceived as equal.
• Whether staff wellbeing has improved.
• Whether professional satisfaction has changed.

Practices may also wish to consider balancing measures to ensure improvements in one area do not create problems elsewhere. For example, a change that increases capacity may inadvertently reduce continuity, while a reduction in administrative burden for one group may transfer pressure to another.

Sustainable models depend on professional judgement as well as metrics. The experiences of staff and patients remain important sources of evidence.

Embedding change over time

When a change proves beneficial, the next challenge is ensuring that it becomes part of routine practice rather than an informal exception.

Successful changes are more likely to endure when they are visible, understood and explicitly supported by the wider team. This will often involve adjusting rotas, clarifying responsibilities, documenting agreed arrangements or reviewing partnership expectations.

Without this step, improvements can gradually erode as pressures increase and old patterns re-emerge.

Practices may also benefit from sharing learning through clusters, Local Medical Committees and professional networks. Hearing how others have approached similar challenges can provide reassurance, generate ideas and reduce the sense that individual practices must solve sustainability challenges alone.

Meaningful cultural change rarely occurs through a single intervention. More often it develops through a series of deliberate, incremental improvements that gradually create safer, fairer and more sustainable ways of working.