A chance to press the reset button in general practice

COVID-19 has changed the way GPs work and presents an opportunity to pull general practice out of the administrative nightmare many struggled with before the crisis unfolded, writes Leicestershire GP Mayur Lakhani
Location: UK
Published: Friday 22 May 2020
GP stressed

I am proud of the response of GPs to the COVID-19 pandemic.

GPs have risen to the occasion. They have, overnight, massively reorganised their practices, embraced video consultations, supported vulnerable patients, provided essential services, such as cancer injections and prescriptions, and played their part in helping hospitals.

As a working GP, I have noticed how different the demands are on the practice. Perhaps it is the calm before the storm but a surreal sense of control. For once, a focus on what is clinically relevant, the relative freedom of decision making, the absence of red tape, and hitherto unknown levels of support for GPs.

The incessant governance and regulatory requirements such as revalidation, the Care Quality Commission, multiple reports requested by an alphabet soup of agencies, all in abeyance, at least for now. How empowering this feels. Like a cloud has lifted.

I am reminded of WB Yeats’ immortal phrase in his poem Easter 1916: ‘All changed, changed utterly.’ Can we capture this spirit and continue in this vein?

For it is worth remembering what was happening in general practice only a few weeks ago.

The crisis, insidious in its nature, causing staff to break down in tears and forcing some GPs to retire early. The burgeoning bureaucracy that is changing the nature of general practice with no way of switching it off.

Forcing GPs to spend more time on administration than on direct patient care. Many doctors working late into the evening on their administration, or from home using remote working amid a climate of fear of complaints and regulatory action: features that capture the zeitgeist of modern-day general practice.

This is despite many efforts to deal precisely with this problem. For example, changes to the hospital contract to reduce dumping work on GP practices or new models of care or workflow management. Small differences have been noticed but no overall, game-changing effect.

Let us examine it in more detail. There are three sources of this stress: the electronic health record, GP reporting requirements, and transfers of work from other services.

First, the EHR (electronic health record): a hungry beast that requires constant feeding and takes doctors away from direct patient care. Even with training, they are often hard to use and ‘clunky’, counter-intuitive, and they make an already demanding professional life even more difficult. Multiple logins, passwords, lack of integration and slow connectivity all present a real barrier. Reminders and pop-ups feel oppressive and overwhelming.

Standards exist, but we are a long way away from their full implementation, especially across the whole NHS family. Multiple templates, sometimes conflicting with each other, issued by different authorities with overlap and duplication. Shared records are very welcome, but other services have different conventions for record-keeping. What is at stake here is the wellbeing of GPs: there is a strong link between the usability of EHRs and the odds of burnout.

Second, the reporting requirements of general practice, often requested through a never-ending series of emails, usually from anonymous, corporate – ‘no-reply’ sources. Countless examples exist: reports for NHS England, clinical commissioning groups, at-scale organisations, public health returns; Prescription Pricing Authority returns (FP34D); local quality scheme returns (‘QIPP’); payroll and pensions; Open Exeter returns, immunisation and vaccination; cytology; national alerts action; workforce declaration; Care Quality Commission annual return and phone review; annual contractual declaration; information governance sign off; controlled drugs declaration; data sharing agreements; bank holiday returns; clinical waste returns and claims; business rates claims; Quality and Outcomes Framework recalls; shared care bloods searches, poor quality of care reports and medicines management searches and risk stratification. Phew!

Many reports require complex searches, are time consuming, and need to be completed online through difficult-to-use PDF forms. Practices do not routinely have all the software and have to purchase it personally. There is much duplication, and uncertainty on how they are assessed, with rarely any feedback. Few are automated. This work is the bane of life for hard-pressed practice managers who cannot then focus on much-needed strategic thinking to support their GPs.

And the third issue is the relentless transfer of work from other services. For example, a recent hospital letter stated: ‘I am discharging this patient, but please organise an annual echocardiogram for the next five years.’ And when the results are abnormal, it is hard to get specialist support from those who themselves are under immense pressure. Dealing with such requests ­– often called ‘left shift’ – requires one extra weekly GP session in an average-sized practice. Transfers of work, therefore, represent a significant burden.

How does all this make GPs feel? A sense of hopelessness: the sight of jobs listed on their screens, even before the day has begun! They fill up rapidly as soon as they are actioned with a constant fear of missing an important message, which is often hard to distinguish from routine ones.

There are multiple documents from other services to look at, including important safeguarding alerts, and also rejection letters from other services declining referral because strict, often arbitrary criteria are not met: other services requesting referral to another pathway often in the same provider trust rather than doing this directly. The GP practice then becomes the go-to place in society.

I know people will say that it is a training issue and a matter of how a practice organises itself. But even with new ways of working, the mood is not getting better in any significant way.

Practices need transformational and tangible support to help the transition from their traditional role as an illness service to one of a corporate machine focused on population health management.

This is a massive organisational development ask. The programmes of support contained in the GP Five Year Forward View and the new GP contract for primary care networks are therefore very welcome.

The current systems do not serve patients, GP, or consultants well. Let me be clear: EHRs are essential. I cannot emphasise that enough. After all computerisation, electronic health records, and read codes are some of the most significant advances in medicine, led by GPs, who have the best clinical records. They are essential in modern-day clinical practice.

I love EHRs when they work well: the eureka moment. And a professional life without them is unthinkable now. But we must do better on this by improving the usability of the EHRs using industry-standard best practices like Google and Apple. I am a big fan of digital innovation, and the fourth industrial revolution, which I am sure, will change the future of medicine and may help deal with this very issue.

Data is essential: a crucial part of high performing practice. But we have to heed the advice of the respected Don Berwick, the former president of the Institute for Healthcare Improvement who warned against excessive measurement and advocated measuring only that which is essential. A high-trust approach is necessary.

The new review promised of GP bureaucracy by NHS England as part of the new GP contract is a significant opportunity to address this issue. I hope it has teeth and is radical.

The problem is complex: simple solutions and answers will usually be wrong. But change is possible. We need to do everything possible to make the day to day work of practices easier and meaningful.

It needs to involve GPs and practice managers leading change. This crisis is a brilliant opportunity to press the reset button: to herald an empowered, enthralling, and a resurgent medically directed NHS.

Mayur Lakhani CBE is a practising GP in Leicestershire and the Immediate Past President of the Royal College of GPs