A guide to safe working in general practice

GPs are faced with unmanageable workloads as well as a rapidly shrinking and exhausted workforce – here’s a guide on how to maintain staff wellbeing while preserving patient care

CREDIT: This is an edited version of an article that originally appeared on BMA

General practice is in crisis. The COVID-19 pandemic has generated a vast backlog of care. It is exerting increasing pressure on a system that is already at breaking point.

The contractual changes imposed by NHS England in April 2022 did nothing to recognise these pressures. The present crisis is so severe that it’s recommended that practices take urgent action to preserve patient care and protect the wellbeing of their staff.

Here are some steps to allow your practice to devote its resources to those patients it is best placed to help.

Appointments

Practices must provide enough appointments to meet the reasonable need of their patients. This must be done in a way that is safe for patients and GPs.

Remote consulting and triage are safe and effective ways of delivering care.

It is strongly recommended that practices take immediate measures to move to 15-minute appointments. This is permitted by the GMS contract. By extending appointments to 15 minutes, practices can reduce the need for repeated consultations with patients whilst still preserving quality of care and patient satisfaction.

Unsafe working contracts

The European Union of General Practitioners and BMA have recommended a safe level of patient contacts per day in order for a GP to deliver safe care at not more than 25 contacts per day. 

Present contacts per day by GPs in England are significantly in excess of this. “At Your Service” highlights that GPs are seeing on average 37 patients per day.  

It is strongly recommended to move away from a ‘duty doctor’ system with uncapped demand. Care co-ordinators and appropriately trained reception staff may safely direct patients towards suitable alternative services that work to protocol and are under good clinical governance. 

This is in addition to present triaging arrangements used by many practices. 

Waiting lists

General practices are advised to move to a waiting list system for appointments as demand currently greatly outstrips capacity.

They should have waiting lists that are based on clinical need. This is the approach that exists in secondary care, even if it means that patients with non-urgent problems may wait a number of weeks for an appointment. 

This only formalises the already existing informal waiting lists for patients that cannot get an appointment at a convenient time. This will allow GPs to focus their resources on those with the greatest need.

Patient participation groups (PPGs)

Practice PPGs are a crucial ally and resource for practices. It’s vital to consult PPGs and get their support for any changes that you are considering. GMS regulations allow practices to provide “services delivered in the manner determined by the contractor’s practice in discussion with the patient”. 

PPGs are an important means for communicating these changes and the reasons for them to the wider patient population.

Measurement of workload

NHSE (NHS England) measures GP workload based on appointment data. This gives an incomplete picture of GP activity and fails to reflect the huge number of non-appointment patient contacts.

We encourage all practices to account for patient contacts within their appointment books as a way of recording this workload. When accounting for workload, work performed in relation to repeat prescriptions and documents can be counted separately to direct patient contact.

By doing so, it is possible for practices to better measure and account for all patient contact. This includes even brief and informal types of contact like discussions with community teams regarding specific patients, calling patients about results, and home visits.

Accurate data allows practices to make informed decisions as to how best care for their patients. It also allows GPCE to discuss workload more effectively with NHSE.

‘Core’ general practice

It is crucial that GPs and practices devote their time and energy to providing services and care that are commissioned and resourced.

It is not always clear which services are included within ‘core GMS’ There is a risk that practices in different areas can interpret which services are included in different ways. 

This can result in some practices potentially providing services that are not separately commissioned and resourced.

Generally, if a service is commissioned locally in one area of the country, it cannot be part of core GMS anywhere in the country. 

If these services are not locally commissioned, then practices should decline to provide this unfunded and non-core work. It will be for the local ICS (Integrated Care System) to either then commission this within general practice or elsewhere within the system. 

 By defining what your core offering from general practice is, you’re able to provide the best possible care for your patients, and not be diverted into un-resourced work that should be provided elsewhere or commissioned separately.

Practice list closure

General practices should consider closing their practice list if they have reached the limit of their workforce’s capacity to provide safe care to patients.

There is a clear protocol for undertaking this action within the GMS contract and Regulations. Practices should initially consult with their patient participation group (PPG) and then with their Integrated Care Board (ICB).

Once closure is granted, assignments to the patient list can remain closed for up to 12 months.

In conclusion, your first duty is to your patients. You want to be able to provide safe, high-quality care to them, without risking others or yourself. At a time of unprecedented pressures, you must make changes to your systems to preserve patient care in the face of a shrinking workforce and rising workloads. All this must be done within the constraints of the present GMS contract.

The changes detailed here are not exhaustive but provide an example for practices. The BMA and LMCs are able to support and advise practices further on specific proposals.