Quality First: Managing Workload to Deliver Safe Patient Care

Safe working in general practice

The following extracts and link are taken directly from the BMA webpage :

“General practice is in crisis, with increasing patient need and demand, coupled with a shrinking and exhausted workforce.”

“Action must be taken by practices and GPs in order to preserve safe care for patients, and to protect the health and wellbeing of the existing general practice workforce.”

“Fewer GPs providing care for more patients increases the risk of harm and suboptimal care through decision fatigue, as well as risking harm to the GP through burnout, and psychological injury.”

“As a result of these challenges, the BMA’s England GP committee (GPCE) has generated the following guide to enable practices to prioritise safe patient care, within the present bounds of the GMS contract.”

Key Chapters:

• Appointments
• Patient Participation Groups
• Measurement of Workload
• External un-resourced workload
• Practice list closure
• Workload Prioritisation
• PCN DES

The BMA advise that "the changes detailed on their webpage are not exhaustive but provide an example for practices. The BMA and LMCs are able to support and advise practices further on specific proposals.”

The BMA have also produced guidance on Safe working in general practice (bma.org.uk) and the wellbeing of your workforce, which outlines safe limits on the number of patient contacts per day, and what are considered ‘essential services’ under the GMS contract so that you can plan how you run your practice. This includes a template letter to PPGs (patient participation groups) to explain the rationale for moving to a safer model of delivery. There are a number of other templates for practices to use or adapt where they have been passed un-resourced, non-contractual work from other providers. BMA - Pushing back on inappropriate workload

GP workload management and triage toolkit

As there is currently no standardised triage system for GP practices, to help with the increasing workload, the BMA have developed a tool to support practices with implementing a triage system if they wish to do so.

The toolkit aims to provide a cost neutral aid to reduce the administrative burden on staff members, ensure patients are seen by the right clinician at the right time and allow GPs to spend their time where it is needed the most. This toolkit will not apply to all practices, but the BMA have provided a number of case studies, along with examples of how you can tailor the system to your practice.

Regulation update 2023 - Access

It is also worth noting that there is an update to the GMS Regulations this year (2023) around access. The NHSE letter says that it "will make clear that patients should be offered an assessment of need, or signposted to an appropriate service, at first contact with the practice. Practices will therefore no longer be able to request that patients contact the practice at a later time”. The BMA/GPC England say that whilst they agree with the aspiration of this amended regulation, it believes that this requirement is not achievable for many practices with current resource and workforce.

We would strongly recommend that you look at this requirement in more detail on the BMA webpage - GP Access and meeting the reasonable needs of patients. It highlights what the regulations will now say and also how this may affect safe working guidance. 

Please consider these Wessex LMCs suggested actions

• Circulate the safe working in General Practice document to all you staff
• Discuss it amongst team members
• Put it on the agenda for your main Practice Meeting over the coming week or two and consider if you wish to take any of the actions suggested
• Discuss it amongst neighbouring practices / PCNs
• If you are not implementing the suggestions now, what action will you take in the future if things deteriorate and how will you know when to do this?
• Make sure your practice submits a GPAS return every week so that we can described the pressures in General Practice to our Integrated Care Systems

Wessex LMCs Engagement

We have engaged with the BMA to explain that some of the safe working in General Practice recommendations can be difficult to implement in a system where it feels like GP is the only service that has unlimited access. We all agree that we must to something to make the workplace safe and sustainable.

Our contract states that we must meet the ‘reasonable needs’ of our patients. This is a very open-ended statement. We also have a responsibility to our staff, patients, and ourselves to work safely within our competence as per GMC guidance.

It’s for each practice to decide what is a reasonable number of appointments to safely offer, at which point all but the most urgent cases may have to be asked to wait for an appointment if they are able to (just like they do in secondary care) or be directed to seek advice or support from another service such as 111, NHS website, Wessex Healthier Together website, local pharmacy, MIU or A&E where appropriate. We would have to inform patients that we are effectively on an emergency footing because of unprecedented demand. There will always be those truly urgent cases that need seeing as an extra. The difficulty is that it puts additional pressure on our reception staff to police the access.

It may be that at times of high demand we have to sacrifice routine appointments to meet on the day demand. The risk with this is that our contract will penalise us if we don’t meet QOF targets etc. This is one of the reasons why we are pushing for target-based contracting to be excluded or dramatically and pragmatically reduced in any new contract. We are also asking the ICBs to urgently look at protecting QOF and LES income this year to allow us to focus on the current unprecedented urgent demand.

If you are required to adopt an emergency footing, we would suggest you inform the ICB and your patient participation group.

We can assure you that we are having discussions nationally and locally with commissioners on how we can better manage demand and implement safe working but currently there isn’t a simple one size fits all solution.

Safe Working in General Practice Podcast

Dr Richard Van Mellaerts, London based GP and British Medical Association Deputy Chair of the GP Committee (England) speaks to Dr Edd Rendell, Medical Director of Wessex LMCs about the BMA guidance on Safe Working in General Practice.

They discuss why a practice might implement some of the suggestions within this document and practical advice on how this could be achieved.

Safe working in general practice (bma.org.uk)

Listen to the podcast here