Alleviating unprecedented pressures faced by the General Practice workforce: a conceptual framework based on the extent to which Wessex GPs think that patients presenting with one condition could have been seen and appropriately managed by another healthcare professional [HCP]

Abstract

1. Outline of the problem/context
The number of patients who are finding it difficult to make a GP appointment has increased due to a lack of sufficient resourcing for general practice (i.e. shortage in workforce: GPs and nurses, decreased funding and increased costs) in a context of rapidly growing demand, brought about by the rising demographics, especially, but not exclusively, ageing population with long-term and complex conditions (RCGP 2015; Goodwin et al, 2011; Rosen and Parker, 2013; Deloitte, 2014; Baird et al, 2016).

2. Assessment of problem and analysis of its cause/ literature review
Various solutions have been proposed to decrease the GP workload while also increasing the accessibility of primary care: promoting NHS Choice website (Nelson et al, 2010); improving health and self-management (Goodwin et al, 2011); collaboration between GP practices (Naylor et al, 2013); multi-specialty or multi-disciplinary new integrated models of care (Smith et al, 2013; NHS England 2015; Snow-Miller, 2015; Roland et al, 2015; Matheson, 2016b, 2016c); telephone consultations (Longman, 2012); emails (Atherton et al, 2012) and e-consultations (Adamson and Bachman, 2010; Madan 2014; Longman and Diggines, 2014).

NHS Choice website was deemed in need of more marketing (Nelson et al, 2010). Multi-specialty or multi-disciplinary new integrated models of care have proven to be successful (Langridge, 2015; NHS England 2015; Liles, 2016a, 2016b; Matheson, 2016b, 2016c). Improving health initiatives (Goodwin et al, 2011; HSIC, 2015) and collaboration between GP practices (Naylor et al, 2013) have been slower to show progress.

Although deemed convenient and useful, physicians have been slow to adopt secure patient messaging (Wallwiener et al, 2009). Limited evidence, variable results and shortcomings in data in relation to email has been such that it could not be adequately assessed (Atherton et al, 2012). Telephone-based consultation have shown conflicting evidence: from popular and successful (NHS England, 2015, p38) to ineffective and leading to increased workload (Campbell et al, 2014). Despite various claims (Adamson and Bachman 2010; Madan et al 2014; Longman and Diggines, 2015) of increased access for patient and decreased GP workload, evidence for online consultations has demonstrated a lack of significant benefit and low uptake (NHS England, 2015; Matheson, 2016d).

3. Strategy for change/aims and objectives
To try and identify ways of closing this gap between demand and supply by investigating, from the perspective of GPs, the extent to which HCPs could replace GPs re face-to-face consultations with patients who presented with one condition.

4. Measurement of improvement/methods/outcome measures
A survey questionnaire one side of A4 would be sent via a Wessex LMCs mailing to be completed discretely by hand by GPs ‘live’ during a consultation using 5-bar gate tallies to count the number patients presenting with one condition who could have been seen and appropriately managed by another Healthcare Professional [HCP] and to indicate which HCP (out of a choice of 4) could best do this with free text too for choice of HCP.

5. Effects of changes/results
A total of 212 questionnaires were received from a total of 23 practices spanning 9 Wessex CCGs that recorded 4,303 patient visits with 35% assessed as could have been seen and appropriately managed by another HCP: 18.5% could have been seen by an advanced nurse practitioner; 5.4% by an extended scope physiotherapist; 3.6% by a practice nurse; 3.1% by a MH nurse; 2.6% by a clinical pharmacist; and 1.7% by other HCPs or elsewhere. Of the 35% of consultations that could have been undertaken by an HCP: just over half (52.5%) could have been managed by advanced nurse practitioners; 15.5% by extended scope physiotherapists, 10.4% by practice nurses, 8.9% by MH nurses; 7.4% by clinical pharmacists and 5% by others/elsewhere.

6. Lessons learnt/discussion/strengths and limitations

6.1. Strengths
-First time that GPs have actually been asked to audit their practice ‘live’ to determine how many patients could have been seen and managed by another HCP and to identify which HCP could actually have done this
-The sample represented 13.7% of GP practices in West Hampshire and 15% of GP practices in North Hampshire.
-The survey enabled a dashboard to be built based on the results of the survey that can be populated by individual GP practices so visualise expanding the role of HCPs

6.2. Limitations
-No respondents from Portsmouth CCG and Isle of Wight CCG.
-The results entirely based on the conceptualisation by GPs of the ability of other HCPs to see patients presenting with one problem and to manage them appropriately for one
-Does not take into account patients presenting with more than one problem
-A very brief snapshot lacking in depth and does not take into account the interplay of complex factors.

7. Message for others/recommendations
-The project could be replicated on a larger scale and supplemented by focus group with GPs or an additional electronic survey.
-Involve patients and other HCPs in the design of interventions.

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