At HTN Now Digital Primary Care, we focused on the topic of sustainability in the healthcare industry and the role technology can and will play in transforming general practice. We were joined by Dr Minal Bakhai, Director for Primary Care Transformation at NHS England and GP. Minal discussed how we can lever change differently and the ways in which technology can enhance the experience for patients and staff to create an innovative, sustainable system of care.
Minal began by establishing the “large scale adaptive change” that is needed in order to make a successful digital transformation of general practice and the healthcare system at large.
She said: “Primary care has traditionally relied on contracts and small pots of funding to incentivise change, and while that may lead to compliance, it does not lead to commitment. With ICSs we have an exciting opportunity to drive effective change, but we need to give local leaders space and time to lead, enable those closest to the problems to innovate and own the change. It needs consistent policy and priorities – they can’t keep changing. Of course, that needs to be supported by finance regulation and support.”
In order to make this successful and sustainable, a systematic approach is required along. Lessons must be learned from the existing evidence and investment must be made in the critical enablers of change, which Minal listed as: data, improvement capability, leadership, culture and peer-to-peer learning. By moving away from small funding pots or non-recurrent funding, she explained how systems will be able to plan, recruit and act more efficiently than before.
Statistics and challenges
Minal provided some statistics to highlight some of the challenges facing primary care.
“The challenges are multi-dimensional and our response also needs to be multi-dimensional,” she said.
“Demand for general practice has increased over the pandemic period; there has been a 15 percent increase in the volume of clinical consultations. This doesn’t include all of the administrative work that my colleagues and I also do in practice.”
She noted that there is a correlation between the highest rates of need and areas of increasing deprivation, which has been further exacerbated by the impact of COVID. However we are seeing in the data that the ability for capacity to keep pace with this increasing rate of demand is particularly more difficult for those practices working in the most deprived areas.
“Putting all of this together suggests that general practice, particularly in deprived areas, can’t stretch anymore. This is a significant risk to its sustainability,” said Minal.
Next Minal looked at the workforce challenge. She shared that the number of GP partners has gone down by 30 percent and over the last nine years approximately a quarter of general practices have closed, with the biggest impact landing on the most deprived areas.
“On average, practices in the most deprived areas manage over a thousand more patients per GP partner than those in more affluent areas,” she said, and added that modelling by The Health Foundation suggests that if nothing is done about this, we can expect to see one in four GP posts vacant in 10 years’ time.
“It isn’t therefore surprising that there has been a fall in patient satisfaction with access,” Minal noted. “But I think it’s really important to recognise that whilst the experience of contact and accessing general practice has fallen, the experience of the quality of care provided remains really high. I think that’s a real testament to the hard work of my colleagues.
On digital journeys, Minal said: “We know that online journeys, at the moment, are often confusing, hard to navigate, and leave patients hanging. We know that access or contact can be constricted. There’s also variable experience because there’s limited consistency in what patients can expect.”
The model of general practice has changed, Minal noted, with a move towards working as part of a much wider multi-disciplinary team. “We need to help build patient trust with the wider clinical workforce, beyond GPs,” she acknowledged.
When it comes to choice, she said, it is not always clear to patients about when they have choice (for example, the method through which they access the practice), and when clinical decision-making is taking into account their preferences but is ultimately based on an assessment of clinical needs.
Finally, Minal came to communication. “This is often the crux of things,” she said. “The new model of general practice is complex and it has not really been explained to the public. It is not well-understood by patients. This requires national and local communication and engagement.”
Modernising general practice
“We know that we need to change,” said Minal. “We’re moving towards a more modern general practice – but what does this look like?”
Minal shared the core components of the new model:
- Long-term condition management and proactive care as part of population health management
- Encouraging ‘self-referral’ and self-service for admin tasks to reduce admin burden
- ‘Back office’ automation to reduce admin burden
- Expansion of non-GP services, supported by digital integration
- Use of hubs to provide additional capacity, longer hours or out-of-hospital specialties to a local area
- Use of multi-disciplinary teams and Additional Roles (ARRS) to increase capacity
- Remote and flexible working for clinicians to increase capacity and retention
- Enhanced triage and navigation to route patients to the right place first time
- Choice of patient contact routes and consultation modality: online, phone and face-to-face
Changing general practice
Next, Minal shared some of her experiences as a GP.
“Pre-pandemic, we were at a sustained crisis point,” she said. “Staff were burnt out, we knew we had to radically change the way that we worked. We decided to completely redesign our access and workflow system.”
It was challenging , Minal noted, change isn’t easy, it takes time and can feel very uncertain when you’re doing it, However, it was worth it – our system is more equitable, we can prioritise care and use our workforce more effectively based on a better understanding of needs, appointment waits have gone down and continuity has gone up – we wouldn’t go back and now as a team we find it much easier to make changes.
A key learning for Minal was that the changes were “led by the whole team,” she said. “It was both clinically and administratively led. We involved patients in making changes. We used simple PDSA improvement methodology and we used data and feedback to support the change.”
Another learning was the importance of effective leadership and its role in influencing and motivating. “We had a really clear shared purpose of why we were doing it,” Minal added. “We have a positive team culture and the psychological safety to feedback honestly about what was working and what was not.”
They relied on a systematic approach to quality improvement, she said, building their own learning system using data and evidence which they sought proactively from staff and patients alike. This meant they “meaningfully involved the whole team and patients in the service development process.”
Supporting general practice
It is important that we make the transformation of general practice easier, Minal said.
She shared NHS England’s ambition to embed continuous service improvement, working with and enabling ICBs to lead and deliver primary care transformation.
“We want to help ICSs understand practices’ support needs. We’ve developed a framework which we are currently testing with practices, PCNs and systems, and we use it with the practices that we support nationally. It helps us understand where practices are in terms of transformation maturity and how that translates into the type and intensity of support that they need. It also helps to build a shared understanding between the system and general practice, which I think is really important; a lot of this is based on relationships.”
Based on an understanding of support needs and data, Minal continued, ICSs can provide a much more tailored support offer that better matches the practice needs. “There is no one size fits all approach; we need to understand where to focus support efforts and in what sequence.”
Part of this includes working to make data ‘easier’, which Minal acknowledged always tends to be a challenge. She highlighted the importance of “making near real time operational data easier to visualise at a practice level” and added: “to make use of the data to make change happen we need to support and build improvement capability, capacity and leadership.”
Minal highlighted the accredited National Quality Improvement capability building programmes which are open to all general practices and PCNs. The programmes are designed at different levels to suit different abilities and needs and consist of interactive webinars, drop-in sessions, in person and virtual QI training and leadership programmes and a national community of practice.
In addition, a training programme designed specifically for ARRS digital and transformation lead roles is in development, to help them in supporting PCNs in this space.
Working with ICSs is one of the main facilitators of change, Minal explained. “We need to invest in people and culture. We’re working with ICSs to facilitate a stronger, more coherent voice of primary care, but also to further that culture of collaborative improvement and tackling cross system issues that impact on primary care.
“Finally, we need to make sure improvement is sustainable through working with ICSs to address barriers external to support teams, rationalise the asks to practices and align incentives and priorities, embed a learning system and set up local improvement peer-to-peer communities.”
Benefits of the Accelerate Programme
Minal focused next on the Accelerate Programme, which provides centrally funded, intensive, hands-on structured improvement support, and is currently working with 750 ICS nominated practices.
“We have developed a core model of practice learning and improvement which we’ve iterated and tested and evaluated,” she said. “We do a data driven diagnostic and help them fully understand the problems they’re facing and come up with an action plan. The aim is to help those closest to the challenges innovate and own the change. Then we help them implement that action plan using improvement methodology. We encourage them to share that learning with their peers.”
Some of the key benefits of the programme are outlined below:
- Prioritises support to areas with greatest sustainability challenge, high deprivation and capacity pressures
- Focuses on managing demand, improving access, development team and job satisfaction
- Creates headspace, capability and a culture for staff to innovate and take action
- Delivered in partnership with ICSs to address external barriers and share learning
- Codification of the most effective interventions and quick wins
- 88 percent practices see a productivity gain, releasing and redirecting staff time
- 99 percent of staff say they are better equipped to deal with their work changes
- Helps to build a shared understanding of needs between general practice and ICSs
The core model of support and practice improvement, Minal explained, should be credible; structured but flexible; supportive; locally delivered and nationally enabled; sustainable; evidence based; data driven; and support tapered, reflecting capability of ICSs over the next few years to lead and coordinate improvement as they mature.
Communications pilot and outcomes
Minal moved on to describe how a communications pilot was rolled out in Humber Coast and Vale using the core model described above. The pilot aimed to support practices in raising awareness and understanding of the three ways patients can request care from their practice: online, over the phone and in person.
“The key findings show that there is healthy appetite from patients when it comes to using digital routes,” Minal shared. “53 percent of patients that were surveyed indicated that they were very open to using an online consultation system, yet only 14 percent were aware that online consultation systems existed. This showed that we need to build awareness of these contact routes, but also to build patient confidence.”
Following exposure to awareness-raising materials, 64 percent of patients reported that they felt confident their practice would ‘respond appropriately’ once online consultation requests were explained.
The General Practice Inclusive Access Route evaluation in January 2023 also found that practice managers liked the ‘practical’ and ‘easy to use’ materials used in the project.
Once the whole practice team understood how to support online consultation requests, Minal said, this enabled a change in the conversation with patients and made it ‘easier to build confidence’ on both sides. The team also found that practices with less experience of digital tools would benefit from linking up with more experience practices, allowing their knowledge to be shared quickly.
User research highlighted a gap between the keywords patients search for when navigating digital journeys and the language currently used. Minal explained that a “common approach to language across digital tools in the NHS would help increase the usability of products and to support this the learning has been incorporated into the NHS design guide alongside work with suppliers.”
Intentions going forward
Concluding her session, Minal discussed what a good product and digital experience looks like for patients and staff. She described some clear principles including focusing on the most important services for patients and completing the end to end back-office journey for staff, key products and features being available to all patients using a device and channel that suits them.
She noted that transforming general practice is a continuous process and will require a systematic and ongoing approach to supporting learning and improvement. This involves ensuring practices have access to the right digital tools and data to enable and enhance the change; making the process of change easier and matching the right type of support to practice needs, working with ICSs to create the right conditions for change, and building improvement and data capability; enabling sustainable improvement – creating a continuous learning environment including peer-peer support, evidence and near real time data, alignment of system drivers and integrated approaches to improvement with wider system partners and teams.
Many thanks to Minal for taking the time to join us; questions were taken from the audience from 37:20, available to watch on the video below.