This document discusses strategies for managing workload in general practice through 10 high impact actions: 1. Introducing new ways of working to reduce wasted time and ensure issues are addressed at first contact. 2. Matching capacity to demand by adjusting staffing schedules. 3. Applying lean principles to improve common processes and reduce errors and waste. 4. Optimizing the physical layout and information systems to boost productivity. 5. Supporting self-care through signposting, education, and online access to records and test results. 6. Developing community prevention programs to improve population health.

1. #GPforwardview

2. #GPforwardview
www.england.nhs.uk/gp
england.gpdevelopment@nhs.net

3. #GPforwardview
Welcome
Welcome and housekeeping
Context setting
Your priorities and questions
Running the practice
The importance of sharing
Managing workload in the practice
Share challenges & solutions
Professional development
Leading primary care into the future - lessons so far
Opportunities for sharing and development
Your personal development
Next steps

4. #GPforwardview

5. #GPforwardview
pollev.com/gpfv

6. #GPforwardview

7. #GPforwardview
Context-setting

8. #GPforwardview
Pressures on general practice
↑ population
↑ consultations
↑ complexity
↑ costs
↓ relative funding
↓ relative workforce

9. #GPforwardview
www.england.nhs.uk/gp

10. #GPforwardview
www.england.nhs.uk/gpfv

11. #GPforwardview
Extra £33m included in 2016/17 contract
Repeat winter payments scheme for OOH in 2016
Already actioned
Out of
Hours
Payment to all practices in April
2017 and 2018 based on average
indemnity increases
Work on new scheme for OOH
support with BMA
Next steps
GP Indemnity Review Group to look at cover for new members of the workforce
and other more radical options
Longer term
In
hours

12. #GPforwardview
Training for clerical & reception staff
• 5 year fund: total 80p/patient (eg £8,000 for 10,000 list practice)
• 2016/17 portion allocated to CCGs Sept 2016
• Full information:
www.england.nhs.uk/gp/gpfv/redesign/gpdp/reception-clerical/
Online consultations
• 4 year fund: total 80p/patient
• First portion in Apr 2017
• Full information:
www.england.nhs.uk/gp/gpfv/redesign/gpdp/consultation-systems/

13. #GPforwardview
www.england.nhs.uk/gpfv

14. #GPforwardview
www.england.nhs.uk/gpfv

15. #GPforwardview
Make GP
attractive again
Expand the Medical Workforce
5,000 Net WTE doctors in general practice by 2020/21
Encourage
Recruitment
Retention
Reduce workload
Induction & refresher scheme
Bursaries in under-doctored areas
Retainer Scheme
Leadership training opportunities
Training Hubs
Flexible career schemes
Career coaching for senior GPs
GP Health Service
Work with medical schools
Increased training places
250 Post-CCT fellowships
Major campaigns
CSU Marketing support
International recruitment

16. #GPforwardview
Develop the workforce
5,000 additional staff by 2020/21
• Major new practice nursing
review underway
• £15M to be invested
NURSES
• 3,000 new mental health therapists
• Focus on longterm physical conditions
MENTAL HEALTH
Training 1,000 physician
associates by 2020
• Regulatory and indemnity
enablers
PHYSICIAN ASSOCIATES
£6m of new support over 4 years
• Expanded national network
• Professional development
PRACTICE MANAGERS
Current £31m to pilot 470
pharmacists in >700 practices,
• Plus new £112m for additional
1,500 pharmacists by 2020 (a
pharmacist / 30,000 patients)
• Clinical pharmacists in 111 hubs
PHARMACISTS

17. #GPforwardview
www.england.nhs.uk/gpfv

18. #GPforwardview
www.england.nhs.uk/gpfv

19. #GPforwardview
www.england.nhs.uk/gpfv

20. #GPforwardview
Simplify reporting and regulation
Streamline payment systems
Move away from micro-incentives
Greater
specialist
support
Self-help and GP Online
Better sign posting
• Care navigation
• Social prescribing
• Minor ailments
• Remote triage/care
• Open access AHPs
Reformed 111/Urgent Care
Collective
working and
MCP contract
GP PRACTICE
Community
services
Changes
to
Standard
Contract
HOSPITAL
Access
hub
Demand
Management
Practice Resilience Programme
Ten High Impact Actions
Development Programme
Tools to measure & plan work
Receptionist & clerical training

21. #GPforwardview
www.england.nhs.uk/gpfv

22. #GPforwardview
Where are we now?
Investment secured and in planning guidance
Indemnity till April 2019 (OOHs ongoing)
Induction & Refresher / Retainer Schemes
£20K Bursaries & 250 Post-CCT Fellowships
International Recruitment Pilots
470 Clinical Pharmacists (Phase 2 soon)
National GP Health Service from Jan 2017
Practice Resilience Scheme
General Practice Development Programme
Medical Assistant and Care Navigation
Standard Contract Changes / Interface Group
Expansion of capacity through Access Hubs
MCP Framework and voluntary contract
GMC/CQC/NHSE joint work
Pipeline 800 of premises schemes
GPFV Scrutiny and Architecture in place
Medical School places increased
Vulnerable Practices Scheme
Leadership Training Opportunities (400 pa)
Training Hubs
111 Online Clinical Assessment Hubs
Practice Manager Training Consultation
Capacity Planning Tools being rolled out
BMA Approved Lease with package
C
O
M
M
U
N
I
C
A
T
I
O
N

23. #GPforwardview
www.england.nhs.uk/gpfv

24. #GPforwardview
www.nhsalliance.org/making-time-in-general-practice/
info@primarycarefoundation.co.uk

25. #GPforwardview
Pressures from bureaucracy

26. #GPforwardview
Self-rating by GPs
5,128 consultations info@primarycarefoundation.co.uk

27. #GPforwardview
Nationally info@primarycarefoundation.co.uk

28. #GPforwardview
Typical practice 6,700 patients info@primarycarefoundation.co.uk

29. #GPforwardview
www.england.nhs.uk/gpfv

30. #GPforwardview
What are the biggest challenges in
running the practice productively?
What would you most like to learn from
colleagues today?
Your priorities

31. #GPforwardview

32. #GPforwardview
What are the biggest challenges in
running the practice productively?
What would you most like to learn from
colleagues today?
Your priorities

33. #GPforwardview

34. The importance of sharing ~
The GP Forward View and Practice Manager
Development Programme
Welcome!

35. • Practice manager development
• Practice managers are a vital resource in the NHS, playing a key role
in maintaining a quality service and in redesigning care for the
future. Yet they are also one of the most neglected parts of the
workforce, receiving relatively little formal training or ongoing
development. Many practice managers report feeling overburdened
and isolated in their role, and it is often noted that the most
efficient ways of working are slow to spread between practices.
• NHS England 2016
General Practice – The increasing
workload

36. • Practice manager development
• We want to share our wide experience as business managers with
our colleagues in practice management and with others in the NHS.
We want to promote excellence, provide practical support and
identify examples of good practice. We will identify sources of
expertise and encourage collaboration.
• We will champion the cause of practice management and the
development of ever higher professional standards.
• Practice Management Network 2009
General Practice – The increasing
workload

37. • Aligned to 7 health
organisations
• 10 high impact actions
champions
• 209 CCG lead opportunities
• 7,500+ Practice Managers
• 70,000+ Practice Staff
• The Practice Management
Network (initially supported by
the Department of Health)
• Over 4,100 registered managers
• 14 steering group members
• 4 regional representatives
General Practice – The importance of
sharing

38. General Practice – The Way Forward
10 High Impact Actions Champions
Active signposting -
New consultation types -
Reduce DNA’s -
Develop the team -
Productive work flows -
Personal productivity -
Partnership working –
Use social prescribing –
Support self care and management -
Build QI expertise -
2 x Co-chairs
NORTH
SOUTH
MIDLANDS AND
EAST LONDON
209 CCG’s
BMA
NEW NHS ALLIANCE
IHM
RCGP
AMSPAR
NAPC
FAMILY DOCTORS
ASSOCIATION

39. • Performance reviews
• Other resources
• The GP forward view
• Leader or follower ?
• General Practice Today –
The Challenges
• Who’s who in your practice
• Practice policies
• Practice benefits
General Practice – The importance of
sharing

40. • Support for PM’s and a voice
• Representing the profession, professional development and
primary care transformation
• Support for PM’s in terms of brainstorming and problems
• To ensure that PM’s are fully supported in their work and are
allowed to develop their skills
General Practice – What You Say
SUPPORT

41. • Understanding the main
challenges faced in surgery.
• Supporting your team to
manage workload and
identifying where to delegate
appropriate tasks
• How does this fit into the
General Practice Forward View?
• What do the Five Year and
General Practice Forward Views
mean to my practice.
• How can I take part in the
initiatives and access funding?
• Taking a leadership role in
driving improvements in
provision of primary care.
General Practice – The Challenges

42. General Practice – The Way Forward
In a survey of almost 2,000 people in Great Britain, the most
commonly perceived barriers to seeing a GP were finding it
difficult to get an appointment with a particular doctor (42 per
cent), or at a convenient time (42 per cent), and disliking
having to talk to GP receptionists about symptoms (40
percent).
11th October 2016

43. General Practice – The Way Forward
Receptionists 'put people off seeing doctor‘
11th October 2016
Patient: "They (receptionists) sometimes think they're the
doctors"
Receptionists quizzing patients about why they need to see
their GP could be putting some sick people off visiting their
surgery, a survey suggests.
Of almost 2,000 adults questioned for Cancer Research UK,
four in 10 said they disliked having to discuss their ills with
office staff in order to get an appointment.

44. General Practice – The Way Forward

45. General Practice – The Way Forward

46. General Practice – The Way Forward

47. General Practice – The Way Forward

48. General Practice – The Way Forward
The PMn is in discussion with NHSE to determine how the
funding of £6 million can be best utilised
AMSPAR already provide education and training with the
Level 5 certificate/diploma in Primary Care Healthcare
Management and offer professional membership
The NAPC with help from the PMn will be introducing an Advanced
Practice Manager Programme – expected October 2017

49. General Practice – The Way Forward
Share your knowledge.
It’s a way to achieve
immortality.
Dalai Lama
(1357-1419, high lama of
Tibetan Buddhism)
Let’s try it once without the parachute.
Image: Cartoonresource (Shutterstock)

50. C’mon guys, we’ll find someone with the answers. Just keep
looking.
Image: Cartoonresource (Shutterstock)
Sharing is sometimes
more demanding than giving.
Mary Catherine Bateson
(*1939, American writer and cultural anthropologist)
Scientia potentia est: Knowledge is Power.
commonly attributed to Sir Francis Bacon
(1561-1626, English philosopher, statesman, and scientist)

51. Sharing is caring.Unknown

52. @robertvarnam
Managing workload
in the practice
Dr Robert Varnam
Head of General Practice Development
NHS England
@robertvarnam

53. #GPforwardview
www.nhsalliance.org/making-time-in-general-practice/
info@primarycarefoundation.co.uk

54. #GPforwardview

55. #GPforwardview

56. #GPforwardview

57. #GPforwardview
Bureaucracy audit
cfep.net/u6k

58. #GPforwardview
10 high impact actions
to release time for care

59. #GPforwardview
10 High Impact Actions to release time for care
Innovations from around England
that release time for GPs to do
more of what only they can do.
bit.ly/gpcapacityforum

60. #GPforwardview
10 High Impact Actions to release time for care
Innovations from around England
that release time for GPs to do
more of what only they can do.
bit.ly/gpcapacityforum
bit.ly/gpcapacityforum

61. #GPforwardview
10 High Impact Actions to release time for care
Innovations from around England
that release time for GPs to do
more of what only they can do.
bit.ly/gpcapacityforum
Consultation audit
www.primarycarefoundation.co.uk
/audit-tool.html

62. #GPforwardview
10 High Impact Actions to release time for care
Innovations from around England
that release time for GPs to do
more of what only they can do.
bit.ly/gpcapacityforum
Introduce new ways of working which enable staff to work smarter, not just harder. These can reduce wasted time, reduce queues, ensure more
problems are dealt with first time and that uncomplicated follow-ups are less reliant on GPs consultations.
Match capacity with demand
Appointment systems and staff rotas are designed in order to ensure sufficient capacity is available to match patterns of demand as they vary
through the week and the year. This requires an ongoing system of measuring demand and adjusting capacity accordingly. It may also involve
scheduling routine work (eg annual reviews and clinical audit) for less busy times of the year. The benefits are a reduction in delays for
appointments, less stress for staff and patients, and better access.
Efficient processes
The application of Lean principles to measure, understand and improve common processes in the practice, in order to reduce waste and errors.
Typical targets include clinical follow-up protocols, processing of letters and test results, requests from patients, staff messages and team
decision making. Staff themselves often have a wealth of ideas about ways in which processes could be improved to release time. Practices who
take a systematic approach to identifying and testing these generally find that this improves care for patients as well as freeing staff time for other
things. The use of pre-prepared plans for managing common simple follow-up processes can improve their reliability and efficiency, freeing GP
time. Common examples include management of hypertension, monitoring of tests after the initiation of new medication, and adjustment of
medication doses to reach a target.
Productive environment
The physical layout within the practice is assessed for its effect on staff's productivity, and improvements are introduced which reduce wasted
time. The Lean technique of 5S is the best known approach for doing this. Additionally, work can be undertaken to ensure that staff can access
information needed to support their work quickly. This reduces time spent searching for information and can improve patient safety as well.

63. #GPforwardview
10 High Impact Actions to release time for care
Innovations from around England
that release time for GPs to do
more of what only they can do.
bit.ly/gpcapacityforum
Take every opportunity to support people to play a greater role in their own health and care. This begins before the consultation, with methods of
signposting patients to sources of information, advice and support in the community. Common examples include patient information websites,
community pharmacies and patient support groups. For people with longterm conditions, this involves working in partnership to understand
patients' mental and social needs as well as physical. Many patients will benefit from training in managing their condition, as well as connections
to care and support services in the community.
Prevention
Some practices are fostering links with their local community and launching new programmes to improve population health and prevent disease.
This spans a range of activities, including health education, promoting healthy eating and physical activity, and influencing other aspects of public
health. A common feature is a focus on communities helping themselves, with statutory services providing support.
Patient online
Technology changes are enabling patients to access their personal record online, through web portals and a growing number of health apps for
mobile phones. This makes common transactions such as ordering a repeat prescription quicker for the patient and for practice staff. It also
allows patients to become better informed about their health and care, and to play a more active role. With explanation and support, patients and
their carers are able to check test results, the progress of investigations and referrals, read and share their care plan, and enter details of home
monitoring, such as blood pressure, weight, and sugar tests. As well as being popular with patients, GP practices are reporting a reduction in
workload as a result of patients using these online services.
Acute episodes
Practices are increasingly involved in supporting patients with minor ailments to care for themselves. This often includes providing advice and
signposting to services provided by community pharmacy. Education also plays a part, with growing numbers of practies contributing to efforts to
teach people about the best ways to seek help when ill. This often begins with engagement in local primary schools.
Longterm conditions
For people with longterm conditions, a more proactive approach to care is being adopted, alongside a focused effort to help people play a more
active role in monitoring and managing their condition. Initiatives include supporting people to access their full medical record online, the use of
health coaching in clinical consultations and the provision of training and support in the community, aiming to build the knowledge, skills and
confidence for patients and carers to manage their condition. This builds patients’ own assets and quality of life, as well as reducing their
dependence on services such as the general practice.

64. Booking and cancelling
of appointments
Ordering of
repeat prescriptions
Access to
GP records
What is Patient Online?
Over 97% of all practices in England are currently offering these online
services to their patients. This was a requirement in last year’s GP
contract.
This year, the BMA and NHS agreed that all practices should aim to get
at least 10% of their patients signed up for online services by the 31st of
March 2017.
In the North region 57.1% of practices are already
offering online services.

65. Why should I do it?
Convenient way for patients to contact the
practice 24/7
Reduces footfall
Frees up phone lines for other patients
Reduces the amount of no shows
More efficient prescription process and less
prescription waste
Increases patient satisfaction and self care
Frees up valuable time for other essential tasks

66. New promotional materials available
Patient Online GP online services
Order promotional materials, including posters, patient guides,
leaflets, balloons, bunting and appointment cards, for free via
www.england.nhs.uk/materialsforpatient/

67. www.england.nhs.uk/patient-online

68. #GPforwardview
10 High Impact Actions to release time for care
Innovations from around England
that release time for GPs to do
more of what only they can do.
bit.ly/gpcapacityforum
bit.ly/gpcapacityforum

69. #GPforwardview
Running an effective & efficient practice
What are the challenges? What's worked for you?
1. Managing the business
2. Managing the team
3. Prescription requests
4. Incoming clinical correspondence
5. Test results
6. Using technology (eg Patient Online, etc)
7. Active signposting
8. Freeing up GP appointments (other ideas)

70. #GPforwardview

71. #GPforwardview
Leading primary care into the
future - lessons so far
Dr Robert Varnam
Head of General Practice Development
NHS England
@robertvarnam

72. @robertvarnam
 Where are we heading?
 What size should we be?
 How do we realise the benefits of scale?
 What capabilities will we need?

73. @robertvarnam
 Where are we heading?
 What size should we be?
 How do we realise the benefits of scale?
 What capabilities will we need?

74. #GPforwardview
Specialists
Non-specialist / failed consultant
Gatekeeper / door-holder
King of my castle
It’s all in me
Community
services

75. #GPforwardview
Self
Care
Broader skillmix
Self
management /
social
prescribing
Emergency
care
Collaboration
with specialists
At scale
Population wellbeing management
and holistic person-centred care
provided by a multiprofessional team
led by the GP, supported by at-scale
collaboration and efficiencies.

76. #GPforwardview
What is a Multi-speciality Community Provider?
General
Practice
Community
Services
Outpatient
Services
Mental
Health
Social
Care MCP
Key Features
• CCG-commissioned voluntary
contract
• Place based and population
based provision of care > 100K+
patients (in 30-50K
neighbourhoods)
• Focus on prevention, self-care
and use of community assets
• Enhanced primary and
community-based services
• Wider range of specialists
developing integrated patient
pathways
• New pay for performance
mechanisms with gain/risk share
opportunities
• Accessible and responsive urgent care
• Greater resilience across practice
groups
• Greater career opportunities for all staff
• New organic business models in 10-15
year contracts (with right of return)
Virtual MCP – alliance contract laid over
existing GP contracts
Partially Integrated MCP – GMS +
Community Services
Fully Integrated MCP – One budget, one
team, one service
• Intensive work with 6 aspirant MCPs
areas
• Contract to be available from April 2017

77. @robertvarnam
 Where are we heading?
 What size should we be?
 How do we realise the benefits of scale?
 What capabilities will we need?

78. @robertvarnam
 Where are we heading?
 What size should we be?
 How do we realise the benefits of scale?
 What capabilities will we need?

79. @robertvarnam
Clarity
Commitment
Agility
Alignment
Priorities
Partnerships
4 400
We need
the best of
both worlds
What is the ideal size?

80. @robertvarnam
STP footprint: 300k-2m
Workforce & infrastructure planning
Large scale service reconfiguration
Major partnerships & shifts in priority
MCP: 100-350k
Organisational infrastructure & governance
Specialist staff & services
Employment & career development
Model design (population management, care models)
Strategic partnerships
Hub/Home: 30-60k
Acute care
Locality-tailored services
Shared MDT
Place of ‘belonging’
Core team: 3-4k
Coordinated, complex
multidisciplinary care
Continuity

81. @robertvarnam
 Where are we heading?
 What size should we be?
 How do we realise the benefits of scale?
 What capabilities will we need?

82. @robertvarnam
 Where are we heading?
 What size should we be?
 How do we realise the benefits of scale?
 What capabilities will we need?

83. @robertvarnam
Working at scale: Opportunities for practices

84. #GPforwardview
 Staff pooling
• nurses, reception & clerical staff, sessional GPs
 Overflow support
• phone consultations
• access hub (phone +/- face-to-face)
• home visiting

85. #GPforwardview
 Purchasing
• Indemnity
• Supplies
• Utilities
 Shared functions
• Policies & procedures
• Procurement
• Correspondence management
• IM&T (eg support & maintenance, intranet, web, social media)
 Specialist functions
• HR
• Finance
• Clinical governance
• Business intelligence

86. #GPforwardview
 Planning
• Workforce
• Infrastructure development
• Service reconfiguration
• Public health
 Provision
• Acute care
• Community pharmacy
• Dentistry
• Optometry
• Social care
• Housing
• Welfare
• Voluntary sector

87. #GPforwardview
 Traditional healthcare roles
• Pharmacists
• Specialist nurses
• Physiotherapists
• MH therapists
• Paramedics
 Wellbeing workers
• Social workers
• Care navigators
• Health trainers & coaches
• Welfare advisors

88. #GPforwardview
 QI expertise
 Analytics
• Population health analytics
• Priority setting
• Benchmarking
• Realtime measurement
 Project management

89. #GPforwardview
 HR
 CPD
 Career development
• Leadership
• Mentoring
• Service improvement
• Research

90. @robertvarnam
 Where are we heading?
 What size should we be?
 How do we realise the benefits of scale?
 What capabilities will we need?

91. @robertvarnam
 Where are we heading?
 What size should we be?
 How do we realise the benefits of scale?
 What capabilities will we need?

92. @robertvarnam
Leadership
Creating shared
purpose
Strategic
planning &
partnerships
Leading through
change
Being a leader
Improvement
Patients as
partners
Process design
Using data for
improvement
Rapid cycle
change
Business
Team leadership
Operations
management
H R
I T
At-scale
working
Governance
Contracts
Workforce
Business
intelligence
Capabilities for the future
Interdependent capabilities for leaders & organisations

93. #TimeforCare
www.england.nhs.uk/gp
Local Time for Care
programmes
• Bespoke 9-12 month
programme to support a group
of practices to implement
innovations that release time
for care.
• Training for reception and
clerical staff, for active
signposting and document
management (£45m over 5
years).
• Funding towards purchasing
online consultation systems
(£45m over 4 years, from
2017).
• CCG transformational
support (£171m over 2 years,
from 2017).
General Practice
Improvement Leaders
• At least 400 free places a
year for three years.
• Skills and confidence in
designing and implementing
improvements within the
practice rapidly and
sustainably.
• RCGP Supporting
Federations Network and
NHS Collaborate (NAPC &
NHS Alliance) for leaders of
at-scale primary care.
• Funding facilitated peer
networking for practice
managers of all 7,800
practices, with support to
develop professional skills.
• 24 regional GPFV roadshows
• 30 local High Impact Actions
showcase events
• Web resources (60 and
growing)
• Fortnightly webinars
• Network of champions
10 High Impact Actions
to release time for care
www.england.nhs.uk/gp

94. @robertvarnam
 Where are we heading?
 What size should we be?
 How do we realise the benefits of scale?
 What capabilities will we need?
Implications
for me?

95. #GPforwardview
Opportunities for sharing and
development
James Dillon
Practice Index

96. #GPforwardview

97. #GPforwardview
Your personal development
• find someone you don't know
• share:
• best things you've done to develop yourself
• things you're most interested to do in future
• write things down!

98. #GPforwardview
Next steps

99. #GPforwardview
www.england.nhs.uk/gp
england.gpdevelopment@nhs.net