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When we talk about NHS administration, it often gets described as systems, processes, inefficiencies. That’s not how it feels in general practice. From where I sit as a practice manager, administration is the bit that either helps a patient get care – or quietly stops them from getting it at all, writes Kay Keane in this guest blog for The King's Fund. The recent report from The King's Fund talks about patients feeling ‘lost in the system’. What is less visible is the amount of work happening every single day to stop that from happening.  

Increasing the amount of advice and guidance – where hospital specialists provide advice to GPs so that they can manage the patient without a referral to hospital – is a key part of ambitions to bring down NHS waiting lists. Lucina Rolewicz, Stuti Bagri and Sarah Scobie look at whether the target to increase advice and guidance is likely to be met, and what it might mean for those hopes that it will reduce waiting lists.

 Despite its extremely low funding, Professor Lord Ara Darzi’s September 2024 report on the productivity of the NHS across England singled out general practice for its unprecedentedly high activity. The ‘front door’ to the NHS for an average of nearly 1.5 million appointments every day, yet collapsing from 15 years of funding erosion, GP practices across England currently only receive 5.5p out of every pound spent on the NHS for the core (essential) services they are contracted to deliver. The new Labour Government has begun to invest, but the scale of the challenge is clear: recent uplifts have only contributed a single additional penny per patient per day. Around 2,000 independent GP practices have been lost since 2010 – that’s one in five local surgeries. That’s a problem for all of us as patients and the NHS in general. This paper from the BMA is a vision and a toolkit for how to deliver what patients want from the NHS. Fixing the NHS must start with bringing back the family doctor. Patients want the Government to fix the broken general practice it has inherited and deliver them a safe and stable local GP surgery and the family doctor they know and trust. We need: more GPs to meet the needs of our patients more GP appointments to stop the 8am rush more GP Practice Nurses – familiar faces known and trusted by the patients who need them most more GP Practice Nurse appointments delivering local joined-up care closer to home in the community better continuity of care – by seeing the same clinician, patients can build trust in who delivers their care and receive better customer service.

Primary care – general practice, community pharmacy, optometry and dental services – delivers 90% of NHS interactions, face to face, by phone or online. The Primary care patient safety strategy describes the national and local commitments to improve patient safety in primary care, supporting all areas in this sector to fully implement the NHS Patient Safety Strategy. This strategy has three core areas of focus: Developing a supportive, learning environment and just culture in primary care, with sharing across the system so that the services can continually improve. Ensuring that the safety and wellbeing of patients and staff is central, and that our approach to managing safety is systematic and based on safety science and systems thinking. Involving patients in the identification and co-design of primary care patient safety ambitions, opportunities and improvements. This strategy seeks to continuously improve patient safety through existing processes and structures as much as possible, rather than adding work. The timeframes for the implementation of the local commitments are intentionally flexible to allow for the piloting of different approaches, and, while this strategy is for all areas of primary care, some improvements will be implemented first in general practice and the successes and learning then used in the rollout to community pharmacy, optometry and dental services. In summary: Safety culture: participate in the NHS staff survey. Safety systems: complete patient safety syllabus training. Insight: register for and use the new incident recording (LFPSE) and incident response (PSIRF) systems. Involvement: identify patient safety leads and lay patient safety partners. Improvement: review and test patient safety improvements in diagnosis, medication, referrals, optometry and dental services.

Even those at the top admit the NHS can’t do what is being asked of it today. But it is far from unsalvageable – we just need serious politicians who will commit to funding it, writes Gavin Francis, who shares his experience as a GP in this Guardian long read.

The Health and Social Care Select Committee report on the future of general practice examined the pressure currently facing general practice, highlighting the challenges being faced by general practice and provided clear recommendations to respond to them. This document sets out the Government’s reply to each of these recommendations. Government's response to the recommendations: The Government needs to acknowledge that general practice in in crisis and that patient access to a GP is unacceptably poor. Partially accept. The Government should commission a review into short-term problems that constrain primary care, including the interface between primary and secondary care, prescribing from signing to dispensing, administrative tasks, day-to-day usability of IT hardware and software and reviewing of bloods, pathology and imaging reports. Partially accept. The Government should provide funding to create 1,000 additional GP training places per year and consider extending the GP training scheme to four years. Partially accept. The Government and NHS England should identify mechanisms to distribute GP trainees more equitably across the country. Accept. NHS England should set out how it plans to increase the flexibility of the Additional Roles Reimbursement Scheme to allow Primary Care Networks to hire both clinical and non-clinical professionals. Partially accept. Given they are often the first point of contact with primary care for most patients, NHS England should review and consider providing standardised national training for receptionists to drive up standards and equip receptionists with the skills required. Accept. The Government and NHS England should explore the possibility of providing an uplift to the Additional Roles Reimbursement Scheme to support non-staff costs such as supervision and training or to provide weighted salaries in areas where the cost of living is high or it is hard to recruit. Partially accept. NHS England should take further steps to address the administrative workload in general practice, including by introducing e- prescribing in hospitals and focusing on the primary-secondary care interface by encouraging ICSs to provide a reporting tool for GPs to report inappropriate workload transfer. Partially accept. The Government should also fund research into the specific role that machine learning can play in the automation of reporting and coding test results to reduce clinical admin in general practice. Partially accept. The Government should undertake a full review of primary care IT systems from the perspective of the clinicians with an emphasis on improving the end user interface. Partially accept. NHS England should include a specific focus on encouraging locum GPs back into regular employment by supporting GP practices to offer more flexible working patterns. Partially accept. Urgent work needs to be done to stop a bidding war for the services of locums and establish requirements for a minimum fair share of administrative duties. Do not accept. The Government and NHS England should adopt the recommendations related to NHS pensions in the recent Report on Workforce: recruitment, training and retention in health and social care. Partially accept. The Government and NHS England must acknowledge the decline in continuity of care in recent years and make it an explicit national priority to reverse this decline. Partially accept. NHS England should introduce a national measure of continuity of care to be reported by all GP practices by 2024. It should also provide Primary Care Networks with additional funding to appoint a ‘continuity lead’ for at least one session per week. Partially accept. NHS England should provide Primary Care Networks with additional funding to appoint a ‘continuity lead’ for at least one session per week, and additional admin staff funding to support the lead in the role. The role of the continuity lead GP would be to support practices within their network to increase the proportion of patients consulting with their named or regular GP, learning from best practice around the country. Do not accept. NHS England should champion the personal list model and re-implement personal lists in the GP contract from 2030 onwards. Do not accept. The Government should examine the possibility of limiting the list size of patients to, for example, 2500 on a list, which would slowly reduce to a figure of around 1850 over five years as more GPs are recruited as planned. Do not accept. NHS England should re-implement personal lists in the GP contract from 2030 onwards. Do not accept. Integrated Care Systems should prioritise simplifying the patient interface with the NHS by improving access, triage and referral across first-contact NHS organisations including general practice. Accept. NHS England should abolish the Quality and Outcomes Framework and Impact and Investment Framework and re-invest the funding in the core contract, weighted to account for patient demographics including deprivation, to incentivise continuity of care. Partially accept. In particular, NHS England should focus on significantly improving the outcomes data provided to GPs by focusing data collection and analytical resource on outcomes measures rather than the process data and reporting required by these micro-incentives. Partially accept. NHS England should support Integrated Care Systems to implement gain sharing so that Primary Care Networks and individual practices that support the reduction of secondary care expenditure, such as through reducing unplanned admissions, are able to share in the financial gains. Partially accept. NHS England should revise the Carr-Hill formula to ensure that core funding given to GP practices is better weighted for deprivation. Partially accept. The Government and NHS England should increase the level of organisational support provided to GPs with a particular focus on important back-office functions such as HR, data and estates management. Accept. The Government should reaffirm its commitment to maintaining the GP partnership model and explain how it will take forward our recommendations to better support the partnership model, alongside ongoing work to enable other models of primary care provision. Partially accept. The Government should consider adopting the approach to GP premises taken in Scotland and conduct its own analysis of whether this would be viable for general practice in England. Partially accept. The Government should accelerate plans to allow GP partners to operate as Limited Liability Partnerships or other similar models which limit the amount of risk to which GP partners are exposed. Partially accept.

Patients who visit their GP practice with an ongoing health problem may see several different GPs about the same symptoms. To make sure they receive safe and efficient care, there needs to be a system in place to ensure continuity of care. In the context of this report, continuity of care is where a patient has an ongoing relationship with a specific doctor, or when information is managed in a way that allows any doctor to care for a patient. While some GP practices in England operate a formalised system of continuity of care, many do not. This investigation explored the safety risk associated with the lack of a system of continuity of care within GP practices. The investigation focused on: How GP practices manage continuity of care. This includes how electronic record systems alert GPs to repeat attendances for symptoms that are not resolving and how information is shared across the healthcare system. Workload pressures that affect the ability of GP practices to deliver continuity of care. This investigation’s findings, safety recommendations and safety observations aim to prevent the delayed diagnosis of serious health conditions caused by a lack of continuity of care and to improve care for patients across the NHS. Reference event Brian had a history of breast cancer and had been discharged from the breast cancer service. Two years later he began to have back pain. Initially the pain was so severe that Brian visited his local emergency department (ED). He was discharged from the ED with pain relief and was advised to contact his GP practice. A month later, Brian telephoned his GP practice and saw his named GP. The GP referred Brian to the GP practice’s physiotherapist and requested a blood test. Brian saw the physiotherapist, who gave him advice about exercises to help relieve the back pain. The exercises did not relieve Brian’s pain and over the following 8 months he saw two out-of-hours GPs and six practice GPs, a nurse and a physiotherapist at the GP practice. Brian also had consultations with healthcare professionals during this time for other conditions not relating to his back pain. When Brian saw a GP at end of the 8-month period, the GP found a lump on his spine and advised Brian to go to the local ED. At the ED, Brian had a computerised tomography (CT) scan. A lump was found on his spine which was later diagnosed as metastatic breast cancer (that is, breast cancer that had spread to his spine). Findings The GP contract, which sets out the mandatory requirements for GP services commissioned by the NHS, does not specifically require GP practices to adopt an approach that ensures continuity of care, but practices can do so voluntarily. Many GP practices do not operate a formalised system of continuity of care. There is no standard framework to deliver continuity of care in GP practices, so it is done differently across the country. Many GPs understand the benefits of continuity of care; however, some practices did not believe that it was possible to deliver such a system. Other practices were able to maintain continuity of care through systems developed by those practices. There is no requirement for GP IT systems to consider continuity of care or to ‘surface’ information (that is, identify and flag up relevant patient information) to GPs when they see a patient with unresolving symptoms. Patients told the investigation that they found it beneficial to see their named GP for long-term health conditions, including mental health conditions. GPs working in a practice with a system of continuity of care had more time to process information during consultations and to carry out any follow-on actions to ensure patients received the care they needed. GP practices that operated a system of continuity of care reported to have better staff welfare and retention, and fewer recruitment issues, than those that did not. Safety recommendations HSSIB recommends that the Department of Health and Social Care ensures that the GP contract explicitly includes and supports the need for GP practices to deliver continuity of care. This is to improve patient safety by building clinician–patient relationships as well as providing continuity of information. HSSIB recommends that NHS England updates the GP IT standards to ensure that patient continuity of care is maintained, including the identification and prioritisation (technically known as ‘clear surfacing’) of information to health and care professionals, when patients visit GP practices multiple times with unresolving symptoms. Safety observation GP practices can improve patient safety by aligning their staff wellbeing and patient safety policies to those of NHS England’s proposed patient safety strategy.

People with chronic pain need personalised care – an approach offering patients choice and control over their mental and physical health, basing care on what matters to them personally, and focusing on individual strengths and needs. People in this position need someone to listen and acknowledge that these symptoms are real, not all in their head. They need someone to explain their chronic pain and other symptoms, but also someone for everything else too. As well as medical care, people need time and emotional care. But how on earth can this be achieved in UK primary care in 2023? Is this really the role of a modern GP? Even if it was how can it now be in our over-stretched, fragmented, target-driven services? In North-West London, Selena Stellman and Benjamin Ellis have tested a personalised care model to improve the care offered to patients with fibromyalgia and high impact chronic pain. In this opinion piece in BJGP Life, they discuss the two key changes in their approach.