Written evidence submitted by The Healthcare Improvement Studies Institute (FGP0215)

1           Questions of interest

1.1          What are the main challenges facing general practice in the next 5 years?

1.2          What can be done to reduce bureaucracy and burnout, and improve morale, in general practice?

2           About The Healthcare Improvement Studies (THIS) Institute

2.1          THIS Institute’s goal is to create a world-leading scientific asset for the NHS about how to improve quality and safety in healthcare. We are guided by a highly participatory, collaborative ethos that combines academic rigour with the real concerns of the people who use and work in the NHS. THIS Institute is supported by the Health Foundation, an independent charity committed to bringing about better health and healthcare for people in the UK.

3           Summary of key points

3.1          Reducing burnout and improving morale in general practice requires comprehensive, evidence-based understanding of what consumes GPs’ time and what might hamper them in their work.

3.2          New research produced by THIS Institute using direct observations shows that operational failures – defined as disruptions or errors in the supply of necessary materials or information to employees - are a common and highly consequential challenge in general practice.

3.3          Examples of operational failures in general practice include inadequate communication of patient information from other healthcare services, malfunctioning computers or software, and missing equipment.

3.4          Some of the most high impact challenges arise from GPs’ roles in coordinating care and information across multiple fragmented parts of the system.

3.5          GPs respond to operational failures by undertaking compensatory actions, characteristically involving administrative tasks, often “patching together” information and processes. This frustrating work consumes at least 4% of GPs’ professional time, which represents significant waste when considered across 58,000 GPs working in the NHS.

3.6          Operational failures in general practice obstruct the flow of work for GPs, generate additional tasks in an already overloaded system, and negatively affect GPs’ experience of work causing stress, anxiety, and frustration, and impairing their relationships with patients.

3.7          While every operational failure reported in our research merits further attention, emerging evidence from surveys with GPs and patients points to failures that compromise GPs’ ability to deliver on their role in co-ordinating patient care, including problems in communication from other healthcare services to GPs, as urgent priorities for improvement.

4           Context and evidence

4.1          The pressures experienced by general practices have been well documented: rising patient demand, increasing complexity of patient need and difficulties recruiting GPs, culminating in high levels of stress and burn out for those GPs who stay in general practice.1-3 The approaches used to address the workforce and workload crisis in general practice have so far included efforts to train and retain more GPs, build resilience in the existing workforce, and improve efficiencies in general practice (e.g. the GP Access Fund, the General Practice Development Programme, Releasing Time for Care initiative).4-6 While these supports for general practice are welcome, recent evidence 7 showing 60% of GPs find their work extremely or very stressful signals that insufficient attention has been given to the GP work environment or how it could be optimised.

4.2          The concept of operational failures, defined as disruptions or errors in the supply of necessary materials or information to employees, is very important in understanding how GPs’ work might be frustrated by inadequacies in their work systems and in identifying targets for improvement. 8 In four linked studies, we explored how operational failures in primary care, showing their impacts on efficiency and experiences of the general practice work environment, and identifying where improvement could be targeted.

Systematic review of studies on operational failures in primary care

4.3          An extensive literature review and synthesis of the existing research literature on operational failures in primary care 9 found no study specifically addressing operational failures in general practice, suggesting this is an under-researched area. When we included studies that described problems that conformed to the general definition (e.g. system-level errors in the supply of necessary materials, equipment or information to employees), we identified 8544 unique citations, retrieved 372 full-texts, and included 95 studies in the final synthesis. The majority of these studies were from the US but 13 related to the NHS.

4.4          The most frequently reported operational failures related to information technology, such as problems with electronic health records (n=19 studies), computer decision support systems (n=18), e-prescribing (n=9) and e-referral systems (n=3). Failures in practice processes were the next most frequent focus, including problems with the distribution of information within practices (n=30) or missing supplies (n=3). Fewer studies dealt with operational failures arising from incoming information to GPs, such as suboptimal communication of patient information (n=7), or medication discrepancies (n=4).

4.5          The impacts of the operational failures (Table 1) included wasting time, disrupting task completion, delaying clinical decisions, and interfering with the doctor-patient relationship. Operational failures required GPs to undertake additional tasks to resolve failures and deliver on the obligations of GPs’ professional role. We have called this additional work “compensatory labour”. Often invisible and unaccounted for in GPs’ schedules, compensatory labour typically involved mundane tasks that crowded clinical work and led to unwanted consequences such as stress and burnout.

 

Table 1. Impact of operational failures on GPs

Impact of operational failure on GPs

Examples

  1.                               Additional steps required to complete task
  •                                 Double documentation; duplicating and repeating notes if no link exists between notification systems and patients record
  •                                 Work shifting to GPs that was previously done by others (e.g. filling in forms, scheduling patients, updating patient contact information)
  •                                 “Looping” of tasks between clinical and non-clinical staff due to uncertainty over responsibilities within practice
  1.                               Having to use workarounds
  •                                 Contacting other professionals or the patient for missing information if records are thought to be inaccurate or information is missing
  •                                 Using paper-based tracking systems of ordered tests, abnormal results etc. because electronic record does not facilitate this tracking
  •                                 Printing out notes owing to difficulties in switching between computer screens
  •                                 Disabling or ignoring disruptive electronic health record functions
  •                                 Hand-writing prescriptions or test-requests if want to add additional details that are not permitted within electronic systems
  1.                               Consumed time
  •                                 Manually inputting information that could be auto-populated
  •                                 Information systems that frequently freeze or lock GP out
  •                                 Repetitive unnecessary alerts
  1.                               Disruptions
  •                                 Interruptions to consultation from staff, other patients, phone calls
  •                                 Computer decision support alerts taking GP to other tasks
  •                                 Having to leave consultations to seek missing equipment or supplies
  1.                               Delayed decision-making
  •                                 Lack of information feedback from and difficulty reaching other healthcare providers
  •                                 Missing or delayed test results
  •                                 Trying to determine who should undertake tests requested by other healthcare services
  •                                 Not being able to locate necessary information in the notes
  1.                               Effect on GP-patient relationship
  •                                 Poorly-designed electronic health records that shift GPs’ focus away from the patient
  •                                 Alerts requesting GP to input clerical information during consultations, thereby shifting focus from patient’s complaint
  1.                               Cognitive burden
  •                                 Information overload due to multiple streams of incoming information, with relevant information obscured by repetitive or unnecessary information
  •                                 Decision support systems creating unhelpful signal–noise ratio with clinically irrelevant alerts and alert fatigue
  1.                               Dissatisfaction
  •                                 Frustration associated with delayed or missing critical information from other providers, laboratories etc.
  •                                 Stress arising from disruptions, inefficient practice organisation, hectic schedules and time pressures
  •                                 Dissatisfaction associated with large volumes of non-clinical tasks

 

Interview study with GPs about what frustrates their work

4.6          To generate evidence on the operational failures presenting the greatest challenges in the specific setting of general practice in the NHS, we conducted a qualitative study 10 involving interviews with GPs from a diverse range of practices in the East of England. Every GP participant reported experiencing multiple operational failures that were hugely burdensome. The most common failures here related to problems in the supply of information to GPs from sources outside of their own practice (e.g. delayed or missing hospital discharge letters) and systems for communicating with or referring patients to other healthcare services. Technology problems, such as crashing or non-booting computers, added extra pressure due to the already strained ten-minute consultations provided in the NHS. GPs also reported frequent unpredictable interruptions of their work by other practice staff, especially in practices with an expanded skill-mix delivering care that would have previously been delivered by a GP.

4.7          Repeatedly compensating for operational failures that were not of their own doing led to further time pressure for already overstretched GPs, and contributed to feelings of stress and low morale. GPs were often reluctant to attempt to change processes to mitigate against the recurrence of operational failures, in part because they felt they lacked time, skills or capacity to design, implement, quality assure and oversee new processes.

Mixed-method observation study of how GPs spend their time and the impact of   operational failures during clinical sessions

4.8          To quantify the impact of operational failures in terms of time consumed, we ran a mixed-method study involving (i) time-motion methods to quantify the time spent on GP tasks, and disruptions to tasks, (ii) ethnographic observations to characterise the nature and impact of operational failures, and (iii) interviews to understand what was observed from the perspective of GPs. 11

4.9          Direct observations of over 238 hours of GP work showed that operational failures represented at least 5% of GPs’ work tasks and consumed 4% of GPs’ time - a staggering proportion when extrapolated to general practices across the NHS. Further, these figures are likely to be an underestimate as observations took place within the official start and end times of clinical sessions, so failures experienced by GPs before or after the start of clinical sessions (e.g. paperwork undertaken before appointments began or once the session was completed), worked over lunch, or took work home were not captured.

4.10      Observations showed that unexpected interruptions to GPs’ work by practice colleagues, external individuals, or electronic requests seeking immediate response accounted for the majority of operational failures (approx. 80%). Missing equipment or supplies were the next most frequent category (9.4% of failures). Problems with computers and technology represented 8.6% of the failures recorded in the time-motion data, but resolving these failures consumed a disproportionate amount of GPs’ time (14.2% of time spent dealing with failures).

4.11      Consistent with the findings of the qualitative study, many operational failures related to the distinctive role of the GP in coordinating patient care - a role which necessitates up-to-date accurate information transfer to the GP from other healthcare services and healthcare providers. Failures in the supply of information from other healthcare services were very disruptive with delayed, missing and ambiguous discharge letters especially troublesome. Despite GPs’ compensatory efforts to remedy these problems (e.g. writing letters, calling other services, or working with practice colleagues to track down missing information), information failures were seen to negatively impact and delay patient care.

4.12      Another stark observation was that the GPs’ formal schedule did little to accommodate the realities of GPs’ work. As well as the workload of coordinating patients’ care and dealing with operational failures, requests and demands originated from an increasing number of external sources, much of which was fitted into the interstices of the GPs’ day. Further, it was evident that practices lacked sufficient time to design, plan and implement internal improvements that could effectively respond to changes in the volume or character of work over time, or mitigate against the risk or impact of operational failures, or character of work over time, or mitigate against the risk or impact of operational failures.

Consultation with GPs and patients about priorities for improving operational failures in primary care

4.13      To build consensus on the operational failures to prioritise for improvement work, we ran an online modified Delphi process with GPs and patients (unpublished). A convenience sample of GPs from across the NHS (n=33 across two rounds) were presented with a list of 45 failures identified in the earlier studies. They rated the following operational failures as the key challenges where improvements are crucial:

         electronic health records not functioning properly

4.14      Patients (n=33 over two rounds) were invited to participate via Healthwatch UK groups in Wakefield, Blackpool, Lincolnshire, Luton, Swindon, Lambeth and Medway. Healthwatch UK is the national health and social care champion that works to ensure the patient voice is heard by NHS leaders and policymakers. From a list of 14 operational failures (the highest scoring in the GP survey), our diverse group of patient representatives rated the following failures as priorities for intervention:

5                         Recommendations

5.1          Based on our findings, we suggest that simply recruiting more GPs and other primary care healthcare professionals – while vital – is unlikely to solve the primary care crisis on its own. Our evidence highlights a glaring void between “work-as-imagined” in general practice and “work-as-done”. To arrest current trends in stress and burnout in general practice, future policy must be designed for the world which is inhabited by GPs - and not force already exhausted GPs to function in work systems that are poorly optimised for them to deliver on their goals.

Improve health information systems using co-design

5.2          Both GPs and patients agree that reorganisation of the health information systems used to support care during clinical sessions and to share patient-related information between secondary, primary, community and social care is a priority. At its most basic, addressing this challenge requires that general practices have computers and software that function quickly and reliably, with accessible troubleshooting and back-up available to them in the event of problems.

5.3          But it also involves far more co-design across systems – including primary care, secondary care, community and social services, and patients themselves – to ensure shared goals and usability and reliability of processes and systems. A co-designed, user-tested approach would help to ensure that GPs can complete essential tasks such as referrals or other process requiring information to be sent to other services quickly and smoothly, without frustrating “computer says no” experiences. It would also help to improve the quality, veracity and timeliness of information sent to GPs by other health and social services, ensuring that it is relevant and actionable. All of this will require interdependent, integrated action with horizontal accountability and cooperation between all stakeholders, and an appreciation for the significance, challenges and vulnerabilities associated with GPs’ coordination role.

Offer practical support for improvement at practice level

5.4          Given time is already at a premium in general practice, improving systems and processes in primary care will require additional investment in terms of staffing and training to support the identification of internal failures, the development of considered, team-based approaches to address the failure and the implementation and re-evaluation of change. Options for channelling this investment include the primary care networks, or the Time for Care programme which has an existing network of development advisors and improvers in primary care.4 We recommend moving towards co-design and testing of solutions at scale, rather than having each practice trying to resolve problems individually.12

Resolve ambiguities about legal liability for delegated tasks

5.5          The evidence suggests that some improvement support can also be usefully targeted within practices, but does require external alignment to create the right conditions. One challenge, for example, is that GPs tend to retain ownership over many tasks that are potentially “do-able” by other practice staff. This is unsustainable given the rising demands on GPs and the multiple new roles that could potentially share the burden of work within general practice (e.g. physician assistants, pharmacists, nurse practitioners, paramedics etc.). Some of GPs’ reluctance arises from medico-legal uncertainties relating to task delegation. Consultation with the medical indemnity companies (e.g. MPS, MDU etc.) to clarify the medico-legal situation with respect to delegation of tasks that sit on the clinical – administrative divide, including resolution of operational failures, would facilitate more efficient task allocation within general practices, and permit GPs to focus on work only they are trained to do.

Create a reporting system for operational failures in primary care

5.6          GPs tend to resolve operational failures in real-time rather than report them to authorities such as GP liaison officers, commissioners and others. We recommend the development of pathways for GPs and practices to report the operational failures that they encounter, potentially at the level of integrated care systems. Desirable features of this system include a simple reporting template (that would not in itself add significantly to GP workload) and prompt feedback to GPs that their report is being investigated and acted on. Such a system would also help in identifying recurring problems and focusing efforts for improvement.

 

 

 

 

 

 

 

 

 

 

References

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2. Fisher RF, Croxson CH, Ashdown HF, et al. GP views on strategies to cope with increasing workload: a qualitative interview study. The British journal of general practice : the journal of the Royal College of General Practitioners 2017;67(655):e148-e56. doi: 10.3399/bjgp17X688861 [published Online First: 2017/01/18]

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4. NHS England. Releasing time for care https://www.england.nhs.uk/gp/gpfv/redesign/gpdp/releasing-time/ [accessed 28th October 2020.

5. NHS England. GP Access Fund, https://www.england.nhs.uk/gp/gpfv/redesign/improving-access/gp-access-fund/ [accessed 28th October 2020.

6. NHS England. General Practice Resilience Programme 2018–19,. https://www.england.nhs.uk/wp-content/uploads/2017/07/gp-resilience-programme-guidance-1819.pdf 2018.

7. Fisher RFT, C.; Gershlick, B.; Alderwick, H.; THorlby, R. Feeling the strain. What The Commonwealth Fund’s 2019 international survey of general practitioners means for the UK. The Health Foundation 2020

8. Tucker AL. The impact of operational failures on hospital nurses and their patients. Journal of Operations Management 2004;22(2):151-69. doi: 10.1016/j.jom.2003.12.006

9. Sinnott C, Georgiadis A, Park J, et al. Impacts of Operational Failures on Primary Care Physicians' Work: A Critical Interpretive Synthesis of the Literature. Annals of family medicine 2020;18(2):159-68. doi: 10.1370/afm.2485 [published Online First: 2020/03/11]

10. Sinnott C, Georgiadis A, Dixon-Woods M. Operational failures and how they influence the work of GPs: a qualitative study in primary care. The British journal of general practice : the journal of the Royal College of General Practitioners 2020 doi: 10.3399/bjgp20X713009 [published Online First: 2020/09/23]

11. Sinnott C, Moxey JM, Marjanovic S, et al. Identifying how GPs spend their time and the obstacles they face: a mixed-methods study. The British journal of general practice : the journal of the Royal College of General Practitioners 2021 doi: 10.3399/bjgp.2021.0357 [published Online First: 2021/12/01]

12. van der Scheer JW, Woodward M, Ansari A, et al. How to specify healthcare process improvements collaboratively using rapid, remote consensus-building: a framework and a case study of its application. BMC medical research methodology 2021;21(1):103. doi: 10.1186/s12874-021-01288-9

December 2021