Safe working limits for GPs

Mar 30, 2023

The GP workforce is experiencing extreme pressure, exacerbated by staff shortages and unprecedented demand from patients with increasingly complex needs. Long working hours and excessive workload are leading to stress, burnout, and low morale. These factors impact on the quality of patient care and increase the risk of errors in decision-making.

April is Stress Awareness Month, so we take this opportunity to look at how practices and GPs can prioritise care to deliver health services within safe working limits.

Pressure on GP services is unsustainable

The winter of 2022/23 has seen exceptional demand for GP services. Many surgeries have struggled to cope with the deluge of patients requiring same-day appointments, leaving some practices with no choice but to cap the number of urgent appointments.

Based on its ‘Fit for the Future: GP Pressures Report 2023’ report, the Royal College of General Practice (RCGP) has warned that one in four practices is at risk of closing, with “unmanageable workload and workforce pressures fuelling an exodus of fully qualified GPs”.

Clearly, support is needed to retain the practice workforce and manage ongoing demand in a way that prioritises safety and wellbeing of both staff and patients.

What does a safe workload look like?

The British Medical Association (BMA) report on ‘Workload Control in General Practice’ highlights the importance of agreeing individual limits for safe practice, which will depend on the practice setting, contractual status and preferences of the individual, as well as the complexity of patient needs.

In its guide to ‘Safe working in general practice’, the BMA recommends that:

• A safe level of patient contacts for a GP is not more than 25 per day. However, the number of daily contacts considered ‘safe’ may vary according to the above factors.
• Practices should move to 15-minute appointments. This is in line with evidence on quality of care, reduces the need for repeat consultations and maintains patient satisfaction.
• A standard GP session lasting 4 hours 10 minutes should include a maximum of 3 hours with patients as well as adequate rest breaks to avoid risk of harm to patients and clinicians.
• Practices should consider closing their practice list if they are at the limit of their capacity to provide safe care.

Strategies to promote safe working limits

The BMA states, “The present crisis is so severe that we recommend practices take urgent action to preserve patient care and protect the wellbeing of their staff.” This must be done within the constraints of the general medical services (GMS) contract.

Strategies the BMA recommends include:

Manage same-day demand. The BMA strongly recommends moving away from a duty doctor system with uncapped demand. Triage by appropriately-trained staff should prioritise care according to clinical need, and when the daily safe limit on capacity is exceeded, patients should be redirected to other services or placed on a waiting list. If a waiting list is used for non-urgent care, patients should be given instructions about what to do if their clinical condition deteriorates.

When demand outstrips capacity, patients may be redirected to services including NHS 111, urgent treatment centres, extended access hubs, walk-in clinics, clinical pharmacy consultation services, or ARRS staff. Emergency or urgent problems may be directed to emergency departments or 999.

Importantly, the GMS contract for 2023/24, which is being imposed from April 2023, states that “patients should be offered an assessment of need, or signposted to an appropriate service, at first contact with the practice. Practices will therefore no longer be able to request that patients contact the practice at a later time.”

Prioritise core GP functions. The BMA urges practices to focus on providing core GP services within the GMS contract and to cease doing unfunded non-core work. Practices are not obliged to undertake non-contracted work on behalf of secondary care providers and other agencies. Such requests may be pushed back and the Integrated Care Board notified (the BMA provides template letters).

In addition, practices are advised to consider whether the requirements of the Primary Care Network Directed Enhanced Service (PCN DES) outweigh the benefits. Practices may tell their Integrated Care System that they wish to discontinue the DES between 1 and 30 April 2023 or whenever there is a change to the DES.

The BMA says: “It is likely to be the case that practices provide fewer services to their patients in order to preserve the central core services of general practice.”

Record data on all patient contacts and monitor working hours. Accurate data is essential for effectively managing workloads. The BMA encourages practices to account for all patient contact within their appointment books, so that NHS England data reflects reality. Once recognised, excessive work demands can be prioritised and appropriately managed or delegated.

Please contact us at Medical Defense Society if excessive workload in your practice may be affecting your wellbeing or compromising the safety of your patients. We provide members with expert medico-legal advice 24/7.

Supporting junior doctors in general practice

Mar 1, 2023

Junior doctors in England have voted overwhelmingly for strike action as they campaign for increased pay. The 72-hour walkout, on 13–15 March, will include GP trainees, who make up 15% of all junior doctors in England. Therefore, GP practices should be prepared for potential disruption to services during this time.

The real-terms pay cuts and unsustainable working conditions that lie behind the wave of NHS strikes are also driving junior doctors to leave for better pay and quality of life in positions elsewhere. Given the GP workforce shortages, it is vital that primary care teams make every effort to support junior doctors in general practice to encourage increased recruitment and retention of GP trainees.

Employers’ responsibilities towards junior doctors in general practice

Many junior doctors choose to specialise in general practice and see it as a potentially rewarding, if challenging, career to pursue. However, the experiences they have as GP trainees will influence whether they continue to work as GPs for the NHS in the long-term. Their employers in general practice have an important role in helping them feel valued, supported, and safe as they undertake their training. In return, GP trainees can bring new skills and ideas to a practice and contribute to appointments and administrative work.

The British Medical Association (BMA) provides advice for practices in England that choose to employ GP trainees under the 2016 contract. In particular, practices and employers must be aware of their contractual obligations in work scheduling, exception reporting, and provision of guardians of safe working:

Work scheduling:

• Each trainee receives a generic work schedule, detailing work commitments, training objectives and a rota. The trainee and their clinical supervisor must personalise this to suit the trainee’s learning needs and the opportunities available, with ongoing review to ensure that it remains fit for purpose. Employers are also required to take account of reasonable requests to ensure the work schedule fits around the trainee’s life (e.g. caring commitments).
• GP specialty training in a general practice setting is subject to specific requirements with regards to work scheduling; the relevant guidelines, templates and examples are available from NHS Employers.

Exception reporting:

• Trainees must be provided with an electronic system for submission of exception reports and encouraged to use it to detail instances where their actual work and training differ from their work schedule.
• Clinical supervisors must review and discuss exception reports with the trainee to agree any actions, such as revising the work schedule and approving claims for additional pay or time off in lieu.

Guardians of safe working:

• Trainees must have access to a guardian of safe working who will oversee compliance with safeguards in the 2016 contract and be a champion of safe working hours for junior doctors.
• The guardian will receive a copy of exception reports and should be consulted about any concerns over working hours or training opportunities if the GP trainee and clinical supervisor cannot find a solution together.
• The guardian may levy a penalty fine if the trainee’s working hours breach certain limits, although this should never occur if work scheduling and exception reporting systems are applied correctly. If a fine is necessary, it should prompt an investigation and remedial action to ensure that the breach is not repeated.
• Information and resources for guardians are available from NHS Employers.

Supporting industrial action by junior doctors

In previous NHS strikes, the BMA has urged doctors to support their colleagues and advised members on how to show moral support without compromising their professional responsibilities. With the upcoming industrial action by junior doctors, practices employing GP trainees can demonstrate their support by understanding and upholding their junior colleagues’ employee rights.

The BMA guidance for junior doctors about strike action considers their employee rights including protection from unfair dismissal, allowances for annual leave, as well as the consequences for pay. Note that all GP trainees working under a contract with an NHS employer (single lead employer and/or GP practice) can join the strike, although the decision to take part is a personal choice.

Ahead of the industrial action, NHS trusts and employers will need to plan carefully to minimise disruption of essential services. In primary care, some patient appointments with GP trainees may need to be rearranged and certain clinics may have to be cancelled. However, the full impact of the strikes may be difficult to predict. It is important to know that junior doctors are not obliged to inform their NHS trust about their intention to participate in strikes and the BMA advises that to do so would undermine the action.

If you would like more advice about junior doctors’ rights during strike action or if you need medico-legal support regarding any other aspect of GP training, please get in touch with our expert team at Medical Defense Society.