In his latest blog Ben reflects on attempts to set up an outsourced GP visiting service and what it taught him about the way GP practices innovate.

A few years ago, when I was working in a GP federation, we set up a GP visiting service. The basic premise of the service was that, because GPs were so busy, they were not able to meet all the patient requests for visits. As a result, we hypothesised, patients were being admitted to hospital when an admission could potentially have been avoided if a visit had taken place. So we funded a pilot in which the out-of-hours service provided a GP to carry out visits during the day that they would not otherwise have been able to carry out.

Do you think it worked? It didn’t. The service was not fully utilised (despite only one GP being available for 30 practices). Uptake was limited to a relatively small number of practices, with many of the practices rarely, if ever, using the service. It was not possible to produce any correlation between the service itself and emergency admission rates (which instead stubbornly continued to rise), and, unsurprisingly, the pilot was stopped.

Contrast this with a practice I visited recently. There they have paramedics for 6 sessions a week, who carry out 5 or 6 visits a day, for a practice that in total undertakes between 7 and 10 visits a day. There are clear parameters in place for visits the paramedic will undertake and those that are best carried out by a GP, e.g. palliative care visits. The practice is extremely happy with the service and is soon to increase the number of paramedic sessions from 6 to 8.

In Shropshire the local out-of-hours provider Shropdoc has developed an Urgent Care Practitioner role in which staff with a paramedic, nursing or physician associate background are trained to be able to offer (amongst other things) home visits for GP practices. The role is proving extremely popular both with staff and practices alike. You can see a video of the service here.

A visit for a GP, with all of the travel involved, is a time consuming activity. While average consultation times may average 8-10 minutes, the total time required for a visit is at least double that, and often much more. Practices vary considerably in the number of visits they undertake. A recent comparison across five practices working in the same town revealed a fivefold difference in visit rates – varying from an average of 0.2 visits per 1000 patient population per day, to 1 visit per 1000 patient population per day.

So where did I go wrong with the GP visiting service we instituted, and what are others now doing right? I think I failed to fully understand visits are an integral part of the service a GP practice offers. Any attempts to change the way they are carried out must be fully owned and bought into by the GPs in the practice. Trying to “outsource” visits to a separate agency that does not know the patients is unlikely to work. A more successful approach is to use other roles, as long as they operate under the guidance of the GPs and not separate from them.

Equally, success in the redesign of GP visits cannot in isolation be measured by the number of emergency admissions. It is the continuity of care GP practices offer that will ultimately support patients to manage their conditions effectively. Freeing up scarce GP time to be deployed where it is needed most (which, paradoxically, will sometimes be in a patient’s home) is now a critical factor in enabling this, and would have been a much better measure of success.

It is hard to replace the long hours GPs work (at no extra cost) with a paramedic or nurse practitioner in a small, cash-strapped practice. As practices become bigger they have more freedom and more flexibility to experiment with different systems for triaging requests for visits, with the introduction of new roles, and with new ways of working for visits.

In my attempts to set up a visiting service I should have remembered that most successful change in general practice is generated within the practice itself, not imposed from outside. Changing the system for practice visits proved to be no exception. In future, as practices become larger they will have more capacity to test different ways of working and that is one of the reasons I established Ockham Healthcare; to support and promote the many innovations that will inevitably result.