This series of three short articles highlight projects I’ve worked on that help describe the future direction of the NHS, supporting the government’s 10-year plan, and the ambitions of our wider health and social service systems in response.
NHS Futures 1 of 3: Population Health & Systemic Shifts
NHS Futures 3 of 3: Health Ecosystems & Open Cultures
Context and Why This Matters
I have been involved in a number of digital transformation projects within the NHS and across partners. Some projects operate in the more abstract and internal world of organisational change, with the behind-the-scenes effects felt by staff and patients indirectly. Other projects dive deeply into the experiences and interactions of staff and patients with current and upcoming technology, often lighting the way forward for positive changes and the introduction of new interfaces and systems.
This particular project dealt with the very immediate and tangible ‘8am scramble’ for appointments at GP surgeries.
The current (and thankfully quickly receding) experience often looks and feels like this: Phone lines open at 8am, when many people are taking kids to school, commuting to work or need to get out of the house and start their day. Patients are in competition with one another in phone queues for a limited number of appointments. Some surgeries only allow same-day bookings, with the unlucky ones still on hold being told to try again tomorrow.
Finding ourselves in this situation had become a national source of frustration and was often referred to as an indicator that the NHS was struggling to cope. Furthermore, in a world where we can book anything anytime, from hotels to after school care to taxis to pub tables, these everyday service comparisons underlined the gap between service expectation and what was being provided.
The Project & Approach
33 practices in 4 Primary Care Networks were involved and committed to improving patient access, in pursuit of fulfilling the 2023 GP Contract which states that patients should be offered an assessment of need or be signposted to an appropriate service at first contact. But each practice has a unique context of different population characteristics, needs and demographics, staffing approaches and technology platforms, as well as holding different visions of what improved access might look like and how to bring this about.
Understanding patient experiences, needs, channels and behaviours quickly underlined the obvious pain points and yielded insights as to the latent needs and underlying factors. But in order to make change it was crucial to understand the experiences and constraints on surgeries and staff, and understanding what underlying systemic and operational factors were driving how we ended up in this situation. The demands on call-handling staff affected staffing levels, and patients who were rightly disappointed and frustrated could sap morale and even create a siege mentality, where administrative staff felt they were a squeezed line of defence between patients and clinicians. This even effected the physical layout of waiting rooms we visited, with barrier lines of reception desks and high glass walls.
A patchwork of technology (aka ‘App salad’) and hybrid adoption approaches had created change fatigue and skepticism of new systems, with veteran staff understandably defaulting to what they knew. Reception administrators held a lot of tacit knowledge and intuition in order to triage and redirect effectively, and could ‘feel’ a constantly shifting picture in their minds of capacity and flexibility, beyond what current systems were able to tell them. Everyone cared and wanted the system to work, but too often felt that change was too difficult, or ignored contexts and constraints.
Image: Simplified diagrams showing appointment requests across practices throughout the day and common flows through different channels
Four Key Approaches, Insights and Outcomes
Build Trust In Person
Twelve practices were visited for in-person research with patients and different staff roles, providing bottom-up insights that were balanced with the top-down priorities on technology adoption and performance outcomes. This time amongst people at surgeries was invaluable for building relationships and trust, and ensuring that practices were heard and their situations and aspirations were represented. We took pains to plan in-person workshops with all practices that had plenty of time dedicated to airing and sharing common experiences and barriers before moving into designed activities.
Decentralise Change, Share and Celebrate What is Working
Key to making this transformation happen was to not take a centralised, top-down or mandated approach for making change, but to create a community of practice and a process of practice-led learning and improvement building towards a common vision. With every practice we visited, we took pains to identify ‘What other practices can ask us about’ to help facilitate the sharing of good practice and to not position ourselves as the arbiters of ‘good’. Encouraging GP surgeries to report back on different metrics on the channels patients were using to make appointments created tangible progress and friendly competition, which was married with case studies and celebrating successes that acknowledged each unique context.
Prove It!
Staff accept that introducing new models involves extra time in training and getting systems up and running, but rightly have very clear requirements that a new system should save time, reduce the number of steps to the desired outcome, and that any new steps or processes must return new value in the form of time saved elsewhere, or more useful features and desirable functions. With so many variables between each practice, this could not be an exercise solely in promoting adoption of new tech and processes as a panacea, but ensuring that everyone could see and feel positive difference through adjustments to patient communications, staff training and other wider changes beyond technology.
Digital Is Not For Everyone
With multiple routes and channels to reach their local GP practice, patients become keenly aware of the paths of least resistance and trade-offs. Some prefer a human confirmation and knowingly choose the longer wait on the phone; others adopt digital platforms early as a way to book appointments on the move, and some choose seeing their regular GP at a later date later rather than take up an offer to see another suitable clinician sooner.
There were strong demographic trends around app adoption or rejection among patients, but by highlighting which practices had higher adoption, how they achieved it and how it reduced call volumes, other practices were encouraged to redouble their efforts in more targeted ways.
Wider Systemic Benefits
This project had to make sense to every practice, and married the reflections and observations of staff and patients with the hard data of adoption and performance across practices. It catalysed uptake and adoption of the tech platforms available, tailored to each GP surgery’s staff, context and population.
But zooming out from fixing the ‘front door of the NHS’ and improving access to primary care we know that we can take pressure off the system in the future by detecting and acting early to prevent and proactively treat conditions. This is directly demonstrated with the outcome below:
– North West London ICB