Our response to the Darzi Report

Primary Care is not alone in feeling the pressure to achieve more with less; the NHS is stretched across all functions. The release of Lord Darzi’s findings last week do not come as a surprise to anyone working in the NHS. Significant changes are needed to ensure improved productivity, outcomes, patient safety, and workforce satisfaction. The report highlighted that productivity is low, and NHS budget not being spent where it should be; too much is being spent in hospitals and too little in the community.

Despite being difficult to measure, it is widely accepted that in 2024, NHS productivity remains lower than pre-pandemic levels. The COVID-19 pandemic catalysed a pivot to teleconsultation and remote monitoring, with the hope that these would be the solution. Four years on, we are not seeing the productivity gains required to tackle rising chronic disease in an ageing population. There is a national drive to create sustainable productivity growth to an average of 1.9% from 2025-26 to 2029-30, rising to 2% over the final 2 yearsⁱ, but the question remains: with a waning workforce and increasing costs, how do we achieve this? According to the NHS, key leversⁱ  include:

Like many practices, our client worked hard to ensure that their coding was as accurate as possible. This included:

• Focusing on health rather than illness (proactive, tailored care)
• Maximising value for money (reducing duplication in the system and increasing efficiency)
• Embracing 21^st century technology (ensuring fit-for-purpose hardware and software that aids, rather than hinders, our workforce)

These are mirrored by Lord Darzi, who calls to:

• Lock in the shift of care closer to home by hardwiring financial flows
• Simplify and innovate care delivery for a neighbourhood NHS
• Tilt towards technology

One challenge many GP Practices face is where to focus effort at different times of the year. The nature of Primary Care and its associated QOF and Long Term Condition (LTC) remuneration, means that there will always be two large buckets of work to complete throughout a financial year; predictable work (QOF requirements, LTC monitoring), and less predictable work (acute, unscheduled care). However, an ageing population means an increased number of patients with one, or more, LTCs, which means the first bucket grows year on year. The Darzi report shows that by the time patients are 65-74, the majority will have one LTC, and 40% will have two or moreⁱⁱ (see Fig. 1 below from the Darzi report).

Government and media pressure to provide rapid acute access distracts from the ability to focus on known predictable work, and the ability to focus on health, rather than illness. The QOF and LTC system means that even the proactive care that we do provide, largely focusses on preventing existing illness from progressing, rather than on preventing healthy individuals developing illness. Nationwide, there is a scramble to complete outstanding monitoring during February and March. This makes the last month of winter especially challenging for GP Practices trying to complete the requirements fortheir remuneration, whilst simultaneously providing winter acute care. By utilising health data, in theory each practice should be able to forecast and plan its predictable workload to distribute it in manageable portions throughout the year, and avoid the end of QOF year push. This would enable more efficient workforce planning, and undoubtedly increased workforce satisfaction.

The challenges for Primary Care do not stop there. The Darzi report states that we have almost 16 per cent fewer fully qualified GPs than other high income countries (OECD 19) relative to our populationⁱⁱⁱ, meaning each GP is responsible for more patients, year on year. The Health Foundation predicts that by 2030/31 there will be a shortfall of between 3,300 and 20,400 GPs^iv, depending on whether you subscribe to best or worst case scenarios.

Despite this, it is commonly agreed amongst healthcare providers, patients, and Lord Darzi, that good preventative healthcare in the community reduces the requirements for secondary care intervention. There will continue to be huge pressures on Primary Care to provide urgent and unscheduled access, whilst maintaining patient safety through LTC management and monitoring. Although the latter demand fits into the predictable bucket of work, inefficient use of available data, a dwindling workforce and a reliance on workarounds, manual processes and fragmented technology, mean that many GP Practices will find it increasingly difficult to achieve what is expected. To complicate this further, monitoring requirements stem from different rulesets and for multiple LTCs. In practice, this requires

• Significant time investment from the workforce
• Slow Searches within the patient record
• Duplication of appointments due to missed monitoring opportunities

This entire process can be improved by investing inappropriate, integrated and fit-for-purpose technology. However, despite research by the NHS Confederation showing that spending in primary and community settings has a superior return on investment^vi, the Darzi report confirms that investment in IT systems continues to focus on acute hospitals, rather than other providers. Despite this, the onus remains on Primary Care to achieve more, with less.

The most commonly accepted measure of Productivity compares the number of outputs (appointments and procedures) against the number of inputs (staff numbers and costs). According to the Royal College of General Practitioners (RCGP), GPs carried out 36 million more appointments during 2023 than during 2019^viii, even when excluding COVID-19 vaccination appointments. This is despite the number of fully qualified GPs in the workforce dropping by 7% since 2015^ix, and real term GP funding per patient falling by 7% since 2019^x. Judging by these metrics, isn’t Primary Care already contributing its fair share of effort to the NHS Productivity drive?

On face value, the levers identified by the NHS and Lord Darzi seem to be the correct tools, but what do they mean for Primary Care? Are they enough, and how can we achieve them? By drilling down more, we identify 3 core pillars with which we can achieve more without increasing demands on our workforce. This will require a strong foundation of strategic planning to:

• Integrate automation: Integrate best-in-class technology in practices to reduce repetitive manual tasks, reduce inefficiency, and increase valuable time for workforce to deliver proactive care. Increase value for money by enabling staff to focus on higher value tasks and care provision.
• Make Every Contact Count: Enable opportunistic, proactive care and monitoring; increasing appointment efficiency, and reducing the need to call patients back again. This reduces duplication, increases capacity, and enables a focus on health, rather than illness, through opportunistic care and screening.
• Forecast, and plan for, predictable work: Flatten, or even invert, the curve of activity throughout the year to allow consistent workforce planning to meet demand. Increase focus during summer months and avoid end-of-year staff burn out; increase workforce satisfaction and possibly improve retention.

The technology to enable automated proactive care already exists. We call for evidence based investment in technology systems that work to achieve the above in Primary Care settings. Over 30 Integrated Care Systems and 130 Primary Care Networks have already started on this journey by embedding Abtrace Proactive Monitoring to automate their recall, ensure easy visibility of opportunistic patient requirements, and to use real time dashboards to plan for predictable demand.

Practices are already achieving a 71% success rate for Blood Pressure recall within 5 days of automation and spending 60% less time on repeat prescriptions by taking advantage of clear, tailored traffic light ratings for patients’ monitoring requirements.

If this can be achieved at grass roots practice level, imagine what could be achieved at-scale, with centralised investment that prioritises LTC monitoring and management. By incorporating best in class technology, we may already be on track to achieve productivity targets, without sacrificing our precious workforce’s morale. The tools for increased productivity are already available to us; we just have to be bold enough to use them.