The humour of David Walliams’ character Carol Beer is all human, of course. “Computer says no” would never work if an actual computer said it. At least the hapless customer can try to reason, to get that look from Carol.
So when an actual computer says no to your patient in their time of need, it’s a punch in the face.
Let’s say you have pain in your hand (arm,, shoulder, hip, knee, ankle, foot, it matters not). It’s been there over six months, came on gradually, still mild but you decide you are going to do something about it and see the GP.
You put all this into webGP/eConsult, as you can’t seem to get through by phone. Then it asks:
Did the pain come on after an injury?
Yes No Not sure.
Honestly after six months it’s not at all clear, so “Not sure”
Computer says no.
Up comes the big red box listing six things you should do, from “seek urgent medical advice” right up to “go to A&E”. The one thing you can’t do is carry on with the eConsult. It stops right there.
Now I’m not suggesting that A&Es are filling up with cases of mild hand pain of uncertain origin over six months old. Most patients have far more sense. But who do we have to thank for this sage advice? Drs Clare Gerada, Arvind Madan, Murray Ellender and co at Hurley.
At the last count some 212 of what they call “red flags” were embedded in eConsult, sometimes as subtle as the difference between scoring pain at 5 or 6 out of 10. It can be a superhuman challenge to navigate your way through a questionnaire to reach the submit button.
“Red flags” are touted as a safety feature, but of course there is logically no way to cover all red flags for all patients in all circumstances. Any reassurance we may feel is false. Yet thinking you are wearing a safety belt, when it’s made of paper, is itself dangerous.
The one thing patients don’t have is patience, and this is the killer with red flag thinking. When the computer keeps saying no, patients won’t bother again, they go back to pleading with a human, however stressful. This is at the root of the study finding, “Online consultations don’t save time or money” where 36 Bristol practice running eConsult moved just 0.16% or 1 in 600 demands online, and this most commonly for admin issues.
As you know we have an interest in this through askmyGP, but our thinking is driven by the evidence of “what works?” We have to enable GPs to be much more efficient, and while online consultations can be a part of this (GPs tell me they save 3 minutes with each one), they only work if lots and lots of patients use them.
We’re up to 30% so far (see Concord case study), and we’re working on 50%. That will only happen if we welcome all patients, all problems, we give them a great service, and we find that patients want to help.
Computer NEVER says no.
PS You can try askmyGP as a patient on Bramley Demo Surgery. It’s simple because we tried clever and complex and it sort of worked, just not well enough. If only we’d realsed sooner! Anyway patients and practices love the new simpler version, and it’s focussed all our efforts on GP productivity.
PPS If you can’t get enough of Carol’s “Computer says no” you can see her with German subtitles for extra giggles.
Known since before Tudor times, named Gresham’s law in 1860, thoughtful observers have realised that “Bad money drives out good”. When two forms of currency are in circulation, the debased version quickly replaces that of true value. It’s happening now, paid for by the NHS, in general practice.
Oxford CCG proudly trumpets the big numbers, “15,000 extra GP appointments in £4m scheme.” Divide £4m by 15,000 x 12 months and we find the cost per appointment is £67. That’s over twice the fully absorbed average cost of a regular GP appointment.
It gets worse: regular GPs are funded by capitation, not by activity (per appointment) and their contract means they are already responsible for their registered patients who are or believe themselves to be ill. The CCG is paying £6 per patient for a service already fully funded – it’s paying twice. But not the CCG – it comes from an NHS England pot, descended from a GP Access fund which covered less than 10% of England – a lottery as to whether your area is included.
It gets worse: a GP federation officer says it’s for those patients having to wait 2 to 3 weeks to see their own GP. These GPs are failing their patients with an appalling service. They are being rewarded for failure, incentivised to fail more as worse access will move more of their patients into the “extended service hubs”. Patients at GPs offering an excellent service, such as Oak Tree Didcot which we helped over 5 years ago, have no need and no desire to travel further to see a doctor they don’t know.
It gets worse: my Didcot GP friend tells me “it is virtually impossible to find GP locums or recruit GPs because many are now working in these hubs seeing relatively straight forward problems, with 15 minute appointments, whether the patient needs 15 minutes or not.” [and we know that utilisation of slots is low, many will be left empty]
All right thinking people can see this. So why is it happening? Control of the money lies with those who don’t want to see: NHS England, who knows why, Oxford CCG who think they have a “nice” headline, and the GP federation owners so happy to take up the offer of highly profitable light duties. £4m will get soaked up in a year with no difficulty at all, and when the money stops, so will the service. This is the very antithesis of sustainable continuous improvement.
What can you do? Fight this debasing of general practice with every bone in your body. The RCGP, BMA and all in leadership positions should be calling this out. Local GP Dr Helen Salisbury says, “It might be better if we could just fund GPs properly,’ Too right. NHS funding must go to where it is of highest quality, most effective and productive, core general practice.
I don’t like to end without hope, because we need hope, and Gregory Bateson’s analogue is worth noting: “the oversimplified ideas will always displace the sophisticated, and the vulgar and hateful will always displace the beautiful. And yet the beautiful persists.”
Fight for the beautiful.
PS last week’s launch in Surrey has gone well, GPs dealing with all demand on the day, patients amazed. A couple of examples stood out for me on day one: the lady who walked straight to the desk at 8:35 expecting a queue of 10 and a rammed waiting room: nobody. Look of total bewilderment – “are you open?” And the patient late in the afternoon who, on the way out, stopped at reception to thank the whole team for the wonderful service she’d had. Gets me out of bed every morning.
I do hope you are thoroughly refreshed and have enjoyed the break from my blog. I mean your work. Oh, whatever, I’ll stop digging.
But I wonder how you view the thought of a 10 hour working day? Horror or relief? It’s relative isn’t it, because to some that would be 2.5 hours over the regulation 7.5, to others it might bring sanity at last to a regime which has been 12 or even 14 hours. People aren’t made for that and whatever you earn, it can make life not worth living.
So I was struck when a GP partner recently said she had this burning ambition for a 10 hour day, when completing our Leading Change Questionnaire (we do this with everyone thinking about system change. Nothing matters more than having a burning ambition).
Reducing GP workload has been number one topic in Pulse, BMA, RCGP and goodness knows where else, and the bad news is that we can’t wave a magic wand to reduce it. There are lots of factors. One is patient demand, which is remarkably constant, whatever we do. It isn’t going up, though revisiting a Liverpool practice we first helped five years ago is encouraging – demand is down 10%.
But what we can do, and to some this does seem like a miracle, is dramatically improve efficiency. It’s intense, and getting it right means careful analysis of consultation times, modes, referral and resolve rates, but it does work. Unmet demand is a factor, and simply meeting this can soak up a proportion of time freed up by a 20% efficiency gain, but almost always there’s plenty left over for getting the hours down.
Efficiency is our absolute laser focus – how you convert that to your benefit is up to you.
Overwhelmingly GPs tell us “I feel more in control”, as another partner did last month having launched in June, and it’s the control that makes work satisfying, even though it can be intense.
We love what we do and those kind of comments get me out of bed every morning. It will be an early start Monday to be at our first autumn launch in Surrey – I can hardly wait.
Are you enjoying the Proms? I’ve only been a couple of times but I love the wealth of music on offer, some familiar, some challenging.
David Sawer’s “The Greatest Happiness Principle” and the Proms Extra talk got me thinking last Saturday. We put “Happier GPs” on our askmyGP home page, because it’s a direct quote from GPs. But what might that mean? A non-stop cheesy grin, I think not.
The evidence is that we don’t consciously think of ourselves in a state of happiness (the strong conscious emotions are the negatives), but we are living in the moment. Contributors include:
- doing something good for others
- flow, being totally absorbed at the limit of our capability
- control of our own time and efforts
It isn’t the same as an “easy life”, pleasures with which we may relax but too much of which don’t give us meaning. So we aren’t saying to GPs, put your feet up, but reflecting the kind of things they say. Last week I was in a practice where one partner reflected “I feel so much safer now” (they are dealing with all demand same day, where it had been only 40%).
In another, the manager said last Thursday they had all finished by 4pm so they went home except for the one on duty, who dealt with five calls before 6.30. That’s not every day, but most GPs would have a clinic full of patients booked three weeks ago who may or may not turn up. In contrast, knowing you are providing a fabulous service and can have that flexibility is enormously liberating.
You don’t need me to tell you that the narrative in the medical press is so different, and BMJ front page last week has BURNOUT in big capitals. But the editorial is right on the mark: “Solutions have traditionally focused on individuals and their resilience.” whereas, they continue, “A systems level approach is imperative…”
We couldn’t agree more. It’s the system.
PS this makes me a little bit happy, the first askmyGP feedback at 8 this morning, “I really like this new service and I cannot say enough how much easier this is to access medical treatment. The surgery is fantastic.” This theme is so often repeated that it’s getting boring. The meaning for me comes in asking, “How can we multiply it by ten thousand?”
When I was five I used to love asking my farmer uncle how he counted his sheep. “Count the legs and divide by four” he was sure to reply, and I was sure to giggle. Thanks Ray, for the laughter and learning you sparked.
Measurement, a kind of counting with maths, is a huge part of what we do and we are always trying to make it simpler and clearer.
The simplest, most important measure in general practice is demand – by month, week, day, hour.
Then comes the service response – how fast, how soon? That’s what matters most to patients. Why isn’t anyone else doing this?
Then comes efficiency – how long does it take to deal with all those demands? That’s what matters to GPs and staff – they want a reasonable working day, and without harming patients improving efficiency is the surest way.
All these are operational measures we derive on an industrial scale with minimal effort and immediate visibility.
So It grieves me to see hundreds of £k spent on fiddly little “improvements” which make no attempt to measure benefit for patients. They trumpet thousands of hours saved – which turn out to be approximately 17 minutes per GP per week.
It grieves me to see the vast expense on poor substitutes for measures, postal surveys with small samples and smaller response rates, reported months later. Counting legs.
It grieves me to see the BMA making threats to close GP lists, unable or unwilling to frame questions of capacity in terms of efficiency.
When you make a step change in efficiency, lots more becomes possible in ways we can’t measure with numbers.
Read in Pulse how Dr Steve Edgar describes “Taking back control”, using terms like autonomy, mastery and purpose, with time for the simple team huddle.
If you’re heading to the hills this week you’re sure to see a few sheep. Yan, tan, tethera…
PS Reminder of the poster study of online consultations at Concord Medical Centre. Another step on the efficiency road.
A quick note with exciting news, we’ve just had our poster published at the Society of Academic Primary Care SAPC Annual Scientific Meeting in Warwick.
askmyGP has now passed over 50,000 patient episodes, 4,000 of them on the all new platform launched just two months ago.
The case study with Concord Medical Centre, Bristol, is here:
What took demand to 30% online? In a nutshell, it’s:
– Personal (“Hello, I’m Dr Bradley…)
– Universal (all patients, all problems)
– Responsive (we’ll get back within the hour)
– Simple (“Easy to use” main theme of feedback)
We took the decision in version 2 to take OUT the clever technology we’d put in v1.
It’s much simpler, with the aim of putting patients in faster, easier, touch with their GP, and vice versa. It builds trust by allowing patients to express exactly what they mean.
The result? Positive feedback has shot up, both from patients and GPs.
Dr Simon Bradley comments:
“The thought that goes into putting something into writing often helps the patient to have reflected on their problem prior to initiating a request.
Then for the clinician to have reflected on the request and reviewed relevant elements of the record means we can be more aligned with the patient’s agenda.
Online communication is asynchronous which allows both patient and practice to use their time more effectively.”
Aha. Time. The only absolutely finite resource.
Time for recreation too – enjoy the weekend.
Download pdf: What makes patients use online consultations?
Summer may be a-coming in, we will see beaches and I promised to take a look at that pattern of patient tidal flow.
GP demand is like a rolling wave. Or quite like a skijump, or one side of a volcano, but let’s stay with the wave for the purposes of surfing.
We’ve analysed hundreds of practices and when you allow patients call any time in working hours the pattern is strikingly similar across the board. The calls start high when you open at 8, stay there for a short time and from 9 fall rapidly through the morning. They flatten out through the middle of the day and early afternoon, then tail off from around four down to very little by 6.
Aha. So how to respond?
- Tidal deniers: “We hold our partnership meetings at 8.30 on a Monday morning. Works well for us as everyone is in, perfect start to the week”. If only they spent five minutes in reception.
- Tidal self harmers: “Sorry, what do you expect, it’s already 8.17 and there’s nothing left. Call back tomorrow but make it early I should to be sure of an appointment” Funny how every day is the same.
- Dudes: we’re ready, on it as the demand comes in, phone or online first response, deal with it now, decide to see some later when incoming is quieter. Stay on the wave, take a break, mentally prepare for face to faces, back for next session. It’s a full on day, but we feel in control.
Someone accused me on Twitter this week of common sense and I strenuously deny all charges, but really, is it that hard? So why do patients wait an average of 5 days to get help from their GP? And why do GPs end the day shredded?
One practice we’re working with has hit a median response time by a GP to any patient demand of 17 minutes. Within five weeks of launch. 17 minutes. Surfin’
askmyGP & GP Access Ltd
PS Delighted to see that Matthew Swindells, new Director of Operations at NHS England, is starting to call out NHS111 for the monstrous waste that it is. I wrote this on the launch of 111 in 2013. Sad to say that it’s taken a change of personnel to admit the truth, while those four years have seen hundreds of £m wasted, never mind the frustrations for patients, GPs and staff. So will he actually do the necessary?
Are you in a caring profession? I had the opportunity last week to visit the Midlands hub of a rather different one, no less caring, but where the object of their care is a parcel.
You’d think it was a different world to general practice and on the surface that appears to be the case, but the parallels are striking and fascinating. They call it a hub not as the latest management fad to soak up taxpayers’ money but because the hub is essential to the design and operation of the system. (All competing parcels businesses have a Midlands hub by the way).
It means that a parcel can be collected from your door anywhere in the UK and delivered to another door anywhere in the UK within 24 hours, and to do that for 5kg in any shape or size, for under £10, is simply astonishing.
At the system’s centre is the hub where lorries from 40 depots arrive throughout the evening and depart into the night. An arriving parcel can go out to any destination, and if it’s one of the 70% to go on the automated system it will spend just 7 minutes in the building. Most of the 300 workers however handle the odd shapes, sizes and special requirements of the 35,000 per night which can’t be automated. They are glad of £12-£14/hour for the 8pm – 3am shift, many of them immigrants and a third on agency books. It was hot on Monday night, and only the control room has a/c, but the work ethic, and it is hard work, is phenomenal.
So what about the parallels? You’d think a parcel is a parcel, but the “undifferentiated demand” they see ranges from a 150g padded envelope to a 1.5 tonne truck engine, a factor of 10,000 times by weight. They all get the same service. Is it urgent? Some are marked as such but there is no way of knowing the unique story behind each item. In truth it makes little difference, as there is no point hanging onto parcels overnight – they would just get in the way of tomorrow’s work.
What about the ethos? They sort everything tonight, barring a handful of especially fragile or flammable patients, I mean parcels, kept in for special treatment. They walk the lines to ensure nothing was missed and only then declare “End of sort”. Only then do they go home, and if it’s after 3am, they stay until done – last night was 3.39.
There’s the variety, and there’s the flow. Like general practice, parcels are not scheduled, they just turn up when they feel like it. But the volumes are predictable within quite a narrow range, and the pattern is tidal. Every evening lorries come in around the same time, every night they go out again full (except for the exceptions, breakdowns, accidents and so on, managed by humans).
“Tidal” seems to me the best description for general practice demand, predictable by day and by week, and I sense the next blog forming around a theme – the tidal deniers, tidal self harmers and tidal surfers.
Help me with a name, “How to be a GP surfer dude” or something.
askmyGP & GP Access Ltd
PS Thank you to Dr Kerri Monk, GP at Audley Mills, for her addition to last week’s blog. “I feel as a group of drs we’re finally working as a team. It’s great. I’m looking forward to week 2 already.”
PPS Fascinating interview on automating healthcare with Dr Jonathan Tomlinson, aka @mellojonny, in the Technoskeptic. “We got this fantastic robot that does the work of two men, but unfortunately it takes three to work it.’ The WebGP/eConsult thing is like that.”
We agree. And that’s why we have a totally different philosophy from webGP/eConsult, who are trying to divert patients from seeing a GP, or diagnose themselves and then get asked so many questions they lose the will to live. It doesn’t work. Computers are rubbish at this. Computers are very good at taking down what people say and speeding up communication. Which is how they save time for GPs. Which is why one of our GPs using askmyGP said to me last week she could manage a patient demand in two minutes which previously would have taken five minutes. Aha.
So now they are trying to increase the proportion of patient demands coming through askmyGP up from the current 20%. The clue on how comes from the main theme of patient feedback: “Easy to use and quick service.” Aha. “Quick service” is down to the practice, “Easy to use” is down to us and you’d be amazed how hard it is to make something easy! Our never finished project.
This week’s blog was written by a patient to his local paper, and I loved it so much I’ve copied it here in full:
My local doctor’s surgery, Audley Mills in Rayleigh, has changed its appointment system.
When you call for an appointment you will be called back by a doctor. The doctor will then either deal with your query over the phone or ask you to come in to the surgery.
I used the system today, and I must say that it worked for me. I was asked to come in, and got to see a doctor within minutes. The waiting room was almost empty, and the consultation did not feel rushed at all.
I expect the majority of queries can be dealt with quite adequately over the phone, and doing so allows for quicker and less rushed appointments for patients who really need a face-to-face meeting with a doctor.
I was very impressed.
Simon Bishop, Rayleigh
What I most love about his letter, sent the day after Audley Mills launch on June 12th, was this phrase “the consultation did not feel rushed at all” It recalled the fourth principle of consultations from John Launer’s article last week – unhurried.
Like you, I’m suspicious of anecdotes unless they illustrate a body of evidence. But here’s the survey data from Audley Mills week one: they called 46 patients at random, of whom 39 said the new system was better, 5 same and 2 worse. A staggering 85% say better, and only 21 of the 46 had seen the doctor.
I spoke yesterday to lead GP Dr Luke Whiting who said Monday had been very busy but demand had tailed off over the week and now they had free slots, unused. It’s so predictable. We allow 15% for random variation in our plans, so it’s not uncommon to have free time.
Luke: “We’ve been tearing our hair out for years. Now suddenly the place feels relaxed, the building is so quiet, we’re on top of the work.”
So what made the difference at Audley Mills? Why could they do this when others all around are still tearing their hair out? Are they larger, smaller, younger, older, more urban, more rural, whatever, than the rest?
No, just one thing: they made a decision.
PS The data shows no change in average face to face consultation time before and after launch. But the range increases as GPs have more flexibility to give the appropriate time to each patient.
PPS I’ve been speaking at NHS England and CCG events in the last month. There is no doubt about the appetite for change. What’s needed is evidence, method and frankly, a sense of urgency.
Quite a week but let’s put all that to one side and reflect on a fabulous article I came across, which put into perspective what we are trying to do.
Dr John Launer of HEE asks in BMJ Is there a crisis in clinical consultations? Although he sets the paper in a hospital context, most of his working life has been in primary care and the same principles and questions apply. It’s all about
“the idea that making it easier for clinicians simply to talk with patients may solve many problems that managers might assume need far more complex technological solutions”
Aha. Let’s add to that the assumptions of politicians, along with structural, financial and all kinds of other complicated solutions.
Launer quotes Dr Gordon Caldwell who has outlined ten fundamental conditions to optimise consultations, including:
- The patient should be as prepared as possible
- The clinician should be as prepared as possible
- Ready supply of information into the consultation
Telephone consulting pioneer Dr Steve Laitner contrasts traditional general practice in a tweet, “like having a day of back to back meetings every ten minutes with no idea who you’re meeting and no agendas”
Stressful and far less productive than it might be.
Yet patients are willing to spend their own time writing and preparing when they seek help – we need the system to make it available to GPs.
A recurring theme of patient feedback on askmyGP is “I was able to gather my thoughts before seeing the doctor. I so often forget things when I’m in there.”
Clinicians value enormously what patients write, whether preparing for a phone or face to face consultation. Our task is to develop the handful of questions which provide the most useful information, and I’m delighted to say that researchers are interested in this too.
Our other focus is to make online access so easy and attractive that it becomes the norm. We are over 30% in one practice and it will take a lot of experiment and refinement but I’m looking forward to reaching 50%, which I hope will make a big contribution to clinical quality.
I’ll leave you to look up all ten principles in Launer’s article, but here’s one you will like: “The clinician should be regularly refreshed”. He doesn’t say what with.
askmyGP & GP Access Ltd