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
Poster presented at FMLM Belfast conference, 9 March 2017. Download pdf here
Couple of mornings ago I was just enjoying my porridge when the Today programme told me that four out of five hospitals need to improve! Spluttering, I had to leave the porridge to cool while I took to Twitter.
No, it’s not the four I’m worried about, but the other one which presumably thinks it doesn’t need to improve. All of us need to improve – companies large and small, hospitals, GPs, parish councils and governments. A minute later Radio 4 was telling us that 2/3 police forces were performing well while 1/3 weren’t. Utter nonsense.
The real scandal is not the hospitals, or the police forces, but the thinking which labels performance as binary good/bad, pass/fail, and it’s this system of rating which infects government from top to bottom. People moan about CQC for its charges, its bureaucracy and bother, but the heart of the evil it spreads is the way that it rates its victims.
Measurement is crucial to improvement, but it matters what you measure and how. The best place to start is with what matters most to patients, and if you don’t know, think about the last time you wanted help from your GP. Yes, it’s how fast you can get help. Not the only thing that matters by any means, but you’d have thought that at least the multi £million CQC would have realised.
Recently we’ve produced datasets for two practices, one labelled by CQC as “good” and the other “inadequate”. It’s clear from the former that patients are being turned away almost all day from 8.45, and are struggling to make appointments. The latter, while ticked off for records on staff checks and vaccines, has a policy of never turning patients away, and it’s clear from their data that they don’t, accepting calls right up to closing time.
Do you want a tick box culture in general practice, or one with a passion for patient service at its heart? I know what I want, and if the government wants it then nothing short of a total rethink of CQC will get there.
“When the Facts Change, I Change My Mind. What Do You Do, Sir?” There’s a lengthy discussion on who said it first, perhaps not Keynes or Churchill, but never mind.
I’ve been saying that there is no evidence of patients being diverted from seeing their GP through online help, and now that’s changed.
Our evidence is from two hard tests to see whether askmyGP can reduce demand. The first is to measure overall demand (by analysing all consultation records for practices in time series over months) and we’ve seen no measurable change up or down, a valuable finding in itself. Demand doesn’t increase even when 20% of it now arrives online. Nor have we seen overall reductions.
The second test is at the patient level, where we offer symptom specific NHS Choices information to patients. Many view this and find it helpful, but very few are deflected from consulting: we measure this continually, so far only 30 out of 38,000 episodes.
Then this Dutch study arrives, high quality evidence of 12% overall demand reduction. Enormously interesting, because the Dutch registered list and capitated system is similar to ours in the NHS (though insurance funded). The reduction was over 2 years and the result not only of the technology but also a complex intervention of GPs advising and encouraging their patients to use it.
But the technology matters too. It’s notable that while NHS Choices is also very popular, there is no evidence of demand reduction as achieved by thuisarts.nl. It was created by NHG, the Dutch equivalent of RCGP. The differences between the two websites may appear subtle, but the fact is, one of them works.
But reducing demand has been an aspiration, subject to finding something that works – perhaps we are now a little closer.
Some of you reading this may be in a position of power and influence. With these new facts, I know what I’d do.
Dealing as I do with GPs week after week I admit to a twinge of envy that I will never personally be able to help a patient as a doctor, while they get the privilege every day.
But we get a little something from the feedback patients leave on askmyGP, and I wanted to share with you everything that’s come in the last 24 hours. Each one carries a story, and they are typical of recurring themes over the last two years.
They range from the simple, for which I’m grateful:
“Excellent facility.” male 54
to the more specific:
“Well structured questions to analyse symptoms etc.” male 62, sciatica
solving a real problem for many stressed parents:
“Much better as can use at any time and also don’t have 2 keep trying 2 get through on the phone in the morning” Parent of 3 year old, earache
and towards the other end of a lifespan, relief about the:
“Option for relatives of elderly patients.” on behalf of a 96 year old
Improving access without increasing surgery hours, and the importance of rapid response:
“This system worked well for us the first time we used it. We emailed out of hours but got a fast response as soon as the surgery opened.” male 81
Lastly something rather special, helping the clinical encounter itself by changing the channel:
“I get nervous talking about personal matters – this way the Dr can see what they are dealing with prior to speaking with me” female 44.
Perhaps we have shared in the privilege of helping this unknown lady. Being able to reflect and write down the problem is quite a common theme. There is lots of patient engagement online with 15% leaving feedback, over 5,600 items so far and we keep a running summary here.
The desire to help one another runs deep in the human psyche, and I think that is why, above all the cacophony of crisis, the long term studies of job satisfaction always feature GPs near the top.
Don’t talk yourselves down, and don’t dwell on the latest “GP-as-victim” blog in the columns of Pulse. Margaret McCartney writes powerfully in this week’s BMJ on the intrinsic value of long term relationships which GPs enjoy with their patients, unique not only among the professions but specific to general practitioners.
Treasure it, enjoy it, guard it.
PS Many more have enquired since last week about how to get Resilience funding for their practice to improve service and workload. We are doing our best but it seems time is tight, so please get in touch soonest.
PPS I’m a big fan of Julian Patterson’s NHS Networks blog and this week’s consultation on STPs is a must. Light up a grey day!
“A year ago in February 2016 we took the plunge and embarked on GP Access. The time between making that decision and going live was barely 4 weeks, but in that time Harry and his team analysed our data, gave us information about staffing levels, leaflets and publicity for our patients and training for staff.
Since then we haven’t really looked back. It is fair to say that some of our patients have taken longer than others to get used to the system, but now mostly they all understand how it works and comply. We do still get the occasional walk-ins, but manage these effectively. Our DNA rate has also dropped dramatically.
We have developed our own way of using the system, which is unique to us – but that is the beauty of the concept.
From the point of view of our patients, in particular those who ring in the first couple of hours of the working day, by mid-morning most will have spoken to the Doctor of their choice and be coming to the Surgery either to have a face to face consultation with a doctor, nurse or to have investigations carried out prior to a GP appt… Or at the other end of the day, those phoning after 4pm have been called back and seen by 6pm if that is what is needed!
We often get remarks about the lack of patients lingering in our Waiting Room and it was interesting that when the CQC came to inspect us only a couple of months after we had embarked on the new way of working, they were most disappointed not to find anyone who had waited ‘hours’ in the Waiting Room to interview opportunistically. I think it came as quite a shock to them!”
Michèle Hole, Senior Receptionist, Millbrook Surgery, Castle Cary, Somerset.
See what a Millbrook patient wrote in the local paper in June 2016.
Dear Mr Trump,
I get your sense of terror towards all those out groups like women, liberals, Mexicans, Muslims, Chinese (not Russians, oddly?), hordes from abroad… but they aren’t your biggest worry.
You’ve made a great start on dismantling the hateful Obamacare. OK, 20 miliion more Americans got health insurance, but it didn’t make much of a dent in the 17% of GDP you spend on healthcare. I agree, however well intentioned it didn’t go nearly far enough. You want something like our beautiful NHS, halve the cost and cover everyone, dontcha?
You can do even better, ‘cos ours ain’t even free! Hard working adults have to pay £8.40 just for a prescription. And hospital car parking can add up to the cost of essentials such as a pint of beer or a couple of newspapers. Then there’s the appalling inefficiency – most of the population have to wait more than a day to see their GP.
Butt – if you saved half the cost of healthcare, think of all the walls you could build, and the missile shields. They’re damned expensive, even against friendly missiles, ‘cos those things are soooo unpredictable.
No, the real terror is on a whole different page. They come in boats and planes as well as over land borders. They never get work permits, never pay taxes, they can run AND they can hide. They can move at the speed of light. They have intent, and meaning, they act alone or in deadly organised cells known as “sentences”. They threaten your policies and even your person. One traced to a middle eastern source said “Many who are first will be last.”
They are words, Mr Trump. Beware words.
PS And now for some good honest real news. This tiny seaside village is so achingly beautiful I can’t wait to go. They’ve just dived in to askmyGP online access and their website is absolutely the coolest I’ve ever seen (I’ve seen hundreds). Take a deep breath – you’ll feel better instantly.
Ballywalter, population 2,027, lies on the Ards peninsula in Co Down. Just smell the sea!
In the first full week (from 16th January) 72 patients used askmyGP to get help from the 5,200 patient surgery. That’s 20% shifting channel from telephone to online. Since then it has risen closer to 30% and the effects are growing.
Practice manager Leah Larmour writes:
“I have to say over the last several weeks things have been really difficult in the Practice, both with the launch of the system and a few other issues going on. They didn’t really settle until the end of last week when we had launched the online system and had a Practice meeting to discuss what further ‘tweaks’ the GPs wanted to make to the system. This week has gone much more smoothly so I will be submitting figures and patient surveys from the past week…
The online element getting up and running has definitely been a turning point and we are now feeling the difference we hoped for. All our telephone demand is dealt with the same day and the online requests the same day or following day depending on demand and what time the form was submitted. The patients are finding it easier to get through to reception as there no longer needs to be a rush to get through at 8.30 before all the appointment and telephone slots are filled (often this was by 8.50am)…
The system has massively improved access for our patients and made the workload more manageable for the GPs. I think it is important to note for other surgeries thinking of taking up the system that they may not feel the immediate positive impact that some have. If it does initially get more challenging it is most definitely worth persevering as the end results will be worth it with patients being happier with easier access and GPs feeling in control of their workload.”
Patient feedback has been flowing too:
“Brilliant to get advice without taking up GP hours. Good that you can still see a GP when needed.” male 34
“Easy and efficient! Highly recommend!!” mother of child, 10
“I am very pleased with the practice’s continuing efforts to make improvements to meet the increased demands placed upon it. A system such as this suits me much better than a frenzied rush to redial/redial/redial… at 8.30am to get medical attention. Thank you.” female 37
I wrote last week to Mr Hunt and sat by the phone all weekend, but it appears ministers are not offering a proper out of hours response so I have little choice but to go direct to Emergency PMQs.
Your headlines: “a large number of surgeries are not providing proper out of hours care – and patients are suffering as a result because they are then forced to go to A&E.”
GPs have a contract since 2004, mostly GMS or PMS, which defines their core hours. Simply saying you don’t like it really won’t do. The Telegraph has “Under Mrs May’s plans, GPs will have to be open from 8am to 8pm every day of the week unless they can prove there is not demand in their catchment area.”
We’ve been measuring demand for over five years and I can assure you there is always demand, but we do need a higher level of understanding from our PM, well intentioned and intelligent as you are. Demand out of hours is predictable and perhaps surprisingly low, but covered by out of hours services (as provided for in the 2004 contract).
But you are confusing demand with capacity. We know precisely the profile of demand, by day, by hour, even by minute, we know what is in and out of hours. We also know that spreading the same capacity over longer hours will cut that capacity and increase costs. When Sir Amyas Morse states “They are seeking to improve access despite not having evaluated the cost- effectiveness of their proposals and without having consistently provided value for money from the existing services.” it is well worth listening. His NAO report says extended hours GP costs are 50% higher than core hours. I’ve seen evidence that the true ratio is closer to three times.
Ignoring the evidence you have deeply upset GPs and confirmed the view of many that they are being bashed. I could call this counterproductive but the language you’ll hear over the next few days is going to put such bland terminology in the shade.
I do more data nerdy stuff than emotions, but I want to finish on a note of hope and if you’re prepared to listen, read one thing. Dr Philip Lusty was exhausted and beaten, along with all his colleagues and staff, as I personally witnessed. Now read what happened.