So the Red Cross tells us there’s a humanitarian crisis in our NHS hospitals and ambulance services. What reactions does that trigger in your mind?
This is the same Red Cross which is helping those left alive flee the ruins of Aleppo, and in context I don’t know about you but I have a problem with that language. I don’t mean to shrug “Crisis, what crisis?” but the point is that it is so easy to make headlines by building on public perceptions and so hard to challenge them.
Many players within the NHS ecosystem and media thrive on continual crisis but strangely it doesn’t help us to measure, analyse, reflect and redesign. We are addicted to firefighting.
Now I want to raise the subject of cognitive dissonance. If you haven’t yet read Matthew Syed’s “Black Box Thinking” then I urge you to do so: well written, engaging and with a powerful message. (the subtitle about marginal gains doesn’t do it justice. It’s much more about learning from failure).
I’ll declare an emotional “COI” here in that aviation comes out much more favourably than healthcare, and some decades ago I was a tiny cog in the industry at Rolls-Royce aero engines. The difference centres around attitudes to failure: forensic analysis, learning and rapid dissemination in aviation, versus cover up in health. Doctors have admitted to me that that’s a huge fear of failure in medicine, but the problem as Syed so eloquently puts it is that failure happens continually and repeatedly. Aviation by contrast is very open, and very safe.
I’ve talked for some time about the primal fears which keep GPs from change, impenetrable to evidence. But perhaps I’m wrong, it’s more the gap between beliefs about current practice and what we imagine we might have to do – cognitive dissonance.
Does reframing the problem make it any easier to solve? Your thoughts gratefully received.
PS Counter that crisis thinking with this US doctor’s experience of the NHS as a patient. We must count our blessings vs USA never mind Syria.
Yesterday in deep frost the view from Great Mell Fell in Cumbria was blissful. I hope your holiday had similar moments, and they will continue to inspire as we get to work in 2017.
I’m optimistic about the year ahead as more and more GPs and their patients are seeing the benefits of a demand led system, whether phone or online. But I’m concerned about polarising views and we saw this only last week when, perhaps to her own surprise, RCGP chair Helen Stokes-Lampard made the front page of the Sun with “A MONTH TO SEE GP” winter misery shocker.
The testimony of hundreds of GPs says there’s no need for a trade off between workload and waiting time, and no need to divide the infinitely variable needs of patients into “urgent, trivial” and “routine, life threatening.” They know they can deal with demand as it comes in, appropriately and compassionately. We shall keep on putting that message across because it happens to be based on evidence.
Already today this year a new practice has launched, in the west of Fermanagh about as rural as it’s possible to be in these islands. There isn’t even a house next to it, just fields.
And this morning these three patients left the latest feedback on askmyGP:
Better since streamlined process. Thanks! (f 41)
Feel I can explain my problem easier writing it than talking about it. Quick service is great (m 38)
I use this service as it saves me from making a phone call, it is easy to use and i have received a follow-up call from the GP quickly (f 17)
This is what should be on the front pages.
Chief Executive, GP Access Ltd
PS we’ve been very busy today with enquiries on askmyGP, as new year prompts new ideas and minds turn to making the most of the GPFV funding. Do get in touch.
Method: Telephone GP practice between 11am and midday today 23/12/16 and ask receptionist how busy they are, compared with an average Friday.
Sample: 10 practices throughout UK, 6 England, 2 NI, 1 Scotland, 1 Wales, mix of urban/rural/socio-economic populations. All operate a demand led system, GP telephone response, no pre-booked face to face appts.
Results: 2 say about normal, 2 somewhat quieter, 6 much quieter.
Analysis: Someone please help me with the p-value.
Discussion: Qualitative comments added to the findings, several echoing the view “It’s going really really well here, the patients are very happy, and so are the doctors, so we are too”. “We were expecting a rush, but it’s been quiet all week.”
None of the respondents admitted to wearing a silly hat, though one said she would be this afternoon.
One referred me to the practice manager, who said they were so quiet they’d sent a doctor to help another local practice. (Kidderminster Church St).
Summary: er, most of them are having a really quiet day.
* not commissioned, not peer reviewed, non-RCT. The author declares a COI.
Thank you for all your contributions this year and wishing you the most peaceful Christmas
PS Learning is one of the joys of the break and Nuffield Trust has put together a wonderful reading list. Delayed half an hour in Belfast last Tuesday I found Matthew Syed’s “Black Box Thinking” – yes, airports can enrich the mind!
And the relevance to our study? Every day we are bombarded with messages of stress, overload, unsustainable soaring tsunamis of demand. So the finding that today is quiet falsifies the dominant view about demand. Do read the book.
3:30 on Tuesday a practice manager tells me, “I’ve got GPs wandering around, wondering what to do. We’ve run out of patients”. Me: “Get them cleaning windows.” It was day 2 of launch.
Last week a receptionist at a practice 3 months in told me “it’s really quiet today” – we often hear the same, and no surprise, as there are some busy days and some quiet days if you’re close to patient demand.
Yesterday a Liverpool GP explains to me how they’d saved £50k as a practice in GP costs, enabled by their demand led system now going 4 years.
So why aren’t you seeing this all over the industry press? You know it doesn’t fit the narrative, #GPinCrisis and the rest. It doesn’t suit the interests of RCGP, BMA, NHS England or even the secretary of state.
Money and power need continual crisis.
GPs and their patients need something rather different, a way of working which is compassionate, sustainable and professionally satisfying.
Hunting down good news has a long history. Sorry if your child got the short straw and had to play King Herod this year, but take heart, the Wise Men got the better of him.
Founder, Chief Executive, GP Access Ltd
PS You must read @jtweeterson’s NHS Networks, a record year for trends “BMA’s Clinical Time Lost to BMA Workload Surveys survey” is the mark of genius.
PPS Did you get one of the emails sent to top GPs yesterday? Businesswoman and GP Clare Gerada writes, “As a leading member of the GP community, I hope you don’t mind in me blatantly promoting Web-GP (now known as e-Consult) an on-line GP consultation platform that myself and my partners developed.”
Some partners too, with businessman and civil servant Dr Arvind Madan now directing NHS England’s primary care. She continues,
“As part of the GPFV, NHSE has announced funding to stimulate the uptake of online consultation services over the course of the next 3 years”. That’s the ring-fenced £45m.
I’m sure you’re aware of the debate over our askmyGP and their webGP/eConsult. Competition on quality, service and evidence is greatly to be encouraged. Taking on the medico-political establishment was not part of our product planning, but hey ho, if that’s what it takes we look forward to it.
Do write to me about your experiences if you’re one of the 300 practices they claim to use eConsult.
You can’t have failed to notice that everyone’s talking about e-consultations and whatever the evidence (or lack of it), the GP Forward View fund is forcing the pace.
Evidence. It’s the key battleground because if £45m is going to be spent the public needs to be assured that it’s value for money (more particularly, the NAO).
But the public. as we measure their actions and views with askmyGP, are saying something very important: we like this more and more. This week feedback includes: “Happy with the quick response.” (f 62), “good, easy, fast” (f 56), “System very easy to use, I will use this again” (m62).
You know my skepticism of anecdotes, but they do illustrate the trend, which is 60% now saying this is a better system.
The common theme is easy and fast, and it’s those practices who understand this that are reaping the benefits. The fact is, patients have to be begged to use a new online channel, they don’t all rush at it, and only bother the GP when they’ve tried Googling for self help (75% in the latest survey).
Those that fear their patients are missing out. “This is a great way to avoid an unnecessary doctor’s appointment.” (f 43), and I really love this one, (m 77), “Both parties benefit by sometimes not needing a surgery visit”.
Pure genius. Patient-centred care means it’s a joint decision on how best to help, not a barrier for patients to overcome.
PS Not just for data nerds, it’s astonishing to see how over the last 20 months askmyGP use on smartphone has shot from only 22% to 48%, as PC use has shrunk.
webGP eConsult GPFV page suggests a rush to sign up to a plan by 23 December.
Claiming 300 practices using the product, it is notable to see the extensive quotes from their 2013 pilot study of 20 practices, 14 of which are their own in Hurley Group. What about the other 286 are not Hurley Group and would provide recent independent testimony? Doesn’t the absence of any more recent case studies seem odd?
“Self-help and signposting options attempt to reduce demand on the practice” – this is a true statement. It is not a claim that it does reduce demand.
Productivity effects are discussed on page 9. The time to process is stated as 2.9 mins per e-consultation, but does that include a phone call to the patient? 60% solved remotely is plausible, but it’s not clear whether the 2.9 mins includes a phone call. The other 40% requires face to face, and if the average duration is 10 minutes, that’s 40% x 10 minutes, a further 4 minutes. The best possible assumption means an average of 6.9 minutes to complete a demand arriving as an e-consultation, 31% saving on 10 minutes. But how much demand has shifted channel?
Speaking at the EMIS NUG on 23/9/16, CEO Dr Murray Ellender showed this chart of demand shift reaching 7%. This is over 2 years, in a young adult metropolitan demographic. Whether this was 7% of demand we don’t know, because if supply is limited, it may be 7% of supply (easily done by restricting numbers of phone or face to face appointments).
The best case is to take it as read, such that 7% x 31% gives an overall saving of 2.17% of consulting time.
We wonder whether sufficiently sensitive measures are in place to detect such a change.
Several reasons lead us to doubt the quality of this evidence, and therefore whether a “best case” assumption is reasonable, beyond the fact that this is a tied practice. This is not a time series chart, although the x-axis may suggest this. It is three data points, with a straight line between them. It contains no actual numbers of episodes, only a % of channel shift, hiding the units. For a comparison of how real data appears, please see our Greenway Belfast case study, a practice which runs a demand led system meaning very rapid access equally from phone or online demand. This is significant as there is no need for patients to use online access to jump the queue, yet the data shows 20% channel shift within 2 weeks of launch.
The lack of independent practice case studies, and the 0.7% demand shift in the original Hurley study, tells us that in the vast majority of practices the channel shift is an order of magnitude lower.
Note: we have requested a fair copy of the original case study from Dr Ellender, but no response was given. The presentation in full is available here. In a November 2016 presentation in Sweden, Dr Omar Hashmi claimed many were at 7% and some up to 30% – I wonder where is the data?
It’s been a fun week after our official endorsement in the Daily Mail which meant two radio interviews before coffee on Monday. Huge support came from many GPs and patients who know the truth that a demand led GP telephone consulting system has transformed their lives and their access – thank you all so much.
The DM is right on the button (in its inverted fashion) as a big report has just been quietly snuck out out by NHS England. It’s the final evaluation of the GP Access Fund wave 1. (yes, it’s right at the bottom of this page, just published though it relates to September 2015).
I’ve read the ever-so-small print and have concerns about some of their arithmetic but the headline is: from a £60m investment they identify £1.9m savings. Nevertheless, one bright spot in the conclusions is “Telephone-based GP consultation models have proved most popular and successful.”
We were involved in several of these, the financials showing a positive investment return (p31) and increasing GP appointments by 7 – 16% within core hours. This is no surprise as we’ve been saying the same for years.
The contrast with the next conclusion is stark, “Other non-traditional modes of contact (for example video or e-consultations) have had fewer tangible benefits and have generally had low patient take-up to date”
Seven schemes offered e-consultations and sadly askmyGP wasn’t among them at that stage but the leading platform was webGP/eConsult.
Moving swiftly on, it’s time for NHS England Shared Planning Guidance. Don’t worry yourself about the evidence for telephone access, the word isn’t mentioned, but on page 50 there’s £45 million ring fenced for e-consultations. That means you can’t spend it on anything else, so your CCG might as well apply. Do hurry! Applications must be in by December 23rd.
Some say it’s no coincidence that the author of the GP Forward View and NHS England National Director for Primary Care, Dr Arvind Madan, is also a major shareholder in Hurley Group/webGP/eConsult, provider of such online e-consultation software. Of course, “I couldn’t possibly comment”.
But I will be reviewing and comparing the evidence on competing platforms over the next few weeks.
As we know, only the Daily Mail can get away with ignoring the evidence.
PS A number of readers have been commenting on this Analysis of access in large GP groups. It’s all from public domain data, so I’d be delighted if any researcher would reproduce or extend it. A close look at the names reveals some surprises.
The BMA guidance includes the key message:
- Doctors must use resources efficiently for the benefits of patients and the public. Difficult decisions about resource allocation are inevitable, but should be evidence based and made in consultation with other colleagues and patients.
I’ve had to re-write the whole thing because, deep joy, we’ve made it to the front page of the Daily Mail. And as everyone knows, the only good news in DM is royal babies so to be traduced in such huge type is truly living the dream.
You can read the fully made up Mail Online version here. We even made it to the leader page where they deliver the knock out punch, “This scheme’s advocates should think again.”
What’s funny about DM is the setting up of falsehoods so easily overturned. “3 minute phonecalls” – no, the average is 5, but they can vary quite a lot. But then we measure the duration rather than just inventing numbers. It’s so much harder work.
“Campaigners warn that some, particularly the elderly, might be fobbed off or end up going to casualty.” Yeah, but then I discovered the pioneers because they had lower A&E numbers. And we have 6,798 patient feedbacks which are overwhelmingly positive, with the elderly especially so.
Forgive me for quoting directly from the Mail’s online comments. There’s the predictable
“Bet the immigrants don’t have to be questioned on the phone.”
“My doc has an online questionnaire and generally a three week wait to see a doc.”
and the well informed
“I had this two weeks ago. GP rang me, quick discussion on my problem and she called me into her surgery the very same morning and saw me. Turns out is was fairly serious, so it worked well for me.”
The patients get it.
PS New evidence this week looking at the GP PES shows how good access is shining through. This is worth a click: Analysis of access in large GP groups.
The policy direction from NHS England is for “General Practice at scale” and while there is no blueprint for how this might be achieved, the emphasis is clearly on larger units. Evidence has been lacking however on the effect of scale or multi-practice groups.
This study set out to use public domain sources to examine the performance of a number of existing GP multiples, using the measure of perceived access as recorded in the GPPES.
Method: list the practice codes forming the members of the multiple group. Extract from GPPES the values by practice on actual wait to see GP, “same day” and “over a week”. Calculate simple average for all practices in each group.
The resulting chart is below, same day in blue, over a week in orange. The red column is the average for all practices not included in the multiples.
Conclusions: most multiples have slightly worse than average performance for “same day”, slightly better for “over a week”, though there are exceptions. Those listed as GP Access do not belong to a multiple group but are all those who had adopted a demand led approach before the survey was taken in July – September 2015.
Author: H Longman, November 2016