It’s been a tumultuous week as big business interests threaten our way of life like never before. Thankfully the attempt by Toblerone to bury the bad news as they cut 10% off our chocolate has spectacularly backfired.
More important news struggling to get heard is the publication of the first of 44 STPs covering England. BMA complains “GPs shut out of STP talks”, so what do they mean for primary care? Well I’ve pored over them so you don’t have to (at least, the parts I want to, with my secret method, ctrl-f in the document and search for the words…).
So I started with “demand” and there are dozens of references. What’s funny is that about half of them bemoan the inexorably growing demand across all our services, usual stuff. And then without a trace of irony, the other half outline our plans to reduce demand. One quotes 30% of GP activity!
Compared with predicting election outcomes, forecasting healthcare demand is laughably easy. Add 1 – 2% to last year’s demand and you’ll be within a gnat’s.
Apart from a few niche areas, the reason that demand keeps going up is because no one has found a way to reduce it. Everyone including us has tried – are we the only ones to admit it isn’t working? So reducing “demand” in STPs is either wishful thinking or in reality reducing supply, more concisely called rationing. That word doesn’t occur even once as it very quickly gets you the sack.
Try another word, “digital”. Dozens and dozens of references, all positive, and generally linked with the word “enabler”. I like this way to describe digital, because it can be an enabler of change though I don’t see it working as a driver. We haven’t yet found a way to reduce demand but it certainly can enable us to deal with demand more efficiently.
There is no doubt that digital is going to be a major component of change in the NHS over the next few years. What is unknown is how, but I’m sure it will only make an impact if it works brilliantly both for patients and GPs.
STOP PRESS: this new Dutch study on the impact of their NHG health info website is seriously encouraging for demand reduction.
PS We put a lot of effort into measuring patient feedback, as unless it’s very positive patients won’t use digital channels. High usage is the only way to get a return on all that investment in technology. We’re putting these patient measures in the public domain and keeping them updated.
I was talking to a lovely Yorkshire GP this week who knows our work and knows his own kind very well. He told me how the GPs would listen carefully to the evidence, hear the testimonies of colleagues, nod sagely at how impressive it all was and would solve precisely the problems they face. Finally they would explain why it couldn’t possibly work in their own practices.
“How did you know!” I gasped. “That’s EXACTLY what happens.”
I often reflect on why, with the steady flow of “new lease of life… feeling more in control… stress has gone from 100 to 0… ” and so on, GPs find it so difficult to imagine the change for themselves.
In the NHS we are used to a 3% improvement being hailed as a major achievement. When it’s 80%, does this sound so unreal that it therefore can’t be true? I wonder whether it’s the Victor Meldrew grumpy old man syndrome. There’s a wonderful YouTube of the best of his “I don’t believe it’s”
Now I’m not suggesting for one moment that GPs are all either grumpy, or old, or men. But you know what I mean. Anyway, the great news is that a growing number, now well over 1%, are realising that yes, it can be me.
It’s 16 years since Dr Chris Barlow first realised, and 5 since we caught up, so we’ve updated the Dover Chart Collection to celebrate all the practices who have seen their waiting times fall off a cliff.
PS Last week I got some flak for saying we need transformation not improvement. Well, yes, of course we need both but let me illustrate from a Kidderminster practice we are working with. They launched last month and the average wait to see a GP dropped from 6 days to 0.3 days (with demand exactly as predicted). That’s transformation. Now they are working on getting the average GP response time down from 2 hours to under 30 minutes. That’s improvement.
PPS Here’s another thing Victor wouldn’t believe, and it makes you proud of the NHS. In the US, the wait to see a GP ranges from 5 days to a jaw dropping 66 days in Boston.
Play the top 70 charts as fast as you like – there’s a picture surprise at the end.
Not long ago a local NHS manager told me they were pursuing the Dave Brailsford model of lots of tiny little improvements – he the cycling supremo who let us bring home so much gold from the Olympics. I thought it a one off comment, but a blog of Roy Lilley’s this week called it an NHS fad. Like him, I’ve no doubt it’s a misguided one.
Cycling is a beautiful thing, highly sophisticated and at the Olympic level, a more streamlined cut of sideburn can make the difference between podium places. But the NHS is not a competitive sport, it’s an operational business and if everyone had a rough imitation of the current best model, we’d all be miles better off.
The problem with thinking about marginal gains when the system is broken is that you miss the biggest opportunities. Attention, that very limited resource, is in the wrong place.
“Improvement is not enough. We need transformation.” W Edwards Deming said it thirty years ago.
“If I had asked people what they wanted, they would have said a faster horse.” Henry Ford said it, a century ago.
If he had listened, we’d have carbon fibre wagon wheels by now.
Gee up, Dobbin.
PS. You’ll have noticed all the noise about STPs. They have transformation in the title, of course. But they are really about money, and I’m afraid that’s no way to achieve transformation. Cost cuttting, yes, restructuring, yes, noise, aplenty. What we need is different thinking, starting with patient demand.
PPS. “Marginal gains secured by new care models…” was the title of a King’s Fund blog this week. Marginal gains? Remember, the new care models were the flagship policy of the Five Year Forward View. Two years in, untold £millions spent, and they are bigging up “marginal gains”??? Please don’t get out of bed. If it was working they would have something more to shout about
I shared a lift to the Best Practice show this week with my very good friend Gareth McCague and crawling along the M6 he asks me, “what does your demand led system mean for premises?”
Well that got me thinking, because one of the first things we notice is the empty chairs on Mondaymorning – GPs are all hard at work, consulting with patients at home. We call it the “no waiting room.” I know of practices who have carved out another consulting room from the unused space – but of course in a new build, cutting the seats from 40 to 20 would make quite a difference to building costs.
Then of course there’s the car park – it’s always a sign of things working well when we can drive straight into one of the many empty spaces. “That’s it!” cries Gareth (who knows everything there is to know about about GP premises and pharmacies by the way)
You’ve all seen the new surgeries where most of the land is taken up by parking. With all the attention on premises in the ETTF & GPFV funds, you can bet lots more tarmac will be laid for patients to park their cars, so they can wait on the chairs, to see a GP they didn’t need to see – it could have all been done in minutes over the phone or online.
Premises, premises won’t solve the problem. Everything is connected – it’s the system.
PS. Michael McKenna runs a single hander practice off the Falls Road in Belfast. There is no parking. Until this April he would have 30 patients lined up of a morning, for his 11 seats. They’ve gone, and I particularly love the bit in the NI video where he looks out of his room on launch day and quietly says “Wow”.
PPS. I admit to writing this in Luton airport, plane delayed. Just noticed in the gents that the new Dyson Airblade dryers are built into the taps. Ah ha – no separate queue for the dryers, lower footprint, value in airport space £££ – everything is connected.
Last week I was at the RCGP annual conference in Harrogate and a jolly good time it was too, meeting friends old and new and having all the same conversations, with a new case study from Belfast. Even made it to a fine Yorkshire tea at Betty’s.
But the highlight by a mile was when I snuck in to one of the plenaries to hear Kate Allatt give her astonishing story. Surviving a rare brain stem stroke, she told how she worked her way out of locked in syndrome, from being left almost for dead on a hospital ward to taking her first running paces a year later.
We will never know all the ups and downs of that year but what hit home to me was when she was back home and struggling daily with 3 young children on top of everything. In desperate need of help she suffers the usual nightmare of trying to get an appointment with her GP.
“Why can’t I call my GP at any time of day?”
What an utterly reasonable request.
Huge applause for her talk, and I think we were all genuinely moved. We’ve talked since and the common bond is that what Kate sees as utterly reasonable, we know is completely possible (and actually less work). Watch this space!
PS I won’t bore you with the agonies of this job but we have survived five years, and just occasionally there’s a shaft of light. Millbrook Surgery in Somerset launched earlier this year and a patient put this story in the local paper.
Greenway Practice in Belfast launched a demand led system on 26 April 2016, initially with GP telephone response, adding the askmyGP online channel in July. We look at the operational effects and quote GPs, staff and patients before and after the change.
Presented for RCGP Annual Conference, Harrogate, 6-7/10/16, but not as an official poster – the abstract submission date was months before the events took place.
All quotes are verbatim, either written or verbal. My favourite is from Dr Andrew Courtney, “My stress has gone from one hundred to zero”.
In response to the post on 1 October, “GPs, where were you when they stole your profession?”, Dr Helen Haywood writes:
I always read your emails with interest and generally find myself agreeing with your viewpoint – yours seem to be a fairly lone voice when it comes to rationally and consistently pointing out flaws with the state of NHS general practice as it is and the direction it’s travelling in.
I find myself less certain about this message however. Partly because I’m not sure I fully grasp the inputs vs outcomes argument and analogy used. Partly also, though, because of the hint of derision towards the Locum workforce seeming to suggest that these freelance GPs are unwilling to make longterm commitments simply due to the possibly adverse impact on their social life.
I absolutely agree with your depiction of market forces and supply and demand issues with regards to extending GP hours and that NHS general practice cat continue in it’s current form in the face of insufficient and decreasing numbers of GP principals to maintain the GMS and GMS system. I also worry about the apparent lack of willingness to take on partnerships, but would argue that the picture it is not one of simple greed, self-interest and lack of support for the NHS PMS/GMS contract on the part of the non-principal GP workforce who may often, in a PMS practice for example, have found themselves falling on the less satisfactory side of this arrangement not being offered the BMA salaried GP model contract, nor an income anywhere near that of a principal, but expected to undertake much the same workload, albeit not carry ultimate responsibility for the practice. I would go as far as to suggest that partnerships of recent years might consider whether they have some responsibility for the current situation when, for example, they might have chosen, in buoyant times, not to offer profit-share partnerships to junior salaried colleagues. Not only that the contract does nothing to encourage appropriate numbers or length of appointments in relation to the capacity of the workforce or to to deter growing list-sizes in order to achieve balance books or achieve adequate profits. Likewise in the early more lucrative days of QOF, always rising to the challenge of achieving the often meaningless targets without ever stopping to challenge the system and simply say no to such a tick-box mentality which in itself must account for at least some of the current squeeze on appointments not to mention its demoralising effect on professionals.
Although the GMS/PMS contract may be wonderful for balancing unlimited accountability for managing the registered patient who is ill, with unlimited discretion on how to manage them, it does not permit easy change or varied styles of practice within partnerships, expansion of general practice provision in it’s original format, with, for example, no option for GPs to set up new practices or indeed to take over contracts from retiring single-handed practitioners without first going in to partnership with the outgoing practitioner on their terms.
I do share your concerns about the extension of GP hours simply diluting the service and diverting attention and investment away from the core service. I also strongly believe that continuity of care, not only facilitates improved patient experience and outcomes, enables true practitioner reflection and continues professional development, but also helps contain demand and costs, contributing to an efficient * health service and am alarmed about the assumptions being made around the idea that larger organisations will necessarily result in savings. My own experience is that the larger the practice, the less continuity for and satisfaction of registered patients. One way around this is what might be considered to be the old-fashioned own-list approach, but I note with interest how an article in last week’s BMJ highlighted a study suggesting that ‘Having a named GP does not improve continuity of care’ ( BMJ 2016; 354:i5048 ). The results of the study undertaken would not be a surprise to any NHS GP practising at the time given that it simply looked for any noticeable changes in relation to the introduction of the requirement that all registered patients over the age of 75 be offered a named accountable GP from April 2014. This was, of course, introduced without any specification of changes to service offered, reporting requirements or additional funding and will accordingly largely have been delivered with the same lack of conviction or commitment to meaningful change in practice. It is a shame, therefore, that the results of such a study are now quite probably going to be used in the argument against the benefits of continuity. Accompanying the same BMJ, it’s BMA News supplement featured a centre-fold two-page spread entitled ‘Care revolution: inventing the future’ suggesting that the emerging ‘New Care Models’ from front-loaded Vanguard projects, such as the Nottinghamshire Multspecialty Community Provider it focuses on are trail-blazing the way forward for primary care, but neglecting to explain where the £7.3 Million that this project is benefitting from will be found if such a model is to be replicated elsewhere.
Such reporting does beg the question of whether we as a profession as a whole, principal, non-principal, salaried, freelance or otherwise, are content to passively let policy roll out, drive changes and transform the NHS as we know it without opposition and if not why we aren’t more obviously actively involved in the discussion and process. I would agree that we all need to get involved in this debate and echo your questions;
GPs, where were you when they stole your profession?
Are you going to stand up?
Before it’s too late?
Doctor 27 years, GP 23 years, including as first wave salaried combined academic-inner City practitioner London scheme, retainer London, salaried Leeds, principal/partner 9 years Leeds, salaried Leeds again 1 year, now locum GP.
People are sending more and more parcels these days, if you’ve noticed the queues at your local post office. This has got me thinking. I’ve learnt from a focus group that people would love to be able to send parcels from home at a time convenient to them, evenings and weekends especially.
So I’ve invented a new service called Mailidioto where we collect from your own home at any time you choose for one simple fixed fee. We take it towards the destination address and if you’re lucky, your fee will get it all the way. Obviously, if the fee runs out before we get there we’ll have to chuck it in the hedge, but that’s business.
How do you rate my chances with Mailidioto? Have I stumbled upon the difference between a contract for inputs and a contract for accountability?
There’s a wonderful thing in the NHS called the GMS/PMS contract for essential services, which balances unlimited accountability for managing the registered patient who is ill (in hours), with unlimited discretion on how to manage them (for the qualified professional performer).
So when we hear talk of salaried models, or “GP hubs”, WICs etc, these are all about inputs. They undermine accountability for the registered list, losing continuity of care and increasing costs. They are about hours worked, or appointments supplied (most APMS contracts) . We know the tenuous connection between “inputs” and “outcomes” (hello USA), and yet we see NHS England promoting these input models.
“£6 per patient to extend GP access from 2019” runs the headline. “Well actually…I’m just going to locum for as long as I can because I cannot see why anyone would want to commit to losing their (social) life” runs the comment from one anguished reader. You all know how hard it is to recruit GP partners. The more sessions are available for transactional GP, both in and out of practices, the harder it is to recruit for long term relational GP – they are the same people.
Extending hours makes no difference to capacity, and therefore has no impact on the three week waits to see a GP. Worse, it cuts capacity as utilisation is lower out of hours. Worse, it takes GP time away from high demand core hours. Worse, the unscrupulous will simply work the same time but claim the extra pay. The unscrupulous near to hubs are simply fending their patients off to them. It’s happening now – bad money drives out good money.
It doesn’t have to be like this. Scotland has abolished the abomination of QOF, and put the money into core funding. Northern Ireland is helping its GMS practices cut the wait for patients to minutes, and cut GP workload at the same time for a tiny fraction of £6.
The BMA and RCGP need to be absolutely clear against this undermining of the GMS contract and GP professional accountability. Put the £6 into core GP, making partnership more attractive. Put it disproportionately into deprived areas, bringing equity in place of the inverse care law.
GPs, where were you when they stole your profession?
Are you going to stand up?
Before it’s too late?
PS We’ll be at the RCGP conference next Thursday/Friday, on stand 33. See you in Harrogate!
PPS “Meet the digital GPs” in Pulse includes an interview with Dr Rupert Bankart about his practice and askmyGP.