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.
“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.
Play the top 70 charts as fast as you like – there’s a picture surprise at the end.
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”.
GPs, staff and patients from four practices in Northern Ireland explain how they have transformed their working lives through adopting a demand led system.
“Patients were angry because they were waiting so long.” turns to “They’re loving it now” – receptionist.
“From being very skeptical… I’m very positive” Donna Casey, manager
“Our big concern was that demand would increase… It’s been a revelation” Dr Tom Black. “The GPs are more relaxed… we have improved our continuity of care.”
They can now respond to patients within minutes, from demand either by telephone or askmyGP online, offer a choice of GP and see those needing a face to face consultation on the same day. They tell their own story.
The Northern Ireland Department of Health have committed to further rollout of askmyGP in their plan, Health and Wellbeing 2026: Delivering Together page 25.
Unusual, but I was rendered pretty nearly speechless this week when a blog appeared on the BMA Northern Ireland Community page.
They lead with an outcome which is vital for patients.
They present the context, tougher in NI than other parts of the UK because of fewer GPs per patient.
They talk about method, rather than lengthy, complicated and evidence-free jiggling with structure as we saw from NHS England last week.
They end with an outcome which is vital for GPs, easing workload.
Struggling back onto my perch, I have nothing to add but will quote this unknown Irish patient, a female of 47 with a sore nose. It’s typical of much feedback we receive, showing that when we stop thinking of patients as the hordes to be diverted at all costs, we find they actually want to help ease the workload:
“Great service. I have had a call back from the GP almost immediately and saved my own time and taking up an appointment slot.”
The link again: BMA Northern Ireland GPs show us how.
Happy weekend and slàinte.
A couple of things this week have given us great joy at GP Access, and I make no apology for talking about them because we need to turn around the prevailing wind of moans.
The first was talking to Rupert Bankart about his practice in Peterborough. For all the reasons which bedevil general practice at present (demand, recruitment, contracts etc) life has not been at all easy. But he told me how in the last month he has become so much more productive, financially better off too, as he has switched his patients to seeking help online.
I really can’t do better than invite you to listen to the interview.
The second was experiencing (remotely I’m afraid) a Somerset practice launching their GP telephone led service. No one would claim it’s all settled after one week, but it was promising to find the GPs had gone home an hour early on day one, all work done. Steve Edgar told me on Friday how much their safety and quality had improved, giving appropriate time to each patient. One had a cyst removed, the whole episode start to finish completed in 45 minutes. Of course, it costs far less like that than the palaver of arranging multiple appointments over several weeks, and the patient is delighted.
Ironic then to see the BJGP publish a rehash of the Lancet August 2014 ESTEEM data, “proving” that telephone consulting doesn’t save time. Tedious to have to go over it again: the point is that this did not test systems, but a technique in isolation. The resolve rate achieved was 25%, by GPs in 13 practices who were paid extra to do the telephone sessions.
We, along with others, and right back to the pioneers 16 years ago, have shown that 60 – 70% can be resolved remotely. One GP friend told me last week she was measuring 72% resolution now, consistently. These simple facts completely upend the findings of a four year, £2m RCT.
I’m reminded of G B Shaw’s saying, “People who say it cannot be done should not interrupt those who are doing it.”
PS Anything I write on this, the BJGP will say I have an interest. Indeed, an interest in what works, declared with pride. But I know many of you already run super efficient GP telephone led systems and would never turn back. Could you please drop me a line and we’ll find someone to co-ordinate a response? Do hurry, they will want it for the April issue.
I spoke to Dr Rupert Bankart about how they had introduced askmyGP at Botolph Bridge Community Health Centre, and what difference it had made to the practice.
In his own words:
Scroll through the slides at your own pace here:
We are starting the New Year with a positive vision of what we collectively can do and how to do it.
Call it a manifesto, in this major new paper we show how GPs can solve their capacity problem, improve patient care and rediscover the joy in their work. Click to view.
Early reviews from leaders in the NHS have been extremely positive. Dr Clifford Mann, President of the College of Emergency Medicine, kindly tweeting from @RCEMPresident “Some great work on demand/capacity issues in primary care from someone with a fabulous pedigree of innovative thinking.”
You’ll find the pdf reads best on a screen larger than a smartphone so I recommend downloading to a PC and 10 minutes concentrated effort.
But demand-led thinking is far less effort than re-organising NHS forms and structures. How do you find the MEPRA model works as a way to describe the process, at any scale?
Looking forward to your thoughts.
I was speaking at the Lincs Practice Managers’ conference on Friday and started chatting over breakfast with another hotel guest, about each other’s work. Neil (not his real name) was passing through on his way back to Harrogate (real name).
Neil went straight into describing his dreadful recent neck and back pain, when he hadn’t been able to see his own GP for 7 days. Try as he might every day at 8.30, he’d be told “You are number 17 in the queue” and then find no appointments left. He was in agony, couldn’t sleep. I absolutely hate to hear this so common story, it drives my passion to do something about it.
Listening to GPs we hear endlessly about patients who abuse the system with trivial demands. We can’t eliminate the problem, but when we have asked GPs to audit their consultations in real time (n>25,000), we’ve found they judge overall just 3% as “should have been self care”. This number doesn’t change when access is easy.
Yet a real time audit in reception (n=40,000) shows that 12% of patients asking to see a GP are told, “Sorry, nothing left”. A rough calculation says those abusing the system are outnumbered 4 to 1 by those abused BY the system – such as Neil. Compassion, the word of the day in our touchy feely NHS, is not a sympathetic smile, it is simply saying yes to a patient in need.
Turning up the volume on the moanometer won’t do. We can and we must change the system.
Neil wanted to test askmyGP to see how it could help. Starting from “back pain” he did a simple questionnaire, which turned out to be 36 one click answers, taking 6 mins 37 seconds (patients are happy to spend their own time if it’s productive). Take a look at the history he produced here. GPs, bearing in mind you would normally have the existing patient record, please decide the first action you would take to help Neil.
How many seconds did it take to make that decision? Compare with the 7 days of agony it took Neil to get in front of his GP.
Founder, Chief Executive
GP Access Ltd
PS Back pain is the second most common presenting symptom through askmyGP. But in a very deprived practice, depression tops the list. Our poster with Wester Hailes “Smarter access improves clinical care” at the RCGP last week explains.
PPS If you’re not a GP, this blog on What do GPs do all day is worth a read on how things have changed. We need to get back the essence and put GPs in better control of their day.