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.
“It’s lovely not being shouted at 24/7”
Receptionist Karen’s first comment to me was both startling and predictable. Her Somerset practice launched their demand led system two weeks ago, and since then she has been able to help every patient. Three weeks ago she and her colleagues were turning away one in five patients (we measured it) but they have moved straight into the super league, with a median response time from the GPs of 26 minutes.
The GPs love it too, but I find they are more buttoned up and try to find at least one thing to grumble about. “I’ll be home early so will have to put the kids to bed,” said one.
That didn’t take too long did it, or seem so hard? It was four weeks of preparation, to abolish the old system and start the new.
So why aren’t we hearing about this from the commentariat? I get a stream of dismal blogs from Nuffield/King’s Fund/Health Foundation (why don’t they just merge, it would save all those personnel transfer costs?) wringing their hands about how hard it is to change anything.
Another one today on General Practice at Scale, is it working? Yawn. Fiddling with structures, the obsession of policy makers who should get out more and ask “WHAT WORKS?”. Instead we’re told,
“Motivations… centred on a desire to offer better access…
Most strikingly, what the survey revealed was just how long enacting change can take – at least two years to even begin to achieve what they’d set out to do.”
Useless. And no measure of performance is even offered. This is why Deming said that motivation is fine but worthless on its own. The question is “By what method?”
Method is central to our work and it’s so repeatable now that the outcome is binary: either the practice decides to change, and it all happens within a month, or it doesn’t, and nothing much happens at all, ever.
But method is not static, we are continually learning and having to adapt. Another Midlands practice told me yesterday they are learning lots from having a GP in reception, sometimes even taking calls from patients, and their performance is rocketing while demand is falling.
I’m not going to call it a trend yet, but if you are a demand led practice you’re probably enjoying the sunshine dividend today. Have a great weekend.
PS Learning a lot from askmyGP users too, with over 1200 episodes and 130 patient feedbacks on the new system, 55 suggestions from staff, a terrific response. We’ve already put dozens into service and next week’s plans include one for low using practices (they will get an email notification of an online demand) and one very much anticipated by high users.
GPs have been emailing patients because it’s convenient – but it’s not secure and poorly controlled for IG and patient safety. From next week those on the Transform programme will be able to securely message patients in a two way conversation. It’s going to be another huge time saver. Will let you know how it goes.
Poster presented at FMLM Belfast conference, 9 March 2017. Download pdf here
“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!
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.
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.
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