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
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.
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”.
Presented by Dr Murray Ellender, CEO of Hurley Innovations Ltd, at EMIS National User Group, East Midlands Conference Centre, 23 September 2016. Continued below.
webGP/eConsult is a competitor product to our own askmyGP. We compare them here. Please note that GP Access in no way endorses the views expressed by Dr Ellender.
“Fantastic service great for busy people”
“It would be extremely hard to use this service if I was working full time”
These two consecutive pieces of feedback came in from patients yesterday and made me smile. Exactly the same service provided by two excellent practices produces two such different reactions.
Since we started askmyGP, feedback from patients has been important and we’ve published many of the results. We gather this at the time of submitting a request, have now had 5,518 responses and it seemed time to present a short review. This represents 14.3% of patients who have sought help from their practice online, of whom 2,667 (48%) have left a text comment as well as checking the three boxes which ask, “Have you used the service before?”, “How does it compare with the previous service?” and “Would you recommend this to others?”
I’ve plotted below one of the charts comparing the askmyGP experience to the previous system which we can see is overwhelmingly positive, now 55% say it’s better, 38% say the same and 7% say worse. Further analysis shows little difference between age groups.
We can also pull out common themes from the text comments, and the main ones are positive:
- Love the convenience of sending in my own time, without having to phone
- Found the process efficient and thorough
- Very happy with rapid response from the practice.
Negative themes are
- Too many questions to answer
- Did not help with my symptoms
- Practice has been slow to respond
I’ve put selected comments on the @askmyGP Twitter account and published examples, but for the sake of transparency I will send a file of all feedback received on request. It is all anonymous as we do not collect patient identifiable data, but we know age and sex. The only exclusions are test data and those from our public demo site Bramley Surgery. The data has been screened for inappropriate content, but none has been removed.
Researchers are welcome to use the latest up to date raw material, quoting the source.
Please email to request from email@example.com
How many times have you heard the promise that patients will self care with health apps and websites instead of bothering their GP? And then compared the promise with the daily reality of demand slowly, steadily ratcheting up?
I wrote The Diversion Myth over a year ago and I’m glad to say we can revisit it with our own real data. We’ve never claimed that our askmyGP online access platform would divert demand away from GPs, but we’ve said there may be potential and we’ve been trying very hard to prove it. Every welcome page links directly to the excellent NHS Choices site, and we go further: having entered their symptoms, patients are invited with one click to go straight to the relevant NHS Choices page. Perfectly tailored patient education!
Since adding the tailored links, the results are:
16,710 total patient submissions
4,458 links presented
519 links visited
10 patients decided not to consult.
One of them was me, with a throbbing earache, discovering to my delight that antibiotics were not advised and it should clear up within 3 days. It did.
Friends, this isn’t going to work. I was hoping for perhaps 5% diversion. 2% would have disappointed. 0.06% is so tiny that even with brilliant optimisation multiplying the effect by a factor of 10, it would reach a barely perceptible 0.6%.
What we have shown is that patients are keen to seek help online. Fears of a deluge of trivia are unfounded, you need to beg them to use it, but so long as they get the message from a trusted GP and they get a rapid response, 20% will shift from phone to online. It’s then easier and less frustrating for patients and practice to manage demand. I don’t think that is impressive, compared with 80% online say for travel bookings, but it’s promising and we are working on how to build that to over 50%.
I’ve explored the challenges and the reality for digital primary care in a poster at last week’s EFPC conference:
Interested in your views on this.
PS Our competitors webGP are still claiming 18% of patients self managed an issue for which they “planned” to consult, indeed that “60% of patients were able to resolve their health concern without a visit”, implying they did so themselves. Strangely, we never see any numbers. Does anyone independent out there using webGP have any evidence of overall demand reduction?
So much has been staked on the promised land of “General Practice at scale” that I always look out for new reports on the evidence. It has moved me to do my own research too.
Nuffield Trust published their latest review on Large Scale GP in England last week. Plough through 47 pages if you have time but this is from the conclusions:
“…well placed to improve safety and quality processes, but pointed to unintended consequences affecting workforce turnover and continuity of care. The views of patients regarding the impact of new forms of largescale general practice collaborations are largely unknown.”
I love unknowns. So I decided to look at how patient satisfaction is affected by practice list size, and if you know where to look it’s not too difficult to find data, using the GP Patient Experience Survey (not my favourite dataset but the best we have.)
The results were as clear as they were surprising, and I presented them last week at the European Forum for Primary Care. It’s a good crowd, bringing together people who care about strong PC with fascinating diversity across both professional groups and nationality. The poster:
Let’s look humbly at the data – I have no axe to grind or misty-eyed nostalgia for smallness – it’s a matter of what’s appropriate. (My early career was in Rolls-Royce plc, a company of thousands because making aero-engines most definitely is not a cottage industry.)
So here’s what we know: patients value continuity of care. It’s possible at any size, but harder to achieve in large units.
The real crime of policy makers is to distract our attention with size, scale and structure when transformation is so quickly and cheaply achieved by simple, sustainable means.
When will they ever learn?
Founder, Chief Executive, GP Access Ltd
PS 2015 study, “How does practice list size affect secondary care costs?”
And this is fascinating, expenses are actually higher per patient in larger practices!
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.