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.
Presented at the European Forum for Primary Care annual conference.
Riga, 4-6 September 2016.
A pdf version of the poster can be downloaded here: EFPC Riga Digital channels v1
Presented at the European Forum for Primary Care annual conference.
Riga 4-6 September 2016.
A pdf version can be downloaded here: EFPC Riga Satisfaction & list size v1.
Back in April I was asked by Pulse to write an article for their debate, “Does telephone triage reduce workload?” and offered the princely sum of £120. After I’d written and submitted it as agreed in good faith, they decided that only the views of GPs would be printed. To be fair to Pulse I suppose that is logical, in the same way that I would expect only train drivers to have relevant opinions on the operation of trains.
Anyway, this week the debate appeared and you can read the views of two GPs on the above link. Interesting points, but neither has experience of GP telephone consulting enabling a demand led system. The two penn’orth I wrote as a non-GP are here:
I don’t care about telephone triage, even though I’ve been asked to write about it. What I care about is an effective and efficient primary care service, and that has been my vision since founding GP Access in 2011, “to transform access to medical care.”
But the simple telephone has proven an outstanding means to that end, when it’s used for first contact by the GP in a demand led system. The problem as we all know is workload, and too much demand for the capacity, which leads to over 100,000 patients each day being turned away from their GP despite their genuine need.
Back in 2000 the earliest pioneer GPs including Chris Barlow and Simon Coupe discovered that 2/3 of patient demands could be resolved over the phone, the other 1/3 being called in for a face to face. This ratio remains the same, and this coupled with the fact that telephone consults take half the time of face to face means that GP capacity is increased. We are proving this week after week.
Two practices launched in Belfast in April, GPs going round with big smiles saying “It’s really quiet this afternoon isn’t it?”. Another in Somerset writes after two months, “We have increased our list and our GP sessions, but now the partners go home on time, and can do the admin generally in the day. It is hard work when in and busy, but feels more satisfying and in control.”
Is it sustainable? The pioneers are still improving over 16 years. Some of those we’ve helped are approaching 5 years, and saying we’ve changed their working lives. The Elms in Liverpool, a high demand inner city practice has seen demand flatten over 4 years, even fall slightly, despite a GP response time of just 12 minutes. Our evidence gives the lie to those who say easier access increases demand. Some make patients wait 12 days, but all this does is to increase anxiety demand, booking just in case, rework and stress.
If there is unmet need, this may be uncovered when access is opened up, but the system is so efficient that for almost all practices there is still excess capacity, and demand then becomes stable and predictable to better than 10% each day.
Some imagine that it doesn’t work for all patients, but it turns out that is only a handful in each practice who can be accommodated individually. Many such questions are raised and while we have published evidence from our database of over 10 million consultations, we welcome full scale independent evaluation which is being done through Tele-First.
So what’s the secret, and why has there been criticism? A whole system demand led approach is critical. Bolting on a hybrid where prebookable face to faces are taken first does increase the workload and I’ve seen much misery result from this. Having helped 100 odd practices through change we’ve seen everything that can go wrong, and even apparently subtle deviations can wreck the system. But with good leadership, the will to succeed and the right support and measurement, the change, even in as little as four weeks, is very secure.
Is telephone triage the final answer? I’m an engineer, we don’t do final answers, we do “the current best model until we have a better one”. The next even more exciting model is online access.
Seeking help from your GP online, presented 6 July 2016. Link to King’s Fund site here, or see below.
For one day at least the bombardment of doom is silenced: GP leaders have lined up to say that the NHS England’s GP Forward View is largely what they wanted. (The same can’t be said of GP forums of course, but we know many of them would make a tabloid editor blush. First comment on Pulse at 2:10am, “this at best delays the collapse”. Bless…)
The main reason is the really quite large number of £2.4bn annual extra funding for primary care. Moving money from secondary to primary is the right thing to do, it can achieve more value and as a taxpayer I applaud it. The real question is not the number, but how will it be spent?
By far the largest part is more of the same. More GPs, more practice nurses, clinical pharmacists, mental health workers, and generally more of a primary care team. This could be valuable if they have the right work to do. There’s more for premises and more for pay, which if it goes to the right people, could also be valuable. (They can’t call it pay though, it has to be packaged as resilience, sustainability and funding formula adjustments. What do they take us for?). I’d direct more to GPs and practices in deprived high demand areas, as this chips away at the Inverse Care Law.
But what is the funding for doing things differently? Here’s the rub. The thinking hasn’t really changed, as it’s all about supply, precious little about understanding demand or even learning the basics from recent experiments. There’s £500m for 7 day opening, and GP hubs, which have been evaluated as a hopeless waste of money and 3 times the cost of core GP.
Well, I am grateful that a small fraction at £45m is earmarked for e-consultations, because askmyGP does exactly that. It’s no surprise to see it there, with Director of Primary Care Dr Arvind Madan writing the foreword. (He’s a 10.7% shareholder in Hurley Innovations Ltd, which does that too through eConsult / webGP). There are lines for development and transformation support too: what’s most important is that they are spent on the basis of evidence.
To see the thrust of the document I’ve done a little word count:
Online – 22 times
Scale – 15
Telephone – 10
Continuity – 4
We know that continuity of care is the bedrock of general practice, and all the evidence says it is central both to quality and efficiency. It is harder (not impossible) to achieve in large scale units. With only four mentions, how is it going to be enhanced and measured?
My view on the forward view: be careful what you wish for.
PS: Getting to grips with demand and capacity through Loadmaster, click to join our webinar Unblocking the appointment system tomorrowFriday 1pm.
Last time people wanted to know how they could do their own Loadmaster, and I’ll explain.
As we have passed 20,000 online demands from patients we review what we have learned about how “undifferentiated demand” converts into the symptoms expressed by patients, the patterns of those over time and differences between populations and their needs.
First presented at Digital Health Oxford DHOx meeting on 18th April 2016.
I suppose it’s a bit like saying, “Those new carbon fibre wheels have done wonders for my cycle speed and handling. I know, why don’t I get a set of four and put them on my car?”
Thus we learn from this week’s Emergency Medicine Journal that all those GPs in A&E schemes don’t work. “There are significant and unexpected consequences of simply transferring interventions that work in one setting without an understanding of context and the process of change…. paradoxical increase in demand… theoretical cost savings not as expected…“
Systems thinking tells us that improvement comes about through consideration of the whole, while trying to optimise one part out of context usually increases variation and costs.
Oh dear. Yesterday I heard another sorry tale of a GP hub scheme which had confused patients, reduced continuity and poured more PMCF £millions down the 7 day opening drain.
Let us never repeat these failures, but let’s not dwell on them either because there is work to do, and everything to hope for.
I was at the RCGP’s “GP Reimagined” event in Newcastle. Sir Donald Irvine’s call to GPs to be imaginative, bold and braverang in our ears as he concluded the keynote, and oh what a contrast to the bleating we so often hear.
Dr Ashley Liston spoke just before me in the afternoon, and I was so moved that I’ve put his story from Encompass practice in Washington here. It’s now three years since we helped them launch a demand led system and he says not only do receptionists never cry now, he can point to lives saved.
Friends, I think we know this, and we must not be deflected. What general practice does best, and does brilliantly, is just that: local, list based general practice with good in-hours access and good continuity.
Let’s do it better.
PS: there’s still time to sign up to the webinar Unblocking the appointment system next Friday 1pm. Feedback from the first run on Thursday was amazement that such a simple tool could make demand and capacity so clear. I’ll explain how you can do your own practice Loadmaster too.