I’m going to make enemies in this blog. Not because I want any more, but because I’m asking for critical thinking, evaluation of evidence, judgment.
The zeitgeist says “no one size fits all”. It’s even written into the NHS Five Year Forward View, page 16. In a postmodern world anything goes. Now anything goes in your choice of hairstyle, if you have the luxury, but anything goes in how to run a supermarket, how to build a car or how to treat a wound? Wherever you are in the world, they are almost identical. Other methods have been competed to the margins or out of existence.
The 5YFV obsesses about structures, yet is ignorant on systems. And when it comes to “how to operate a general practice”, what do we hear from the colleges, the NHS, commissioners and so on? Suit yourself. Nobody knows what matters, so have a go and who cares?
I think there’s a reason for this. Lack of proper measures, lack of transparency and accountabilty and yes, lack of competition all keep patients in the dark. Patient Experience Surveys are useless for operational and quality comparison, and the CQC makes things worse by tick boxes, fluffy commentary and ratings bearing little relevance to patient concerns.
What is the patients’ first concern? The ease and speed of access. Another study (Sirdifield) just said the same thing again. Now consider the variation in performance: a well known London practice told me last week “we don’t do same day appointments” and offered me a 22 day wait. This Thursday I was with Chris Peterson from The Elms, big smile, doing better than ever, his patients wait a median of 12 minutes for the GP to respond in their demand led system.
That’s 32,000 times quicker. But CQC takes no notice.
Friends, we don’t need endless pilots, 75 new models, 10 “high impact” ideas which aren’t. We need relentless pursuit of what we already know works. We need innovation, local adaptation, testing, refinement, yes, but no more mushy, fudgy, bumbling along. We can’t afford it, patients are being let down and GPs are needlessly wearing themselves out.
New enemies and old friends, please bring your evidence and let’s debate. Twitter GP journal club #gpjc this Sunday 20/3 at 8pm on telephone triage – we must do better.
Best regards, Harry Longman
PS The operating system makes all the difference but size per se seems to have no impact on cost. Important to read this paper to the end as the conclusion changes!
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:
Perhaps, looking back, we’ll see it as a milestone.
The Public Accounts Committee is a forum for MPs to grill public servants on how they are spending our money. Last Monday it considered the matter of GP access.
Ros Roughton, NHS England Director of Commissioning, is my star of the show – you can watch the recording. She doesn’t simply rehearse the problems, but highlights the evidence that GP telephone consultations implemented at scale have freed up time for more complex patients, as many don’t need a face to face. We’ve only been saying this for five years – she was reporting our work with Brighton and Birmingham PM GP Access Fund projects.
Chair Meg Hillier MP is quick to respond with the obvious question, “Where there is really good practice which could just be rolled out, what is NHS England doing about it?”
Well, there’s more to it than telephone consulting, and of course online access frees up even more capacity. But without understanding demand no system can work properly, so the MEPRA model makes it simple:
Measure – Predict – Respond – Adjust
Hundreds have downloaded our new paper which explains the how: Enabling Demand-Led General Practice
So, NHS England, the evidence is crying out, let’s roll. Health boards in Scotland, Wales and Northern Ireland are in touch too. Don’t let patients suffer any longer and return with pride to answer the PAC next time.
The wonders of technology are the means, democracy is the end.
The public accounts committee has the role of holding public services to account, and therefore we are delighted to see the subject of access to GPs covered.
Professor Maureen Baker, chair of RCGP, tells us that there’s a mismatch between capacity and demand.
But Ros Roughton, NHS England, says that evaluation of the PM’s GP Access Fund has shown very encouraging results from GP telephone consulting, and it has freed up GP time. Click the link and scroll the slider to 17:06 (unless you really want to watch the whole thing)
So GP capacity can be increased, by changing the model. Readers of this blog will know we’ve been saying this since we started in 2011, perhaps this marks a milestone.
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.
This week NHS England has been flying the flag, proclaiming that 10 million GP appointments will be booked online this year.
The latest projection as I mentioned last week from the NAO is that 368 million appointments will be made in 2015, so 10 million of those represents 2.7%. In a world lived online, this is very strange, so I thought I’d try to find out why.
As I write, my own practice has exactly one GP appointment available online in the next 7 days, out of around 200 which they’ll give. The picture is similar nationally.
For fun, let’s look at booking airline tickets. We could choose shopping online, or banking (2.5 billion logins/year), but at 250m flights/year from the UK it’s roughly comparable. The demographic is not quite the same as seeing a GP, but the overlap is very large. The CAA did a survey this year which showed 76% of bookings were made online. I’m surprised it’s not higher.
So is it easier to book a flight? I’ve tested this, and the absolute minimum if you’ve chosen your airline and already stored your personal and payment details is 30 clicks. Of course, most bookings will be far more complex and take multiple searches, comparisons and decisions about luggage, seating and trying to avoid buying insurance.
To book my GP appointment takes just 6 clicks, and 11 seconds.
Aha. The airlines love online booking, it saves them a fortune and you could not conceive of a new airline entering the market without it. Passengers love the convenience, and will happily spend their time and money complying.
It’s worth it for the providers even more than for the public.
GPs are business people, and they’re not stupid. They have worked out that it’s deeply against their interests to offer all their appointments online, despite the savings in administration. They know that if it takes 11 seconds to grab £27 worth of their time, they’ll see a lot of people who don’t need them and a lot of others who do will be left complaining to reception, never mind the clinical safety issues.
Yet the same public, patients now not passengers, do want to seek help online from their GP, if only they could. By allowing them to seek help, but keeping the GP in control of what help, when and from which clinician, the provider wins too. askmyGP takes at least 80 clicks, but patients love it and we’ve already seen 45% of demand shift online at one practice. It’s sure to grow.
The airlines made the change all on their own. NHS England has the resources of the state, enforcement through the GP contract, publicity in every practice, even pays for all the online technology. And has reached 2.7%. Turning such an abject failure into success needs new thinking which makes this work for GPs.
Do you agree? Please comment below.
PS We’ve been looking for several weeks at examples of patient histories submitted online. I’ve collected them here so you can see how GPs voted to help them.
Far more interesting this week than the spending review was the National Audit Office report “Stocktake of access to General Practice in England”. I know what you’re thinking, but some of my closest friends say I’m not just a data nerd.
NAO headline figures are £7.7bn cost for 372m consultations. Cleverly they divide one by the other and come up with £21 per consultation. Let’s be even cleverer and divide 372m by the population of 53m and get to 7.0 consults per person per year. Of course nearly half of those are not with a GP, the cost each depends on the clinician and so on.
But they are the first to admit that 372m is copied from an RCGP report in which Deloitte extrapolated a series from QResearch which ended in 2008-9. So, Alan has the correct answer… “Nobody knows”.
Does it matter? Well, you could say that knowing the top line for a vital national service where 37,000 GPs deal with over 90% of patient demand in the NHS can be left entirely to guesswork. I’d beg to differ.
The NAO has done its best with what’s available, much of it from surveys, a poor relation to operational data, but it’s a scandal that we don’t know. A figure they quote is that 89% could get an appointment when they tried, worryingly down from 91%. Our audit data is very close at 88%. Let’s put that the other way round, taking their figure. 11% of patients who tried to get an appointment with their GP could not.
11% of 372m is 162,000 people told every working day (5 days!) to go away. It is my personal mission to wipe out that number. We don’t have any money. We have a method.
PS From macro to micro, have you been watching “Doctor in the house”? I happened upon this on BBC1, expecting trashy reality TV, but it’s a real doctor, in a real house, with real patients. I know very few patients can have that much attention, but Dr Rangan Chatterjee is terrific, showing what GP is about, changing lives. This should be the best recruiting story for any medical student. Well worth a catch up on iplayer.
His toughest patients are the middle aged men who never want to bother the GP, and in our series of real patient histories this week’s is one such with an embarrassing problem. He might find it difficult to explain to a GP, let alone a receptionist to get the appointment, but has been very open with a computer. Take a look and vote on your first response.
PPS If you are already curious about the method, spend 5 minutes hearing from a practice on this video.
I have to say I am very frustrated with the PMCF Wave 1 report, titled “Improving Access to General Practice”. You’ll recall my offer to Dave that he could change the name to PM’s GP Access Fund provided it was evidence-based. This does not cut it.
The major failure is not to measure what actually matters to patients. To restate the b*****n’ obvious, the question from patients is, “How soon can I get help from my GP?”. There are 9 national metrics, change of hours, modes and fluffy satisfaction surveys, but this simple measure is missing. Can it be done? We did a little taster of 50 practices in the Dover Collection, showing we could do it on an industrial scale, and offered it to them. But no, they wanted to spend far more money on this glossy verbiage.
So what is useful in the report? Of course we are glad to read in the conclusions p38 “To date telephone-based GP consultation models have proved most popular and successful. There is growing evidence… due to the GP time savings that are being achieved.” Yup, it works and it’s sustainable without more funds. We were involved in delivering the two largest ones (p30) in Brighton and Birmingham. In the latter it was so good that Vitality/Modality have started selling their own version!
But we also read “Other non-traditional modes of contact (for example video or e-consultations) have yet to prove any significant benefits and have had low patient take-up.” The only numerical evidence cited for this is webGP/eConsult, where analysis of the CareUK scheme (p14) shows just 0.3% of demand moved online, even less than webGP’s own data which is around 0.7%.
With up to 45% of demand shifting online via askmyGP it’s a shame this was not evaluated, but there are clearly huge differences in approach. We’ve listed them in this handy comparison chart.
Universality is crucial to uptake, meaning all patients, with any problem, can get help fast, and then they love it. The mother of a 3 year old with foot pain wrote yesterday, “This is much better than being on hold on the telephone. Especially when you have young children and don’t have a lot of time to be on the phone. A big improvement!”
We’ve been doing a series of examples from patients seeking help, and this week’s is very short and simple, a painful eye. It saves them having to argue for an “emergency slot”, suffering for days or going to A&E unnecessarily. It means the GP knows what the problem is before getting in touch, and doesn’t waste time where there’s no need.
Message to Dave: you’re looking in the wrong place for the wrong thing. Hello! Over here!
PS I did my first ever webinar on Thursday, really enjoyed it, and we had about 40 minutes of questions at the end. If you missed it there’s a recorded link here, Understanding demand, the key to better service and lower stress. You can still get the CPD credit in the comfort of your own home.
The PMCF Wave 1 evaluation report by Mott MacDonald makes fascinating reading, but much of it is between the lines.
Summary page VI: “To date telephone-based GP consultation models have proved most popular and successful…
“Other non-traditional modes of contact (for example video or e-consultations) have yet to prove any significant benefits and have had low patient take-up.”
The e-consultation system used is webGP, and more detail is revealed on page 14:
“Care UK implemented a diagnostic and e-consultation system at all eight of its practices but experience suggests that it has a limited appeal for patients; they tend to prefer the pilot’s telephone access offer, which provides patients with a GP response more quickly. Since going live, the pilot has provided 470 on-line consultations up to the end of May 2015”
Care UK’s scheme was run over its 8 practices with a total of 45,000 patients. Demand for a GP is typically 6.5% of practice list size per week, which makes 152,100 per year.
470/152100 is 0.30% of demand. This figure explains the comment of “limited appeal” for patients. Other benefits of the scheme may be claimed but calculation is impossible, apart from the cost of submissions.
The price of 75p/patient per year, including VAT, implies a cost of £33,750 for the scheme. This is £71.80 per submitted consultation.
By contrast, page 30 describes telephone triage systems, in two of which GP Access was involved in delivery. We were not consulted on the evaluation, but the assessment is made, “This is an encouraging outcome to date.”
Our view remains, changing to a demand led system where GPs respond quickly produces rapid and sustainable benefits. With the telephone this is well proven, operating as a whole system, and pays back investment. Online access has not been proven to work in the PMCF, but this is a function of the product and service offered. We have shown how over 45% of demand has shifted online with askmyGP. Fundamentally it is a better solution than telephone only, both for patient convenience and GP efficiency, and the evidence continues to grow.
The PM’s Challenge Fund has been renamed the Prime Minister’s GP Access Fund, and I need to ask your advice.
- Sue. Dave is some new PM on the block and the name’s gone. Who’s this HMG gang anyway?
- Sell him the domain name. There’s only one gpaccess.uk – but does he have the readies?
- Sit down and talk. We could argue over names but there’s a deal on the table: you can borrow it so long as you base the whole shebang on evidence. Don’t worry, we’ve got the evidence.
Here’s the demand over 7 days when patients have 7 day access via the online askmyGP system:
And what time are they seeking help? Is it 12 hours a day, 8-8? When they can access 24 hours, the hourly looks like this:
That’s through the online askmyGP service, at a north London practice. Those demand patterns look pretty close to when the GPs are working, plus a few at other times when it’s convenient. All done for pennies. That should keep George happy.
There’s an academic study out this week which says 0.4% of people want Sunday opening. It’s based on patient surveys. Rather than asking people what they would do, I prefer to measure what they actually do do. Anyway, we all get the picture. Is that a deal Dave?
In the meantime, we are working with lots of your PMCF sites, designing and and delivering better access for patients, and better lives for GPs. My GP Access colleague Chris Hanney was the PMCF Product Manager, and we’re going to have to rename him the GP Access Prime Minister’s GP Access Fund Product Manager. Hell, the expense.
PS Last week I had a huge response from people asking for a link to our Leading Change Questionnaire. It’s a first step to tackle the problems of GP access and workload. Drop me a line if you missed it, and I will forward by return.
PPS Real patient histories submitted online are proving popular with GPs voting on how to help. This week’s is a sore eye, along with the patient’s concerns. Recording what symptoms the patient denies is a key component of the decision on next steps.