Known since before Tudor times, named Gresham’s law in 1860, thoughtful observers have realised that “Bad money drives out good”. When two forms of currency are in circulation, the debased version quickly replaces that of true value. It’s happening now, paid for by the NHS, in general practice.
Oxford CCG proudly trumpets the big numbers, “15,000 extra GP appointments in £4m scheme.” Divide £4m by 15,000 x 12 months and we find the cost per appointment is £67. That’s over twice the fully absorbed average cost of a regular GP appointment.
It gets worse: regular GPs are funded by capitation, not by activity (per appointment) and their contract means they are already responsible for their registered patients who are or believe themselves to be ill. The CCG is paying £6 per patient for a service already fully funded – it’s paying twice. But not the CCG – it comes from an NHS England pot, descended from a GP Access fund which covered less than 10% of England – a lottery as to whether your area is included.
It gets worse: a GP federation officer says it’s for those patients having to wait 2 to 3 weeks to see their own GP. These GPs are failing their patients with an appalling service. They are being rewarded for failure, incentivised to fail more as worse access will move more of their patients into the “extended service hubs”. Patients at GPs offering an excellent service, such as Oak Tree Didcot which we helped over 5 years ago, have no need and no desire to travel further to see a doctor they don’t know.
It gets worse: my Didcot GP friend tells me “it is virtually impossible to find GP locums or recruit GPs because many are now working in these hubs seeing relatively straight forward problems, with 15 minute appointments, whether the patient needs 15 minutes or not.” [and we know that utilisation of slots is low, many will be left empty]
All right thinking people can see this. So why is it happening? Control of the money lies with those who don’t want to see: NHS England, who knows why, Oxford CCG who think they have a “nice” headline, and the GP federation owners so happy to take up the offer of highly profitable light duties. £4m will get soaked up in a year with no difficulty at all, and when the money stops, so will the service. This is the very antithesis of sustainable continuous improvement.
What can you do? Fight this debasing of general practice with every bone in your body. The RCGP, BMA and all in leadership positions should be calling this out. Local GP Dr Helen Salisbury says, “It might be better if we could just fund GPs properly,’ Too right. NHS funding must go to where it is of highest quality, most effective and productive, core general practice.
I don’t like to end without hope, because we need hope, and Gregory Bateson’s analogue is worth noting: “the oversimplified ideas will always displace the sophisticated, and the vulgar and hateful will always displace the beautiful. And yet the beautiful persists.”
Fight for the beautiful.
PS last week’s launch in Surrey has gone well, GPs dealing with all demand on the day, patients amazed. A couple of examples stood out for me on day one: the lady who walked straight to the desk at 8:35 expecting a queue of 10 and a rammed waiting room: nobody. Look of total bewilderment – “are you open?” And the patient late in the afternoon who, on the way out, stopped at reception to thank the whole team for the wonderful service she’d had. Gets me out of bed every morning.
Are you in a caring profession? I had the opportunity last week to visit the Midlands hub of a rather different one, no less caring, but where the object of their care is a parcel.
You’d think it was a different world to general practice and on the surface that appears to be the case, but the parallels are striking and fascinating. They call it a hub not as the latest management fad to soak up taxpayers’ money but because the hub is essential to the design and operation of the system. (All competing parcels businesses have a Midlands hub by the way).
It means that a parcel can be collected from your door anywhere in the UK and delivered to another door anywhere in the UK within 24 hours, and to do that for 5kg in any shape or size, for under £10, is simply astonishing.
At the system’s centre is the hub where lorries from 40 depots arrive throughout the evening and depart into the night. An arriving parcel can go out to any destination, and if it’s one of the 70% to go on the automated system it will spend just 7 minutes in the building. Most of the 300 workers however handle the odd shapes, sizes and special requirements of the 35,000 per night which can’t be automated. They are glad of £12-£14/hour for the 8pm – 3am shift, many of them immigrants and a third on agency books. It was hot on Monday night, and only the control room has a/c, but the work ethic, and it is hard work, is phenomenal.
So what about the parallels? You’d think a parcel is a parcel, but the “undifferentiated demand” they see ranges from a 150g padded envelope to a 1.5 tonne truck engine, a factor of 10,000 times by weight. They all get the same service. Is it urgent? Some are marked as such but there is no way of knowing the unique story behind each item. In truth it makes little difference, as there is no point hanging onto parcels overnight – they would just get in the way of tomorrow’s work.
What about the ethos? They sort everything tonight, barring a handful of especially fragile or flammable patients, I mean parcels, kept in for special treatment. They walk the lines to ensure nothing was missed and only then declare “End of sort”. Only then do they go home, and if it’s after 3am, they stay until done – last night was 3.39.
There’s the variety, and there’s the flow. Like general practice, parcels are not scheduled, they just turn up when they feel like it. But the volumes are predictable within quite a narrow range, and the pattern is tidal. Every evening lorries come in around the same time, every night they go out again full (except for the exceptions, breakdowns, accidents and so on, managed by humans).
“Tidal” seems to me the best description for general practice demand, predictable by day and by week, and I sense the next blog forming around a theme – the tidal deniers, tidal self harmers and tidal surfers.
Help me with a name, “How to be a GP surfer dude” or something.
askmyGP & GP Access Ltd
PS Thank you to Dr Kerri Monk, GP at Audley Mills, for her addition to last week’s blog. “I feel as a group of drs we’re finally working as a team. It’s great. I’m looking forward to week 2 already.”
PPS Fascinating interview on automating healthcare with Dr Jonathan Tomlinson, aka @mellojonny, in the Technoskeptic. “We got this fantastic robot that does the work of two men, but unfortunately it takes three to work it.’ The WebGP/eConsult thing is like that.”
We agree. And that’s why we have a totally different philosophy from webGP/eConsult, who are trying to divert patients from seeing a GP, or diagnose themselves and then get asked so many questions they lose the will to live. It doesn’t work. Computers are rubbish at this. Computers are very good at taking down what people say and speeding up communication. Which is how they save time for GPs. Which is why one of our GPs using askmyGP said to me last week she could manage a patient demand in two minutes which previously would have taken five minutes. Aha.
So now they are trying to increase the proportion of patient demands coming through askmyGP up from the current 20%. The clue on how comes from the main theme of patient feedback: “Easy to use and quick service.” Aha. “Quick service” is down to the practice, “Easy to use” is down to us and you’d be amazed how hard it is to make something easy! Our never finished project.
Quite a week but let’s put all that to one side and reflect on a fabulous article I came across, which put into perspective what we are trying to do.
Dr John Launer of HEE asks in BMJ Is there a crisis in clinical consultations? Although he sets the paper in a hospital context, most of his working life has been in primary care and the same principles and questions apply. It’s all about
“the idea that making it easier for clinicians simply to talk with patients may solve many problems that managers might assume need far more complex technological solutions”
Aha. Let’s add to that the assumptions of politicians, along with structural, financial and all kinds of other complicated solutions.
Launer quotes Dr Gordon Caldwell who has outlined ten fundamental conditions to optimise consultations, including:
- The patient should be as prepared as possible
- The clinician should be as prepared as possible
- Ready supply of information into the consultation
Telephone consulting pioneer Dr Steve Laitner contrasts traditional general practice in a tweet, “like having a day of back to back meetings every ten minutes with no idea who you’re meeting and no agendas”
Stressful and far less productive than it might be.
Yet patients are willing to spend their own time writing and preparing when they seek help – we need the system to make it available to GPs.
A recurring theme of patient feedback on askmyGP is “I was able to gather my thoughts before seeing the doctor. I so often forget things when I’m in there.”
Clinicians value enormously what patients write, whether preparing for a phone or face to face consultation. Our task is to develop the handful of questions which provide the most useful information, and I’m delighted to say that researchers are interested in this too.
Our other focus is to make online access so easy and attractive that it becomes the norm. We are over 30% in one practice and it will take a lot of experiment and refinement but I’m looking forward to reaching 50%, which I hope will make a big contribution to clinical quality.
I’ll leave you to look up all ten principles in Launer’s article, but here’s one you will like: “The clinician should be regularly refreshed”. He doesn’t say what with.
askmyGP & GP Access Ltd
On cloud 9, or, “In a state of blissful happiness” is perhaps a little overstating it, but we are delighted to be on the government’s G-Cloud 9 Procurement Framework from 22nd May.
Phrases like “procurement framework” tend to bring me back down to earth with a bump, but I think this one could mean something really good, and I quote from the gov.uk Digital Marketplace:
“Buying services through frameworks is faster and cheaper than entering into individual procurement contracts.”
Right, so there’s one agreement set up between the Crown Commercial Service and us, following all the OJEU rules and thoroughly tested for compliance with all the relevant standards: NHS IGToolkit, Clinical Safety standards for software SCCI 0129/0160, secure hosting and communication on N3, you name it, all the painful, boring but essential stuff.
Yes it has been painful and I pay tribute to all the GP Access team and our partners who have done such a grand job in getting us there. It is right and proper for the process to be thorough as patient safety and information security are paramount. We have seen too much lately of what can go wrong, yet we must not lose sight of the great benefits that technology can enable for our health service.
In the first couple of weeks we’ve seen over 700 patients use the new askmyGP to get help online. One emailed Concord practice at 9.14am last Monday, a time when patients in most practices would still be hanging on the phone, trying to get through. She already had her problem sorted by the GP and just wanted to say thank you for the outstanding service.
Now that’s what really gets me on cloud 9.
PS Do explore our new askmyGP website, where all the services under What We Do are on the framework. One of the requirements of G-Cloud is that you can’t raise your prices for two years, which we weren’t planning to do anyway, but it means we can guarantee that if all you want is the online consultations Start package, it’s 25p/patient/year plus vat, and that can be fully funded by the ring-fenced GP Forward View allocation to CCGs.
PPS The application process did have its lighter moments, my favourite being where you have to agree to the statement that “all the above statements are true”. Unbeatable logic.
What an exciting week in NHS IT! Sorry I’ve been hiding for a month but we have all been intently focussed on launching version 2 of askmyGP. It draws on our evidence from 46,000 patient episodes in version 1, but the software and delivery mechanism are all new.
So if I said the rollout of the new system went exactly to plan, all pigs were fed and ready to fly, you’d call me a liar and you’d be right.
We were ten days late going live and patients had to go back to the telephone. We had one of those unexpected problems that got through all the testing and didn’t appear until the real world stomped in. We had to spend the weekend fixing it.
Then it worked. Already we’ve had good feedback from the first 300 patient uses, and some great suggestions from the first 7 practices which we have already implemented.
So what’s new? I won’t do too much detail for now but the step in thinking is all about flow. We know about demand, we know it’s predictable and very nearly flat (BMA refers again to “soaring demand” in its manifesto. They haven’t bothered to measure) but we know there’s no simple way to cut demand (we’ve tried like everyone else, and it doesn’t work).
The demand is the demand. But we can do much better if we make it flow, from entry to completion. The new askmyGP is designed exactly to enable that frictionless flow.
Delivered not on NHSmail but over N3, the new system is designed for greater security and reliability…
And then of course Wannacry happened… we switched askmyGP off on Friday night as a precaution but found no evidence of any incursion, so came back on Saturday lunchtime. Already a couple of dozen patients have entered demands at the weekend. They know not to expect help until Monday, but that helps the practice smooth out the morning rush on the phones.
Aha, the beauty of being open all hours, but not there all hours.
Can’t wait to tell you more, it is so exciting, but it’s getting late.
PS Not one but two practices complained to me that demand has been very low the last couple of weeks. I put it down to three causes.
1. Weather. In a demand led system, you get the immediate benefit of the sunshine dividend. If you’re booked up three weeks in advance, you never notice.
2. Randomness. Knowing your average demand and planning capacity for a bit more means that most days are less busy than planned.
3. Anxiety demand has dropped – both practices launched six months ago and patients have got used to the idea that there’s no need to plan illness in advance – the GPs are there when you need them.
Happy days! Now try getting Pulse to publish that.
I wrote last week to Mr Hunt and sat by the phone all weekend, but it appears ministers are not offering a proper out of hours response so I have little choice but to go direct to Emergency PMQs.
Your headlines: “a large number of surgeries are not providing proper out of hours care – and patients are suffering as a result because they are then forced to go to A&E.”
GPs have a contract since 2004, mostly GMS or PMS, which defines their core hours. Simply saying you don’t like it really won’t do. The Telegraph has “Under Mrs May’s plans, GPs will have to be open from 8am to 8pm every day of the week unless they can prove there is not demand in their catchment area.”
We’ve been measuring demand for over five years and I can assure you there is always demand, but we do need a higher level of understanding from our PM, well intentioned and intelligent as you are. Demand out of hours is predictable and perhaps surprisingly low, but covered by out of hours services (as provided for in the 2004 contract).
But you are confusing demand with capacity. We know precisely the profile of demand, by day, by hour, even by minute, we know what is in and out of hours. We also know that spreading the same capacity over longer hours will cut that capacity and increase costs. When Sir Amyas Morse states “They are seeking to improve access despite not having evaluated the cost- effectiveness of their proposals and without having consistently provided value for money from the existing services.” it is well worth listening. His NAO report says extended hours GP costs are 50% higher than core hours. I’ve seen evidence that the true ratio is closer to three times.
Ignoring the evidence you have deeply upset GPs and confirmed the view of many that they are being bashed. I could call this counterproductive but the language you’ll hear over the next few days is going to put such bland terminology in the shade.
I do more data nerdy stuff than emotions, but I want to finish on a note of hope and if you’re prepared to listen, read one thing. Dr Philip Lusty was exhausted and beaten, along with all his colleagues and staff, as I personally witnessed. Now read what happened.
webGP eConsult GPFV page suggests a rush to sign up to a plan by 23 December.
Claiming 300 practices using the product, it is notable to see the extensive quotes from their 2013 pilot study of 20 practices, 14 of which are their own in Hurley Group. What about the other 286 are not Hurley Group and would provide recent independent testimony? Doesn’t the absence of any more recent case studies seem odd?
“Self-help and signposting options attempt to reduce demand on the practice” – this is a true statement. It is not a claim that it does reduce demand.
Productivity effects are discussed on page 9. The time to process is stated as 2.9 mins per e-consultation, but does that include a phone call to the patient? 60% solved remotely is plausible, but it’s not clear whether the 2.9 mins includes a phone call. The other 40% requires face to face, and if the average duration is 10 minutes, that’s 40% x 10 minutes, a further 4 minutes. The best possible assumption means an average of 6.9 minutes to complete a demand arriving as an e-consultation, 31% saving on 10 minutes. But how much demand has shifted channel?
Speaking at the EMIS NUG on 23/9/16, CEO Dr Murray Ellender showed this chart of demand shift reaching 7%. This is over 2 years, in a young adult metropolitan demographic. Whether this was 7% of demand we don’t know, because if supply is limited, it may be 7% of supply (easily done by restricting numbers of phone or face to face appointments).
The best case is to take it as read, such that 7% x 31% gives an overall saving of 2.17% of consulting time.
We wonder whether sufficiently sensitive measures are in place to detect such a change.
Several reasons lead us to doubt the quality of this evidence, and therefore whether a “best case” assumption is reasonable, beyond the fact that this is a tied practice. This is not a time series chart, although the x-axis may suggest this. It is three data points, with a straight line between them. It contains no actual numbers of episodes, only a % of channel shift, hiding the units. For a comparison of how real data appears, please see our Greenway Belfast case study, a practice which runs a demand led system meaning very rapid access equally from phone or online demand. This is significant as there is no need for patients to use online access to jump the queue, yet the data shows 20% channel shift within 2 weeks of launch.
The lack of independent practice case studies, and the 0.7% demand shift in the original Hurley study, tells us that in the vast majority of practices the channel shift is an order of magnitude lower.
Note: we have requested a fair copy of the original case study from Dr Ellender, but no response was given. The presentation in full is available here. In a November 2016 presentation in Sweden, Dr Omar Hashmi claimed many were at 7% and some up to 30% – I wonder where is the data?
I’ve had to re-write the whole thing because, deep joy, we’ve made it to the front page of the Daily Mail. And as everyone knows, the only good news in DM is royal babies so to be traduced in such huge type is truly living the dream.
You can read the fully made up Mail Online version here. We even made it to the leader page where they deliver the knock out punch, “This scheme’s advocates should think again.”
What’s funny about DM is the setting up of falsehoods so easily overturned. “3 minute phonecalls” – no, the average is 5, but they can vary quite a lot. But then we measure the duration rather than just inventing numbers. It’s so much harder work.
“Campaigners warn that some, particularly the elderly, might be fobbed off or end up going to casualty.” Yeah, but then I discovered the pioneers because they had lower A&E numbers. And we have 6,798 patient feedbacks which are overwhelmingly positive, with the elderly especially so.
Forgive me for quoting directly from the Mail’s online comments. There’s the predictable
“Bet the immigrants don’t have to be questioned on the phone.”
“My doc has an online questionnaire and generally a three week wait to see a doc.”
and the well informed
“I had this two weeks ago. GP rang me, quick discussion on my problem and she called me into her surgery the very same morning and saw me. Turns out is was fairly serious, so it worked well for me.”
The patients get it.
PS New evidence this week looking at the GP PES shows how good access is shining through. This is worth a click: Analysis of access in large GP groups.
It’s been a tumultuous week as big business interests threaten our way of life like never before. Thankfully the attempt by Toblerone to bury the bad news as they cut 10% off our chocolate has spectacularly backfired.
More important news struggling to get heard is the publication of the first of 44 STPs covering England. BMA complains “GPs shut out of STP talks”, so what do they mean for primary care? Well I’ve pored over them so you don’t have to (at least, the parts I want to, with my secret method, ctrl-f in the document and search for the words…).
So I started with “demand” and there are dozens of references. What’s funny is that about half of them bemoan the inexorably growing demand across all our services, usual stuff. And then without a trace of irony, the other half outline our plans to reduce demand. One quotes 30% of GP activity!
Compared with predicting election outcomes, forecasting healthcare demand is laughably easy. Add 1 – 2% to last year’s demand and you’ll be within a gnat’s.
Apart from a few niche areas, the reason that demand keeps going up is because no one has found a way to reduce it. Everyone including us has tried – are we the only ones to admit it isn’t working? So reducing “demand” in STPs is either wishful thinking or in reality reducing supply, more concisely called rationing. That word doesn’t occur even once as it very quickly gets you the sack.
Try another word, “digital”. Dozens and dozens of references, all positive, and generally linked with the word “enabler”. I like this way to describe digital, because it can be an enabler of change though I don’t see it working as a driver. We haven’t yet found a way to reduce demand but it certainly can enable us to deal with demand more efficiently.
There is no doubt that digital is going to be a major component of change in the NHS over the next few years. What is unknown is how, but I’m sure it will only make an impact if it works brilliantly both for patients and GPs.
STOP PRESS: this new Dutch study on the impact of their NHG health info website is seriously encouraging for demand reduction.
PS We put a lot of effort into measuring patient feedback, as unless it’s very positive patients won’t use digital channels. High usage is the only way to get a return on all that investment in technology. We’re putting these patient measures in the public domain and keeping them updated.