At long last the CAPC study on eConsult has been published in BJGP.
“Conclusion The experiences of the practices in this study demonstrate that the technology, in its current form, fell short of providing an effective platform for clinicians to consult with patients and did not justify their financial investment in the system.”
From his online response to the study, you might think that chief executive Dr Murray Elliender were running a charity. This is far more than simply capitalism red in tooth and claw. eConsult clearly would not be sustainable were the truth known about its performance, well known at the time to Dr Ellender and his partners as he makes clear.
But one of his Hurley Group partners is Dr Arvind Madan, NHS England National Director, Primary Care and author of the 2016 GP Forward View, which helpfully includes a £45m fund, ring fenced to be spent only on e-consultations, in which the company is already a 90%+ market leader.
Another of his partners is Dr Clare Gerada (BMA council, RCGP council etc) who emailed “50 most influential GPs” on 16 December 2016
“…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 three years ago.
eConsult is designed to make general practice more efficient… NHSE has announced funding… please have a look…contact firstname.lastname@example.org”
I’ll leave aside the misuse of nhs.net email for commercial gain, strictly against NHS rules, as much more is at stake here.
That study on eConsult again “…the overall feeling from practices was that e-consultations did not save time; the system generated work by adding another stage in the workflow for GPs and administration staff.”
So who put the CON into eCONsult?
Sometimes the NHS does spend money on stuff known to be worthless. £92,412 went on homeopathy in 2016, but they’ve stopped that.
The funny thing is that so many GPs, some of them quite prominent, have told me over the last two years the same story of their experience with eCONsult (The study quotes a range of daily use from 0.2 to 2.9. Almost homeopathically tiny concentrations).
The sad thing is that unlike homeopathy, digital triage from online requests for help is fundamentally a sound idea.
This is my note of hope for the day: we set out for askmyGP to have 10 or 100 times the use, and it’s working. Only then can it increase efficiency, and only with rapid parallel service by telephone can it guarantee equity for patients who can’t access online.
We are determined that CCGs should not be forced to waste their ring-fenced funding, but have a choice. That choice should be based on evidence of what works, not who’s behind it.
You cannot have failed to notice Babylon’s GP at hand service all over the media this week. As a PR exercise, on the Today programme, You and Yours, TV, front page of the Times and an almost unheard of positive story in the Daily Wail, it was SIMPLY BRILLIANT.
What you may not have appreciated is the existential threat this makes to regular NHS GPs. While presenting it as “the NHS has suggested that the service may however be less appropriate for…” the list of exclusions is in fact the engine of profit for Babylon. Read the list. It’s 90% of a normal GP workload. It begins with women (twice the consult rate of men in middle years), who are or may be pregnant (more work. And babies – lots of work). All the usual suspects, the elderly, sick, frail, confused and multi-morbid are there. They are work. Babylon doesn’t want them.
Babylon has got something spot on: patients are fed up with the often abysmal service from their current GP.
They want the young, fit and healthy, especially men, who rarely need a GP but when they do, want help fast, and don’t want to bother with going to a surgery unless they have to.
All these patients carry the same capitation. Think: what if you lost half your income and the easy half of your population? But kept 90% of the work? If it isn’t obvious yet, GPs will go under. That may not be you, but your neighbouring practice, whose list will be dispersed… to you… and you know those dispersed will be high demand. Nice.
They are in London so far, but Babylon’s ambition is limitless and I fear a multiplier effect from the mechanism above. They have the law (practice boundaries abolished), the funding model, the technology, the demographics and clearly the PR on their side. No doubt BMA is dreaming up legal challenges as I write, but they are no match for weasel words backed by £60m of VC money, while changing the law takes years, at best.
If it were simply about better GP services, I would be cheering. But the inevitable consequence is to stoke the Inverse Care Law. Those who most need help will find it most difficult to obtain. General practice will be dramatically less profitable in the hardest areas, and will suffer even in the most privileged. This undermines nothing less than the core principles of the NHS, universal, accessible and free at the point of use.
I will end on a note of hope, because this is not hopeless if we act fast. I founded GP Access & askmyGP with the vision “to transform access to medical care” and some might say Babylon have achieved that.
But our vision is universal. We have no exclusions. We understand the quality and safety from relationship continuity, to say nothing of the professional joy in work.
Although Babylon’s offer is getting the PR, it’s actually not that great. 2 hours for a video? So slow. 48 hours to be seen? So long. Travel within zones 1 – 3? So far to go.
You can beat it. Faster, easier, closer, with the GP you know.
As @stevekellGP tweeted yesterday, “All patients contacting the surgery today for GP help have spoken to GP & been seen if needed. No DNAs, clean start tomorrow. No videos needed” – most of them spoken to within half an hour.
If you haven’t seen his 2 minute interview you really must.
Our vision is of a transformed general practice that you own and you run for the care of all your patients. It is not a transformation done over you by the power of money.
I’ve been saying this for six years. Now wake up GPs, before it’s too late.
I’ve enjoyed being at a couple of conferences in the last two weeks, the RCGP and then Best Practice. Dozens of conversations each day left me happy but dazed, even monosyllabic by the end.
One of the funniest ones goes along the lines of “We have a huge problem and we need to get around much faster. I understand you do planes, but we are rather scared of flying, so I wonder whether you could provide us with half a plane?”
There are variations: “We want a plane like yours but with a steel frame, because steel is really strong and low cost.” Fine I say, but it won’t fly.
“We are used to driving piston engined cars and they are very reliable, so we want to put them in one of your planes.” Fine, but it won’t fly.
“We have a lot of wood available, so we need a wood powered plane”. It won’t fly.
A plane of any size flies because it is a system where all the components, power and controls work together to produce the outcome of flight.
Crucial to understanding flight are height and velocity, and of course if you don’t measure these, you could be blissfully happy watching films on the tarmac.
They are like demand and flow in general practice. How many patients and how fast are you dealing with them? Failure to understand these basics are why other organisations are offering so many alternatives:
“4 deployment templates” from eConsult
“6 alternative access systems” from Doctor First
“10 High Impact actions” from NHS England.
They can have no confidence in their models as they have no consistent measures or knowledge of how they perform.
Asking for directions, Alice in Wonderland said, “I don’t much care where I’m going”
“Then it doesn’t matter which way you go,” said the Cat.
Alice would like our Start package which lets you deploy askmyGP any way you like. We’ll measure it for you too.
But if you want to fly, then Transform is our one simple, reliable, current best way.
askmyGP & GP Access Ltd
PS System matters but size doesn’t. Just now we’re helping one of 2,900 patients, another with 32,500. Latest news from Larwood, which Dr Steve Kell kindly spoke of at Best Practice: “The wait to see me has dropped from 5 weeks to 15 minutes.” This astonishing statement produced barely a murmur in the room.
He tells me of Dr B who in fairness had been skeptical. He used to go home and watch Channel 4 news on the +1 channel at 8 o’clock. Delighted now to be back at 6.30 and watch it live at 7, a whole new experience!
PPS If you don’t know what you want yet, then Pathfinder will help you decide and I sincerely hope will calm your fear of flying.
Launch day at a practice is something I always look forward to, yet not without a twinge of nervousness – things can go wrong and a difficult day dents enthusiasm which takes time to recover.
Special circumstances at Larwood in Worksop, Bassetlaw were that they had a two week average wait to overcome, and at 32,500 patients were the largest single practice we’d worked with. Their patients were also used to a walk-in service which was abolished with 1 week’s notice, on the same day (simple message, this is the one system now, it has to work).
Well the phone system fails to go over at 8.30 as it always has… 25 patients turn up unaware of the change… but it would have been 100. A small team from management is in the waiting room guiding patients, being helpful and kind, explaining the system.
The start feels a bit chaotic, with queries from GPs trying out their view of online demand for the first time. But work is being done, and by lunchtime we have the first patient surveys – 81% say the new system is better (27/33) and smiles are breaking out.
I hand over the blog to Dr Steve Kell, because he can communicate and all I can do is watch with humbled awe as the week unfolds in tweets.
Steve Kell @SteveKellGP
Quite a day. Changed practice systems today, introduced @askmygp and all patients who contacted the practice dealt with today. Great team.
Hi. AskmyGP – online and telephone access, huge change but great feedback from staff and patients.
Massive change management task but all patients dealt with yesterday, blank screen again today. Fingers crossed.
2 days into full system change to @askmygp:
Really impressed. Different feel to day
Job satisfaction and service ⬆️
Wait – gone
Day 4 of @askmygp – all patients seen so far if needed. Skin problem for 2 years, seen within 20 minutes of submitting message online. 😀
Week 1 of @askmygp. Exceeded all expectations. Job satisfaction, responsive and one of the best weeks I’ve had as a GP in 18 years.
Have been doing @askmygp 1 week and never had better access AND better continuity. All my patients can speak to me and see me if needed.
The last word is from an anonymous patient, one of 417 who got help online with askmyGP, about 20% of demand in week 1 at Larwood. It surprised me:
“I like this service as it is more personal between me and the doctor . Also it gives the doctor more chance to look at records so they know what has been done in the past . This means I don’t have to wait time trying to explain.”
Relief. The humans are in control, not the computers.
With the publication in this week’s BMJ of the Tele-First study into the telephone first model of general practice, you would expect me to read carefully and respond. So here are the headlines:
- 65% of patients report being phoned by a GP in less than one hour.
- 56% of patients find it more convenient vs 22% less convenient
- Large improvement in length of time to be seen, 20% move in GPPES survey.
At a time when we are told repeatedly that patients are having to wait ever longer to see a GP, often measured in weeks, these are quite astonishing figures, all quoted direct from the report. But, dear reader, these are not the headlines you have seen in Pulse or the BMJ Editorial are they? Studies, and the interpretation of studies, are political. We have an interest, and so does everyone else.
Therefore the first thing I want you to do is read the full text so you can make your own mind up independent of headline writers. It is much more detailed than the print version, framed by an angry looking GP model and a scared looking patient model, giving more space to a commentary piece than the actual study.
There is much to absorb but for brevity I’ll comment on the summary section.
What is already known on this topic
- GPs are struggling with the current demands on general practice and looking for effective ways to manage patient demand
- Claims have been made, reproduced in NHS England literature, that a telephone first approach, in which all patients wanting to see a GP are asked to speak to a GP on the phone first, results in major cost savings for primary care and reductions in secondary care costs
We do not make those claims, but you can still read them here on the home page of PPC Doctor First, a 20% drop in A&E and £30,000 saving per GP per annum. I’m grateful to the authors for proving these false. *
What this study adds
- In general practice, many problems can be dealt with by a GP on the phone
- The new telephone first approach resulted in more phone calls, fewer face to face consultations, and, on average, more time spent consulting
- There was wide variation between individual practices, including large increases and large decreases in workload after adoption of the telephone first approach
- There was no evidence that the telephone first approach would reduce costs of secondary care
In a way it is disappointing to see no secondary care effect, but not unexpected and unless the evidence changes, that is what we accept.
But what has really got GPs aerated is this finding of “more time spent consulting”. This was derived from data sent by us to the study, which we have not used to make a calculation on workload for several reasons: much of it is missing (and as the authors state, had to be imputed), it shows wide variation, and it cannot account for total workload. Let’s consider:
Workload = demand/efficiency + non-clinical work + waste
We do not have a reliable way to measure the total, and given that the study used only one of our three datasets, I don’t see how they can make this assessment. Just one example: many practices have told us of the drop in home visits, each one saving the time for many surgery consultations. This is not measured. It may be a good thing to have more recorded time consulting, if less time is wasted. Not only does this finding seem to me unsafe, it also brings us back to the question of purpose, for the study and indeed for the NHS.
If the purpose is to minimise GP workload, we can do so very simply: design the working day so you see 4 or 5 patients in the morning, take a good lunch and a nap, then spend a little time in personal reflection and development before heading home., purpose achieved.
I’ve worked with a lot of very hard working GPs and they would not be satisfied with that purpose. No, the purpose of general practice and therefore the purpose of change must be to improve patient care.
There’s a missing term in the workload formula, and that is “unmet need”. Behind those words lies untold suffering and frustration of patients, heard perhaps by a receptionist (one wrote last week, “I dread having to tell the patients there’s nothing left”) while others do not even get through on the phone. This is the dirty secret of general practice, and over many years we’ve measured it in practices we’ve helped, variable around an average of 14%.
One in seven patiients is told to go away. Although we offered this data to the study team, they didn’t want it and took no account of it.
Their figures cannot distinguish between the workload of one GP helping 30 patients in a day, who had all waited two weeks, and another helping 40 patients in a day, on the same day they called. It could be life changing for those 10 patients, indeed all 40 of them for not having to suffer two weeks of disease, pain, or anxiety.
Both GPs may have equal skill and compassion, but the difference comes from efficiency.
By framing the question on workload rather than efficiency, the study misses a huge opportunity. It offers no help on how to become more efficient, and while it found wide variation in performance, the data were munged into averages rather than investigating in detail why the best ones worked better.
I’ll tell you a secret: we’re in this for the patients. To help the patients we have to help the GPs be more efficient. There is never a final answer to the method, there is only “the best we know for now, while we look for the still better way”.
We’ve helped around a million patients so far, with another 50,000 to be added in the next month. and as telephone triage (done well) is more efficient than pre-booked face to face, digital triage is already proving to be the next step. Sometimes we fail, but we press on.
Every day over 100,000 patients are told by practice receptionists “Nothing left, call another day”. Not on any basis of clinical need, just because the GPs have no slots.
It’s my personal mission to eliminate that phrase. What’s yours?
* The 20% A&E effect came from my 2011 study, based on pioneer practices with up to 10 years running the model, and promising at the time. The figure was copied by Dr First but never attributed. We could not show that the effect was reproducible, and therefore stopped making any specific claim about A&E 3 years ago. £30,000 saving? We make no such claims, although if GPs tell us about savings we are happy to report them. Why did NHS England swallow this?
Hypothesis: efficient operation of primary care depends on clinical triage of all demand, to optimise the use of scarce consulting resource – GP time.
The faster and simpler the system, the more patients will co-operate.
Who does what, when and how?
Patient “I need help…” Make it easy to provide enough detail for triage. Online, anytime.
Reception ”I’ll assign you to a clinician, unless I can help you myself” (within minutes, verify patient, choose clinician)
GP “I’ll work out how to help, usually phone, may see you, send a message, or refer” (take seconds, within minutes, from online entry)
Consult & complete – precisely appropriate for the patient and episode.
Presented at EFPC European Forum for Primary Care, Annual Conference Porto 24-26 September 2017
Download the poster here:
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.