Not long ago a local NHS manager told me they were pursuing the Dave Brailsford model of lots of tiny little improvements – he the cycling supremo who let us bring home so much gold from the Olympics. I thought it a one off comment, but a blog of Roy Lilley’s this week called it an NHS fad. Like him, I’ve no doubt it’s a misguided one.
Cycling is a beautiful thing, highly sophisticated and at the Olympic level, a more streamlined cut of sideburn can make the difference between podium places. But the NHS is not a competitive sport, it’s an operational business and if everyone had a rough imitation of the current best model, we’d all be miles better off.
The problem with thinking about marginal gains when the system is broken is that you miss the biggest opportunities. Attention, that very limited resource, is in the wrong place.
“Improvement is not enough. We need transformation.” W Edwards Deming said it thirty years ago.
“If I had asked people what they wanted, they would have said a faster horse.” Henry Ford said it, a century ago.
If he had listened, we’d have carbon fibre wagon wheels by now.
Gee up, Dobbin.
PS. You’ll have noticed all the noise about STPs. They have transformation in the title, of course. But they are really about money, and I’m afraid that’s no way to achieve transformation. Cost cuttting, yes, restructuring, yes, noise, aplenty. What we need is different thinking, starting with patient demand.
PPS. “Marginal gains secured by new care models…” was the title of a King’s Fund blog this week. Marginal gains? Remember, the new care models were the flagship policy of the Five Year Forward View. Two years in, untold £millions spent, and they are bigging up “marginal gains”??? Please don’t get out of bed. If it was working they would have something more to shout about
I shared a lift to the Best Practice show this week with my very good friend Gareth McCague and crawling along the M6 he asks me, “what does your demand led system mean for premises?”
Well that got me thinking, because one of the first things we notice is the empty chairs on Mondaymorning – GPs are all hard at work, consulting with patients at home. We call it the “no waiting room.” I know of practices who have carved out another consulting room from the unused space – but of course in a new build, cutting the seats from 40 to 20 would make quite a difference to building costs.
Then of course there’s the car park – it’s always a sign of things working well when we can drive straight into one of the many empty spaces. “That’s it!” cries Gareth (who knows everything there is to know about about GP premises and pharmacies by the way)
You’ve all seen the new surgeries where most of the land is taken up by parking. With all the attention on premises in the ETTF & GPFV funds, you can bet lots more tarmac will be laid for patients to park their cars, so they can wait on the chairs, to see a GP they didn’t need to see – it could have all been done in minutes over the phone or online.
Premises, premises won’t solve the problem. Everything is connected – it’s the system.
PS. Michael McKenna runs a single hander practice off the Falls Road in Belfast. There is no parking. Until this April he would have 30 patients lined up of a morning, for his 11 seats. They’ve gone, and I particularly love the bit in the NI video where he looks out of his room on launch day and quietly says “Wow”.
PPS. I admit to writing this in Luton airport, plane delayed. Just noticed in the gents that the new Dyson Airblade dryers are built into the taps. Ah ha – no separate queue for the dryers, lower footprint, value in airport space £££ – everything is connected.
Last week I was at the RCGP annual conference in Harrogate and a jolly good time it was too, meeting friends old and new and having all the same conversations, with a new case study from Belfast. Even made it to a fine Yorkshire tea at Betty’s.
But the highlight by a mile was when I snuck in to one of the plenaries to hear Kate Allatt give her astonishing story. Surviving a rare brain stem stroke, she told how she worked her way out of locked in syndrome, from being left almost for dead on a hospital ward to taking her first running paces a year later.
We will never know all the ups and downs of that year but what hit home to me was when she was back home and struggling daily with 3 young children on top of everything. In desperate need of help she suffers the usual nightmare of trying to get an appointment with her GP.
“Why can’t I call my GP at any time of day?”
What an utterly reasonable request.
Huge applause for her talk, and I think we were all genuinely moved. We’ve talked since and the common bond is that what Kate sees as utterly reasonable, we know is completely possible (and actually less work). Watch this space!
PS I won’t bore you with the agonies of this job but we have survived five years, and just occasionally there’s a shaft of light. Millbrook Surgery in Somerset launched earlier this year and a patient put this story in the local paper.
In response to the post on 1 October, “GPs, where were you when they stole your profession?”, Dr Helen Haywood writes:
I always read your emails with interest and generally find myself agreeing with your viewpoint – yours seem to be a fairly lone voice when it comes to rationally and consistently pointing out flaws with the state of NHS general practice as it is and the direction it’s travelling in.
I find myself less certain about this message however. Partly because I’m not sure I fully grasp the inputs vs outcomes argument and analogy used. Partly also, though, because of the hint of derision towards the Locum workforce seeming to suggest that these freelance GPs are unwilling to make longterm commitments simply due to the possibly adverse impact on their social life.
I absolutely agree with your depiction of market forces and supply and demand issues with regards to extending GP hours and that NHS general practice cat continue in it’s current form in the face of insufficient and decreasing numbers of GP principals to maintain the GMS and GMS system. I also worry about the apparent lack of willingness to take on partnerships, but would argue that the picture it is not one of simple greed, self-interest and lack of support for the NHS PMS/GMS contract on the part of the non-principal GP workforce who may often, in a PMS practice for example, have found themselves falling on the less satisfactory side of this arrangement not being offered the BMA salaried GP model contract, nor an income anywhere near that of a principal, but expected to undertake much the same workload, albeit not carry ultimate responsibility for the practice. I would go as far as to suggest that partnerships of recent years might consider whether they have some responsibility for the current situation when, for example, they might have chosen, in buoyant times, not to offer profit-share partnerships to junior salaried colleagues. Not only that the contract does nothing to encourage appropriate numbers or length of appointments in relation to the capacity of the workforce or to to deter growing list-sizes in order to achieve balance books or achieve adequate profits. Likewise in the early more lucrative days of QOF, always rising to the challenge of achieving the often meaningless targets without ever stopping to challenge the system and simply say no to such a tick-box mentality which in itself must account for at least some of the current squeeze on appointments not to mention its demoralising effect on professionals.
Although the GMS/PMS contract may be wonderful for balancing unlimited accountability for managing the registered patient who is ill, with unlimited discretion on how to manage them, it does not permit easy change or varied styles of practice within partnerships, expansion of general practice provision in it’s original format, with, for example, no option for GPs to set up new practices or indeed to take over contracts from retiring single-handed practitioners without first going in to partnership with the outgoing practitioner on their terms.
I do share your concerns about the extension of GP hours simply diluting the service and diverting attention and investment away from the core service. I also strongly believe that continuity of care, not only facilitates improved patient experience and outcomes, enables true practitioner reflection and continues professional development, but also helps contain demand and costs, contributing to an efficient * health service and am alarmed about the assumptions being made around the idea that larger organisations will necessarily result in savings. My own experience is that the larger the practice, the less continuity for and satisfaction of registered patients. One way around this is what might be considered to be the old-fashioned own-list approach, but I note with interest how an article in last week’s BMJ highlighted a study suggesting that ‘Having a named GP does not improve continuity of care’ ( BMJ 2016; 354:i5048 ). The results of the study undertaken would not be a surprise to any NHS GP practising at the time given that it simply looked for any noticeable changes in relation to the introduction of the requirement that all registered patients over the age of 75 be offered a named accountable GP from April 2014. This was, of course, introduced without any specification of changes to service offered, reporting requirements or additional funding and will accordingly largely have been delivered with the same lack of conviction or commitment to meaningful change in practice. It is a shame, therefore, that the results of such a study are now quite probably going to be used in the argument against the benefits of continuity. Accompanying the same BMJ, it’s BMA News supplement featured a centre-fold two-page spread entitled ‘Care revolution: inventing the future’ suggesting that the emerging ‘New Care Models’ from front-loaded Vanguard projects, such as the Nottinghamshire Multspecialty Community Provider it focuses on are trail-blazing the way forward for primary care, but neglecting to explain where the £7.3 Million that this project is benefitting from will be found if such a model is to be replicated elsewhere.
Such reporting does beg the question of whether we as a profession as a whole, principal, non-principal, salaried, freelance or otherwise, are content to passively let policy roll out, drive changes and transform the NHS as we know it without opposition and if not why we aren’t more obviously actively involved in the discussion and process. I would agree that we all need to get involved in this debate and echo your questions;
GPs, where were you when they stole your profession?
Are you going to stand up?
Before it’s too late?
Doctor 27 years, GP 23 years, including as first wave salaried combined academic-inner City practitioner London scheme, retainer London, salaried Leeds, principal/partner 9 years Leeds, salaried Leeds again 1 year, now locum GP.
People are sending more and more parcels these days, if you’ve noticed the queues at your local post office. This has got me thinking. I’ve learnt from a focus group that people would love to be able to send parcels from home at a time convenient to them, evenings and weekends especially.
So I’ve invented a new service called Mailidioto where we collect from your own home at any time you choose for one simple fixed fee. We take it towards the destination address and if you’re lucky, your fee will get it all the way. Obviously, if the fee runs out before we get there we’ll have to chuck it in the hedge, but that’s business.
How do you rate my chances with Mailidioto? Have I stumbled upon the difference between a contract for inputs and a contract for accountability?
There’s a wonderful thing in the NHS called the GMS/PMS contract for essential services, which balances unlimited accountability for managing the registered patient who is ill (in hours), with unlimited discretion on how to manage them (for the qualified professional performer).
So when we hear talk of salaried models, or “GP hubs”, WICs etc, these are all about inputs. They undermine accountability for the registered list, losing continuity of care and increasing costs. They are about hours worked, or appointments supplied (most APMS contracts) . We know the tenuous connection between “inputs” and “outcomes” (hello USA), and yet we see NHS England promoting these input models.
“£6 per patient to extend GP access from 2019” runs the headline. “Well actually…I’m just going to locum for as long as I can because I cannot see why anyone would want to commit to losing their (social) life” runs the comment from one anguished reader. You all know how hard it is to recruit GP partners. The more sessions are available for transactional GP, both in and out of practices, the harder it is to recruit for long term relational GP – they are the same people.
Extending hours makes no difference to capacity, and therefore has no impact on the three week waits to see a GP. Worse, it cuts capacity as utilisation is lower out of hours. Worse, it takes GP time away from high demand core hours. Worse, the unscrupulous will simply work the same time but claim the extra pay. The unscrupulous near to hubs are simply fending their patients off to them. It’s happening now – bad money drives out good money.
It doesn’t have to be like this. Scotland has abolished the abomination of QOF, and put the money into core funding. Northern Ireland is helping its GMS practices cut the wait for patients to minutes, and cut GP workload at the same time for a tiny fraction of £6.
The BMA and RCGP need to be absolutely clear against this undermining of the GMS contract and GP professional accountability. Put the £6 into core GP, making partnership more attractive. Put it disproportionately into deprived areas, bringing equity in place of the inverse care law.
GPs, where were you when they stole your profession?
Are you going to stand up?
Before it’s too late?
PS We’ll be at the RCGP conference next Thursday/Friday, on stand 33. See you in Harrogate!
PPS “Meet the digital GPs” in Pulse includes an interview with Dr Rupert Bankart about his practice and askmyGP.
I have to get the blog out early this weekend because today is the annual club ride from Leicester to Skegness. It’s over 100 miles but with crafty drafting in a close knit peloton and a couple of cake stops, I reckon most of us will drink in that bracing air before opening time.
There’s another bunch however who definitely won’t make it. They are the ones not starting, and they got me thinking.
Twice this week a GP asked me, “How many practices succeed with the launch programme?” I answered what we know which is about 75 – 80%. It’s not 100%, but pretty high for major change in any sphere. We try to put off those likely to fail, and we don’t always get it right.
But on reflection the failure rate is well over 90%. We’ve had thousands of enquiries and contacts over five years, yet have helped only about 100 practices to what they often call “a new lease of life”. What happened? They failed to start.
It’s a conundrum, because the funny thing is that they are no different from those that did start, often from very unpromising situations. The difference is not one of nature, skill or circumstances. It is just a matter of making a decision.
Why did so few decide? I have a theory, and it’s not to do with lack of evidence. In the mental fight between evidence and fear, evidence stands little chance. Something more powerful is needed, something like hope, desire, perseverance. If I may quote trampoline silver medallist Bryony Page, “To be the best I could be.”
I’d welcome your views.
When I was young the MSCP was a Multi-Storey Car Park, a blot on the landscape but at least my mum could park close to the shops. Now it’s a Multi Specialty Community Provider and NHS England has a plan for it.
Unfortunately it’s a plan with values on the front page, and the trouble starts there:
clinical engagement, patient involvement, local ownership and national support
If you can stay awake through all 31 pages, you’ll find a document dedicated to large scale providers with concocted supply side designs. When you look for data about actual demand, you find instead one of those made up pyramids, grossly oversimplifying the infinite variety of patient needs which all GPs experience daily. Run a mile when you see them.
There’s not a word on what matters to patients, how to measure it let alone improve it. A reminder of what matters: How soon can I get help from my GP, and for many, can I choose a named GP? The evidence base supports relational continuity, here instead we get the weasel words, “focus on the personalisation of care” in anonymous 30-50,000 lists where continuity is history. We trust our GP, we expect quality care, and as taxpayers we must also demand economy. So what is served up?
“care hubs, integrated teams, place based models of care, the primary care home”. For goodness sake, local registered list NHS general practice has been doing this for decades, and been the envy of the world.
Now they want “collaborative leadership, engine rooms, governance structures, logic models, value propositions”. Gimme strength. Straightforward persons reading that will smell a whole nest of rats.
It would be so tempting for me to say to NHS England (available spend: £100bn pa), “What a lovely plan you have there, do let me help you deliver it”, but I cannot in good conscience bring myself to do so.
“The care model will evolve as the vanguards continue to learn together about what does and doesn’t work.” p4. You can say that again. When you start without evidence, the vast majority will fail. The usual suspect case studies are wheeled out, few have ever been independently evaluated and the economic analysis is utterly lacking. As Nuffield said last week, “insufficient evidence”.
Like a supertanker without a compass, however grand and imposing, it will founder on the rocks of evidence, at eye-watering cost to us all. There it will nestle amid the rotting hulks of Darzi centres, PMCF projects, WICs, NHS111 and so on, there where the fatefully top heavy Mary Rose lay in the layers of governmental hubris.
Meanwhile, we are doing what works, reliably, repeatably, rapidly and cheaply, with providers at every scale who want evidence to back their investment. We’ll keep doing it until we find something better, then we’ll do that. Come on board.
This week saw the release of the Nuffield Trust’s study of 4 large GP practice organisations, headed “Is bigger better?”. The conclusion after 111 pages is roughly that although practices are being nudged in this direction, “we have not been able to provide evidence about improving quality”.
The question arises, why is NHS England nudging on such a lack evidence, but we need to ask specifically, who is looking out for patients? Nuffield says rather coyly in the summary (p 4) “Patients had mixed views about large scale general practice, identifying more with their own practice than with the overarching organisation” but the meat is on p71 where patient satisfaction indicators are listed.
The patient satisfaction survey is not my favourite metric but this is all we have, comparing 3 large GPs with the national average:
Ease of getting through on the telephone: 2 worse, 1 better
Able to get an appointment: all 3 worse (one only slightly)
Seeing preferred GP: all 3 worse
Rating GP for involvement in own care: all 3 worse.
In 11 out of 12 measures the larger organisations are rated by patients as worse than average. Something tells me that however you measure this, it’s not even close.
I have no axe to grind on practice size. We’ve helped all sizes from single handers to tens of thousands. My beef is with those saying we must have bigger, because, er, because it must be better.
What interests are driving them? I’ve seen nothing concerned with patient benefit, and Nuffield has laid out the evidence against. The problems facing patients in getting access to their own GP are well known. Size and structure are not the answer, but they are an ever absorbing distraction from what we should be doing.
I was at a couple of events this week which put forward grand ideas about the future of healthcare. Visionary, aspirational and of course digital. So why is it not happening?
This simple test I did with the audience at King’s Fund illustrates: Stand up if you have flown this year. Two thirds rise. Sit down if you booked your flight online. Every single person sat down. Now stand up if you have seen your GP this year. Again, two thirds rise. Sit down if you booked the consultation online. You guessed it, only a handful took their seats.
The vision, from Downing St downwards, is for health care to be digital, and it should be so much simpler than booking flights, but it’s miles behind. So why the gap?
I think it’s a lack of respect for patients. The vast majority act sensibly when seeking help from their GP, and they want to help their GP too, not waste their time. We get lots of feedback along the lines of this one, “I like it as I am able to ask a question but not take up an appointment time for someone in more need of actually seeing a GP.”
Policy makers in contrast tell us how digital means patients will be diverted from their GP, they just need to get some patient education and learn all about self care. We’ve heard this for decades, it’s highly seductive, and it simply won’t work. Wishful thinking that it will reduce demand drives a digital design ethic which fobs patients off They get the message, they respond quite reasonably and intelligently by ignoring it.
The secret is to make it easier for patients to use the most efficient channel, and easier for GPs to respond. We’ve seen a shift of over 20% in several practices, but there is so much more to do in overcoming fear.
I liked what Bob Wachter said this week: “Digital is not for the purpose of digitising, but for improvement.”
PS Many other Europeans are big fans of the NHS. We have much to contribute at the European Forum EFPC conference in Riga, Latvia, 4-6 September. Do join.
PPS “Seeking help from your GP online” talk at King’s Fund here
I’ve been thinking very hard about how we support GPs in the essentials of their work, and been inspired by a couple of things this week. One is the best single page summary of GP work I’ve ever seen, to which I’ll return, the other perhaps surprisingly is the GMS contract which covers the vast majority of UK GPs (with PMS which borrows most of it).
Wrapped as they are in reams of clauses, the essentials of the GMS contract are wonderfully simple. The suitably qualified contractor, ie a GP, must provide services for the management of “their registered patients who are, or believe themselves to be, ill” (whether temporarily, terminally or chronically).
It is entirely at the patient’s discretion to decide they need help. It is in our terms demand-led, not limited by the contractor’s slots, appointments or whatever they choose to call their capacity. Such an open ended commitment sounds impossible but…
It is entirely at the GPs discretion to decide on the management, which might include consultation, examination, treatment, care or referal as appropriate, “delivered in the manner determined by the practice in discussion with the patient”. Even the “when” is “within core hours, as are appropriate to meet the reasonable needs of its patients.” Who decides what is reasonable?
I think the contract works because it is open ended. It relies on good will, the professional ethos of GPs and the trust of patients that their needs will be met. Yes, it is abused by some patients and some GPs, but that’s humanity.
NHS general practice is the envy of the world because it is local, freely available and relationship based. It is under threat by those trying to dumb it down to transactions, or replace with non-GPs, anon-GPs or computers. Its resources are being squandered on longer hours instead of responding to demand, on costly and unevidenced economies of scale when we need continuity and economies of flow.
By the way, in terms of system flow the fact that over 95% of undifferentiated medical demand is resolved within the ordinary, average practice is astonishing.
Now to that one pager, in this week’s BMJ Dr Phil Whitaker gives us the NHS GP caring for the whole person, and simply a must read. “Interpreter, medical generalist, player-manager . . . on top of these, the GP is an expert friend.”
The essence of general practice is enabled by a contract, but it can’t be written into a contract. The crisis in general practice can’t be fixed by fiddling with the contract or diluting the essence.
We are fixing it by working on the system at practice level, understanding demand, flow, outcomes and how to create change. And we do need to change, in order to stay the same, true to the principles of universal, high quality primary care, free at the point of use.