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.
Have you noticed that everyone talks about MANAGING demand, but no-one wants to hear about managing DEMAND?
Same words, but the meanings are polar opposites. MANAGING demand has a long, high profile history. Recall the court of King Canute telling him he could hold back the tide by his command. A bit like all those notices, hints, tips and interactive websites that claim to turn away patient demand. The GP Forward View falls into the same trap, “assist patients in managing a greater proportion of their minor illnesses themselves”
Gosh, what a novel thought! We wish it were possible too. The only thing against it is all the evidence. Everyone has been trying this for years, and now it’s even better online (more patients visit NHS Choices every day than see their GP). It just doesn’t work and still, as the King’s Fund recently reminded us, demand creeps up at 1.4% per year. It isn’t a tidal wave, it’s roughly what we’d expect from patient demographics.
Patient demand for primary care is more like global warming. There’s not a lot we can do about it in the short term. (People, don’t go anywhere, especially shopping! Switch everything off and stay cold next winter! Hmm, perhaps not.) We keep working on the new technologies which may help, but in the mean time, it’s predictable and we must adapt.
Managing DEMAND takes this view: demand is unavoidable but predictable, and it’s therefore not scary. In accepting it, we can do far far better by learning how to deal with it in much less time.
A note to HEE: kindly don’t poach GPs from other countries who have trained them at huge expense and have a greater need than us. It’s grossly unethical at many levels. We can afford to train the GPs we need, and we can easily innovate faster than 1.4% pa to manage DEMAND.
Do you, like me, wonder what all the fuss is about over a paperless NHS by 2020? I did try to find out whether there was a similar drive to eliminate the quill pen in Whitehall: it was the invention of steel nibs in 1822 rather than a lack of geese apparently.
The danger posed by all this attention to paper is that the systems designed to run with it will simply be automated, when the real opportunity lies in working differently. What is the purpose of primary care? To provide immediate local help to those in medical need. What is the purpose of a GP appointment system? To allocate the time of a GP.
If we start from the point of allocating GP time, then automating the process of booking an appointment is the obvious thing to do. It may save a few minutes of receptionist time. The GP is unaffected (thankfully).
If we start with the purpose of improving the efficiency and effectiveness of primary care, then automating appointment booking is a daft idea. It would be wasting GP time, since two thirds of patients don’t need an appointment.
With that purpose in mind we realise that the GP’s time is at least the same if not more valuable when making well informed decisions about how each patient should be helped. Aiding that decision making process is then the obvious top priority.
Only then is it worth turning to technology to enable the change and on that score we are lucky to be living in such excting times. NHS England has a target of 10% of patients to have interacted online with their GP practice this year. In a way it’s hopelessly ambitious given the huge growth that would imply. But when 90% of patients have online access, and most are using it for everything else, I’m inclined to the opposite view that it’s hopelessly unambitions.
I’m currently on what might very loosely be termed a study tour of Korea and Japan. On the Kyoto underground I noticed that fully 50% of passengers spent the journey staring at their smartphones. In Seoul it was 100%.
With the right applications which help both patients and GPs, the NHS won’t have to urge people to change. It won’t be able to stop them. With the current state of NHS finances, it can’t afford to keep missing these trains.
Well I was right about the bombardment of doom ceasing for just one day. They are at it again, and NHS England’s £2.4 bn GP Forward View is “not nearly enough, not the right stuff and not soon enough.” Never mind, it is what it is.
Though not one of the 1700 words Shakespeare coined, “e-consultation” is centre stage and the thing that is going to transform general practice for a mere £45m. However, with no definition of what it means, I’d like to propose one, starting from the basics.
In our context, a consultation is a personal interaction between patient and clinician in order to provide medical help.
Where traditionally they have all been face to face, remote consultations can take place by telephone, video or digitally. (Letter would also fit the definition but I’ll assume there is little call for this. Even faxes are being smashed in the new modernisated NHS).
E-consultations are therefore a subtype of remote, and to hone the idea let’s look at what falls outside:
- not simply booking an appointment online (no interaction)
- not NHS 111 (even if it is digitised, only an algorithm, not patient-clinician)
- not Skype or other video, as like telephone these are synchronous means, patient and clinician present at the same time.
- not symptom checkers (not personal)
Therefore I propose:
An e-consultation is a personal interaction between patient and clinician initiated by digital means.
All very dry, and I think Shakespeare would have put it in plainer English along the lines of:
The patient seeks help from their GP online.
It’s much more fun to have a go. To my knowledge there are two systems available to NHS GP patients, our own askmyGP and Arvind Madan’s with Hurley Innovations Ltd.
You can try both as a dummy patient:
Next week I’ll compare the two feature by feature from published evidence.
Meanwhile, I’m interested in your views on the definitions and demos – please comment below
PS: If you missed the webinar in our series on Demand Led GP, you can see the recording here of “Unblocking the appointment system” getting to grips with demand and capacity. I explain how you can do your own Loadmaster for £35, which is proving popular.
For one day at least the bombardment of doom is silenced: GP leaders have lined up to say that the NHS England’s GP Forward View is largely what they wanted. (The same can’t be said of GP forums of course, but we know many of them would make a tabloid editor blush. First comment on Pulse at 2:10am, “this at best delays the collapse”. Bless…)
The main reason is the really quite large number of £2.4bn annual extra funding for primary care. Moving money from secondary to primary is the right thing to do, it can achieve more value and as a taxpayer I applaud it. The real question is not the number, but how will it be spent?
By far the largest part is more of the same. More GPs, more practice nurses, clinical pharmacists, mental health workers, and generally more of a primary care team. This could be valuable if they have the right work to do. There’s more for premises and more for pay, which if it goes to the right people, could also be valuable. (They can’t call it pay though, it has to be packaged as resilience, sustainability and funding formula adjustments. What do they take us for?). I’d direct more to GPs and practices in deprived high demand areas, as this chips away at the Inverse Care Law.
But what is the funding for doing things differently? Here’s the rub. The thinking hasn’t really changed, as it’s all about supply, precious little about understanding demand or even learning the basics from recent experiments. There’s £500m for 7 day opening, and GP hubs, which have been evaluated as a hopeless waste of money and 3 times the cost of core GP.
Well, I am grateful that a small fraction at £45m is earmarked for e-consultations, because askmyGP does exactly that. It’s no surprise to see it there, with Director of Primary Care Dr Arvind Madan writing the foreword. (He’s a 10.7% shareholder in Hurley Innovations Ltd, which does that too through eConsult / webGP). There are lines for development and transformation support too: what’s most important is that they are spent on the basis of evidence.
To see the thrust of the document I’ve done a little word count:
Online – 22 times
Scale – 15
Telephone – 10
Continuity – 4
We know that continuity of care is the bedrock of general practice, and all the evidence says it is central both to quality and efficiency. It is harder (not impossible) to achieve in large scale units. With only four mentions, how is it going to be enhanced and measured?
My view on the forward view: be careful what you wish for.
PS: Getting to grips with demand and capacity through Loadmaster, click to join our webinar Unblocking the appointment system tomorrowFriday 1pm.
Last time people wanted to know how they could do their own Loadmaster, and I’ll explain.
askmyGP has been operating for over a year now, long enough to have clocked up a couple of failed practices. That hurts, obviously, and I’m not going to name or blame anyone, but try to draw out what we have learned.
The strange thing in both was not that it didn’t work, but that it did work, or rather the GPs feared that it would work. They were struggling with access, making patients wait 3 weeks for an appointment or take pot luck with the receptionists at 8am on the dot.
Patients act entirely logically: “here’s a way to get help from the doctor, online, I can explain the problem and they’ll get back to me.”
GPs act entirely logically: “these patients are jumping the queue, not fair to others who’ve had to wait 3 weeks, or try for 30 minutes on the phone. We haven’t got time to deal with them, so we won’t, so it’s unsafe for them to think they will get help.”
All entirely logical. Result: nothing happens, no change. Another example of the gulf between technical change and adaptive change.
Technology is an easy bolt on, adaptive change means we the people have to do things differently. The result can be stunning improvements in service and productivity, as we heard last week, but it makes demands, there are no shortcuts.
We have masses of enquiries about askmyGP and I always ask why they are interested. Invariably, they want to solve a problem and the problem is overwork, too much demand and too little GP time. It’s always a big problem, one they have struggled with for years and it’s getting worse.
Then I ask, “Do you want it to work?”. They asssume it’s a silly question, obviously they want it to work. Then we talk about what that means, how if they wish over 40% of demand could shift online, saving them hours of GP time. But it will only happen if they give a great service to these patients who have put work in themselves to help the GP (and they are quite willing to do so).
I find it strange that having explained to me the enormous size of their problem, some are surprised that they think they can solve it with a tiny little tweak. Yes, we have those users who are happy to put askmyGP on the website, keep it quiet, take in a few handfuls of submissions each week, and very little happens. They won’t make a dent in their problems, but that’s a choice.
Yet this week I’m more hopeful than ever. We’ve recently introduced another question on our Leading Change Questionnaire, asking about the burning ambition for the practice. Answers are confidential, but let me tell you that the yearning to serve patients, the community, the ideals of general practice are stronger than ever.
Bring on those burning ambitions. We can do it together.
PS If you are on Twitter, look out for GP Journal Club #gpjc next Sunday 20/3 at 8pm, discussing the BJGP paper on telephone triage. Follow me on @harrylongman, why not also follow @askmyGP for latest patient feedback.