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.
A couple of things this week have given us great joy at GP Access, and I make no apology for talking about them because we need to turn around the prevailing wind of moans.
The first was talking to Rupert Bankart about his practice in Peterborough. For all the reasons which bedevil general practice at present (demand, recruitment, contracts etc) life has not been at all easy. But he told me how in the last month he has become so much more productive, financially better off too, as he has switched his patients to seeking help online.
I really can’t do better than invite you to listen to the interview.
The second was experiencing (remotely I’m afraid) a Somerset practice launching their GP telephone led service. No one would claim it’s all settled after one week, but it was promising to find the GPs had gone home an hour early on day one, all work done. Steve Edgar told me on Friday how much their safety and quality had improved, giving appropriate time to each patient. One had a cyst removed, the whole episode start to finish completed in 45 minutes. Of course, it costs far less like that than the palaver of arranging multiple appointments over several weeks, and the patient is delighted.
Ironic then to see the BJGP publish a rehash of the Lancet August 2014 ESTEEM data, “proving” that telephone consulting doesn’t save time. Tedious to have to go over it again: the point is that this did not test systems, but a technique in isolation. The resolve rate achieved was 25%, by GPs in 13 practices who were paid extra to do the telephone sessions.
We, along with others, and right back to the pioneers 16 years ago, have shown that 60 – 70% can be resolved remotely. One GP friend told me last week she was measuring 72% resolution now, consistently. These simple facts completely upend the findings of a four year, £2m RCT.
I’m reminded of G B Shaw’s saying, “People who say it cannot be done should not interrupt those who are doing it.”
PS Anything I write on this, the BJGP will say I have an interest. Indeed, an interest in what works, declared with pride. But I know many of you already run super efficient GP telephone led systems and would never turn back. Could you please drop me a line and we’ll find someone to co-ordinate a response? Do hurry, they will want it for the April issue.
It just so happened that both BMA News and Professional Engineering flopped through my letterbox this morning. One is full of ideas, people, technology, solving problems (Drax Power on the cover, cutting its carbon emissions by 86% with biomass, “they said it couldn’t be done”). The other, I think you know, crisis, resignations, strikes. Everything they want begins and ends with “The government should…”. A Tweeter during last week’s LMC conference called it “learned helplessness”.
For such a fine profession to see itself so dependent on others I find a great shame. I’ve been to both BMA/RCGP at Tavistock/Euston Squares and living just a stone’s throw apart illustrates how their output is barely distinguishable these days. They give me a nice cup of tea, I go away and nothing happens.
The BMA has an urgent prescription for general practice. The aspirations and values are fine, the survey responses predictable, but the solutions are all about government funding, structures, premises, encouraging self care (how long have they pointlessly banged that drum?), what other people can do for general practice. It won’t work.
The evidence about what general practice can do for itself is compelling and transformational. We’ve been saying it for five years. Demand-led thinking does work and keeps working. They’ve ignored it, touching only the edge when they refer to telephone triage for urgent cases, or that 86% of GPs agree with triage being effective. By the way, failure to consider the whole system makes this an added danger to workload.
Just one story where the practice is happy, doing everything same day, with better continuity and growing the business blows the prescription apart. I dare you to be unmoved by this, and there are lots more. Is the uncomfortable truth that it doesn’t suit the BMA/RCGP narrative?
You’re advocating self care. Look in the mirror.
This week we had over 80 GPs at the webinar “Unlearning the appointment system” (recording now on the link). Asked what they saw as the drivers for change, overwhelmingly they said improved service for patients. Saving GP time was a poor second, increasing income came nowhere. There is a thirst to know how to change, yet so many current beliefs are in the way.
Our next webinar addresses another orthodoxy:
Patient choice: Mirage, deception and the surprising reality.
PPS You heard about Jeremy Hunt’s rash advice this week, Google your child’s rash. Here’s a real one from yesterday, a GP told me. The mother completed an askmyGP for her baby, which invites her to attach a photo of the rash, and sent it in. GP sees it, phones and advises mother no need to bring in. Personal, remote and highly efficient general practice.
The tragic case of baby William Mead reported all over the media this week demands a response. As in so many failures, there were several points at which a different decision might have avoided the patient’s death, but the spotlight has been on advice from NHS 111.
NHS 111 will be “fundamentally” overhauled, the Health Secretary has announced, following a string of scandals. (Telegraph). “We need to improve the simplicity of the system – so that when you get 111 you aren’t asked a barrage of questions, some of which seem quite meaningless” says Jeremy Hunt. I might ask, who will be conducting the fundamental overhaul? The establishment figures who have so consistently defended NHS 111, or those like myself who opposed the concept from the outset? I think we all know the answer.
Hunt is an intelligent man and can surely understand the principles of sensitivity (measures the rate of false negatives, as in this baby case) and specificity (measures the rate of false positives, a bigger problem for 111 given that 17% of callers are sent ambulances or told to go to A&E). The problem is, even if the algorithm is perfect, to increase sensitivity means asking more questions, some of which will seem meaningless, all of which will take time, and false positives will increase.
A simple thought experiment shows that it’s logically impossible to achieve 100% sensitivity, as it requires an infinite number of questions. “Cough: Do you have a red flagpole embedded in your chest?” Just checking.
Our competitor webGP/eConsult has mired itself in the red flag mess. Start with acne and you’ll be asked whether you’ve had a fever and been travelling in a malarial area, both common enough. Now you are directed to go to A&E. But you only went in with acne??? And how is that supposed to relieve pressure on the NHS?
Why don’t they ask whether you’ve taken more than 20 paracetamol in the last day? UK deaths in 2013 from paracetamol, 226 (ONS). Deaths in the same year from malaria, 7. They don’t even touch on a problem which has 30 times the death rate. By the way, if you’re reading this Arvind, that’s not a suggestion. There is no end to it. You can’t say “We’ll only ask the obvious ones” or you’ll have Jeremy Hunt at the despatch box again, offering condolences.
Safety lies in the system as a whole, not its components in isolation. Humans can make good clinicians, but they can’t make computer algorithms as good as good clinicians.
Our view with askmyGP is that the professional clinician should have total control of decision making, assisted by what the computer does best in collecting useful data from the patient. Usually they will look at notes and ask more questions. Crucially that makes the system more efficient, so more demand can be responded to faster, and dealt with in the most appropriate way, both clinically and economically.
“Efficiency is a moral imperative” says Don Berwick, and it is essential for safety. The least safe interaction of a patient with general practice is to be turned away by a receptionist, and that happens in the UK over 100,000 times a day. We are building a better, safer system.
Our next webinars are filling up: “Unlearning the appointment system” – tackles three beliefs which trap us in an unsustainable present.
Thanks for reading, and if you have any reactions then please comment below.
An emergency question was tabled in parliament on the day a report implicated the failure of NHS 111 algorithms in contributing to the death of baby William Mead.
There’s a fashion sweeping GP funding schemes – gotta getta shiny new hub. Chrome, alloy, spokes – what’s yours? Hubtastic!
“Hub” is all over the review of PMCF wave 1, 44 mentions no less, in hallowed tones. But let’s look at some of the numbers which squeeze into the narrative.
£45m spent. £3.2m savings identified.
£30-£50 per available GP slot, only 75% utilised.
Dear friends, excuse my elementary maths but at a time when the NHS needs to make every penny go further, this is an abject failure.
It’s worse, because the hubs are shown to have increased inequality of access, and we’ve seen evidence that around a third of patients seen are redirected to their own GP. This is the cost of rework when continuity is cast aside.
The good life we enjoy in our times is founded on relentless pursuit of higher quality at lower cost. Plainly these hub designs have given us lower quality at higher cost. They are unsustainable.
Response to the evidence? Manchester announces 15 hubs which will sink £5.4m. You’ll know that supply-induced demand is the unintended consequence which dogs so many NHS intitiatives. Nothing unintended here: they are advertising the new supply to persuade patients to go there. You couldn’t make it up.
Resources are needed in core general practice, where they are three to five times more productive. We already have an out of hours service. Fancy funding schemes are directed outside core GP, and powerful interests are shouting about them. Three things are needed to turn this around:
- The method to increase capacity in GP
- The funding mechanism to reward GPs for dealing with all demand
- Imagination, resolve and leadership to make the change.
We know the method and the new thinking: Enabling Demand-Led General Practice
Dr Ed Diggines comments in the report on his own practice case study, “the fact that NHS does not reward increased productivity is a frustration.” So far. But we are building a mechanism to enable the funding to follow the patient. By keeping it in core GP where it is most productive, everyone wins. Intrigued? Drop me a line.
Leadership lies with you. Don’t just be a follower of fashion.
Save the date: we are announcing a new webinar series on the demand-led system, starting at 8-9pm on Thursday 4/2. Unlearning the supply allocation system.