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.
What does a “demand-led” GP surgery really look like?
The idea is simple – but often misunderstood.
Patient demand for help from the healthcare system is highly predictable, meaning that the GP surgery can plan to meet it and offer same-day access.
No one is told to come back tomorrow, or next week, or go to a walk-in centre because all slots are full.
They all get the help they need.
This is radically different from the traditional system, where what matters is not how many patients need appointments, but how many slots are available (“supply-led”).
Once that fixed number of slots is filled – usually within minutes of phone lines opening – patients are rebuffed or redirected. For the rest of the day, practices do not respond to demand but instead try to divert it.
Most attempts to reform our supply-led system have focused on turning the patient away from the professional they really want to see or talk to – their GP – and sending them to a pharmacist or nurse instead. In many cases patients end up self-referring to A&E, or giving up altogether on seeking medical attention.
Demand itself is poorly understood. While most surgeries know that there is a rush of phone calls every morning, particularly on Monday, they probably can’t explain how it ebbs and flows the rest of the week.
The result is a rigid system, where GPs struggle to fit their patients into 10-minute slots, treating them in the same time frame no matter how serious or complex their symptoms.
This supply-led framework goes back to 1948, when access to a GP was dependent on means and the obvious solution was to provide more GPs. But it never evolved into understanding demand or into a system sufficiently flexible to handle the inexorable growth today.
Yet both are easy to do.
In reality, patient demand for GP services is completely, utterly, boringly stable and predictable.
After four weeks of monitoring, the surgeries we’ve worked with can tell within a range of 10% how many patients are going to phone every single day. Even hourly rates are predictable.
That’s right: If you ask how many phone calls the receptionists will field on Tuesday at 11am or Thursday at 4pm, they can provide a reliable working estimate.
The surgeries that have successfully become demand-led record and then harness the data to organise themselves far more efficiently, ensuring there is a good fit between demand (patients requesting appointments), and the number of staff on hand to help them.
The model they follow is ‘MEPRA’: Measure, Predict, Respond and Adjust.
1. Measure – First we need the data to measure when and what type of requests come in. Extracting remotely from the clinical system means this is not a chore, but produces all the information we need, by day, hour, even minutes, and it’s effortlessly updated.
2. Predict – With just a few weeks of data, it becomes easy to predict demand on any given day so that capacity can be planned around it. Did you know that in a typical practice, 28% of demand is on a Monday? There may be local differences, but this means adjusting the rota for receptionists and GPs – perfect for part-timers.
3. Respond – As demand comes in on the day, the surgery staff must handle it rapidly and appropriately.
The key here is to give GPs the tools to treat patients differently, according to their needs. Not everyone needs the same amount of care and attention. Not everyone needs a 10-minute, face-to-face slot. With a more flexible system in place – see here for details – doctors can help a far larger number of patients quickly.
4. Adjust – Over time the surgery will learn valuable lessons about how demand fluctuates and how best to meet it, and be able to optimise the way they work. As the surgery responds better to demand, so demand will shift again. Once patients learn that they do not have to call at 8.30am in order to see their doctor that day or that they do not need to book slots two weeks ahead just in case their cold hasn’t gone away, they stop doing it. Patient behaviour changes as anxiety demand falls and the supply arrangements must change as well.
That’s why MEPRA is a continuous cycle of improvement.
This does not mean the surgery’s staffing arrangements are constantly in flux. As response to demand improves, generally demand smooths, regularises and is easier to manage.
Indeed, although MEPRA may appear daunting at first, practices we have worked with tell us it is ultimately far less work for everyone in the surgery.
Finally, doctors are in control of their schedules – instead of constantly battling a backlog.
Harry Longman is author of Enabling Demand-Led General Practice: How GPs Can Solve Their Capacity Problem, Improve Patient Care, and Rediscover the Joy In Their Work.
Our doubts are traitors
And make us lose the good we oft might win
By fearing to attempt.
Does the New Year make you feel braver, more resolute? A moment of calm, perhaps, when anything seems possible, before Monday crashes in and everything seems impossible, again.
Our “impossible” goal is to put an end to the turning away of patients when they seek help from their GP. That’s over 100,000 times each day in the UK.
It’s easy to sit back, and hope something turns up. It’s easy to moan, easier still to let others do the moaning for you.
It’s easy to have intentions, feel good about them.
It’s hard to act on them and as Shakespeare reminds us, we lose the good we oft might win.
Will you convert your intentions into actions in what remains of 2016?
Planning a meeting for your locality, federation, board or CCG? Change needs the spark of personal contact and I would love to come and talk to your group.
And it came to pass on the last Thursday before Christmas recess, the government published 424 documents, and lo, said the three hundred wise men, they are burying bad news. But verily I say unto thee, there is a greater sin in the land of UK, burying good news.
The truth is that almost everyone has an interest in bad news. The Daily Wail sells newspapers with crisis, and NHS providers get money for crisis. Jeremy wants more winter crisis to squeeze cash out of George. The RCGP wants a workforce crisis to get more of a slice of it (looks two faced when trying to recruit, but hey). The Patients’ Association exists for crisis. The BMA are past masters at crisis.
Moans have fallen, moans on moans, yet right there in their very own BMA News, buried in a story about unmanageable workload, is GP Dr Toni Hazell saying, “the system has hugely improved our access and is beginning to go down better with the patients.” They have introduced a fully GP led telephone triage system. “When patients know they can get a same-day appointment, they are more prepared to wait and see… it’s really nice when I can say to patients, yes, let’s see you today.” And she is pictured in print, affirming “unsustainable demand reduced by triage.”
I’ve been to BMA House twice and had a nice cup of tea. Same at Richmond House, same NHS England. They’ve done nothing. They will try everything and anything that doesn’t work, when the good news they all mortally fear is right under their noses.
We didn’t work directly with the featured practice, but it’s similar and I love it when people discover good news themselves, although we know that most need help to change quickly and reliably. We were delighted when another outfit discovered Clarendon in Salford and made a video of it. Worth five minutes to see Jeremy Tankel saying how safety has improved.
None of this takes reorganisation, regulation, incentives or shaming. It means opening your eyes to good news. The crime of burying it keeps millions of patients suffering, and thousands of GPs at the end of their tether.
Good News at Christmas? There’s a lovely carol you will probably sing, think on the words
“How silently, how silently, the wondrous gift is given.”
PS If you don’t fear dying of laughter, @jtweeterson’s Christmas gift ideas are unmissable.
Planning a meeting for your locality, federation, board or CCG? We’ll be sharing some very good news early in the new year, would love to come and tell you.
I was speaking at the Digital Health Forum in London this week, with a younger and more digitally native audience than I’m usually in front of.
Lots of good questions, but one of the most interesting debates was on the future for AI, artificial intelligence, in medicine. I’d be a fool to speculate on how the scene will look in ten, or even five years time. But let’s ask the question now, would you trust a computer with your life?
When I talk to GPs about online access, the most frequent fear is “How will this affect our insurance?”. Yet one of the most common questions is, “How does this deal with red flag symptoms?”
If you think about it, the two are inextricably linked. A computer which sounds an alarm in any form is offering an implied diagnosis of some sort. It has crossed a line and is now a medical device. Regulations and yes, insurance implications follow.
The patient and the supplier then have to trust that the computer will always act on “red flags”. It leads to an algorithm which becomes so conservative that humans have to be employed to filter its decisions. This is the route taken by NHS 111, which the LMC conference in May labelled “a barrier between patients and their care”, calling for it to be scrapped. 31% of ambulance call outs in England are now generated by this algorithm.
I’ve found one of the most helpful guides in the debate is Nicholas Carr’s “The Glass Cage”. Looking at automation in several spheres including medicine, he points out the dangers of relying on a technology which displays a frightening lack of common sense. This is not to be a Luddite, but show that we have choices between human and machine centred automation. “The goal is to divide roles and responsibilities in a way that not only capitalises on the computer’s speed and precision, but also keeps workers engaged, active and alert”.
With this as the design intent we can get the computer to do what it’s good at, in the case of askmyGP taking a history – to the point where a clinician can take over and take decisions.
My view is that technology must be the servant, but must help us with the presenting problem: too much demand for too few GPs. Not even HEE believes that a net 5,000 increase in GPs is possible. We have to enable our existing GPs to be more productive, to save time, to give the right care to the right patients.
PS Feedback on the webinar, “Understanding Demand, the key to better service and lower stress” has been amazing and sometimes humbling. One GP wrote, “a great insight and vision of Primary Care in the next few years and a potential solution to the GP workforce crisis.”
If you would like a link to the recorded webinar please let me know.
Planning a meeting for your locality, federation, board or CCG? Perhaps I can come and speak in person.
This week NHS England has been flying the flag, proclaiming that 10 million GP appointments will be booked online this year.
The latest projection as I mentioned last week from the NAO is that 368 million appointments will be made in 2015, so 10 million of those represents 2.7%. In a world lived online, this is very strange, so I thought I’d try to find out why.
As I write, my own practice has exactly one GP appointment available online in the next 7 days, out of around 200 which they’ll give. The picture is similar nationally.
For fun, let’s look at booking airline tickets. We could choose shopping online, or banking (2.5 billion logins/year), but at 250m flights/year from the UK it’s roughly comparable. The demographic is not quite the same as seeing a GP, but the overlap is very large. The CAA did a survey this year which showed 76% of bookings were made online. I’m surprised it’s not higher.
So is it easier to book a flight? I’ve tested this, and the absolute minimum if you’ve chosen your airline and already stored your personal and payment details is 30 clicks. Of course, most bookings will be far more complex and take multiple searches, comparisons and decisions about luggage, seating and trying to avoid buying insurance.
To book my GP appointment takes just 6 clicks, and 11 seconds.
Aha. The airlines love online booking, it saves them a fortune and you could not conceive of a new airline entering the market without it. Passengers love the convenience, and will happily spend their time and money complying.
It’s worth it for the providers even more than for the public.
GPs are business people, and they’re not stupid. They have worked out that it’s deeply against their interests to offer all their appointments online, despite the savings in administration. They know that if it takes 11 seconds to grab £27 worth of their time, they’ll see a lot of people who don’t need them and a lot of others who do will be left complaining to reception, never mind the clinical safety issues.
Yet the same public, patients now not passengers, do want to seek help online from their GP, if only they could. By allowing them to seek help, but keeping the GP in control of what help, when and from which clinician, the provider wins too. askmyGP takes at least 80 clicks, but patients love it and we’ve already seen 45% of demand shift online at one practice. It’s sure to grow.
The airlines made the change all on their own. NHS England has the resources of the state, enforcement through the GP contract, publicity in every practice, even pays for all the online technology. And has reached 2.7%. Turning such an abject failure into success needs new thinking which makes this work for GPs.
Do you agree? Please comment below.
PS We’ve been looking for several weeks at examples of patient histories submitted online. I’ve collected them here so you can see how GPs voted to help them.