NHS commentators specialise in gloom as I don’t need to remind you, and this week they have had plenty to moan about with the publication of the latest Nuffield/Kings Fund British Social Attitudes Survey.
Overall satisfaction with the NHS is down 3%, and for the fourth year running the principal reason cited, at 53%, is “It takes too long to get a GP or hospital appointment.”
As sad as it is predictable, the only response from all parties has been “Give us more, more money, time, resources, GPs”. It’s not happening, GP numbers have shrunk this year.
Our latest practice launch this week was a middle of the road performer, with about 60% of demand “on the day” and a long spread thereafter leading to an average wait of 5 days.
In week one they dealt with almost all demand on the same day, achieving a median completion time (that’s completed, not just first response) of 49 minutes. Patients have loved it, with 8 to 1 saying it’s better. All done with no more resources – it’s only possible by saving time, managing 2/3 remotely.
I’ve had two contrasting conversations with practices this week. One is in a prosperous market town, in a brand new multi £million health centre. The GPs know they are making patients wait four weeks for a “routine” appointment, and they are quite happy with that, protected by their contract and local monopoly.
We can’t help them.
Imagine any normal company like us treating our customers like that – we’d be out of business in a minute. And that is why Babylon GP at Hand has a point, even if we don’t share their business model.
The other practice is in a decades old building, serving one of the poorest populations in their city, a minority having English as a first language, and dealing with huge problems of deprivation. Yet they have an absolute passion to help their patients, already providing a superb same day personal service. They just want to make their own working lives sustainable too.
We can help them.
Looking forward to more launches next week. Glad to say that every one gets easier with new features, this week it’s the NHS Spine lookup for patients, improving accuracy and saving time on reception.
PS GPs with that service ethos, don’t miss out any longer. Start with our free online demo.
Today’s guest blog is by Dr Hugh Reeve, senior partner at Nutwood Medical Practice in Grange-over-Sands, Cumbria. Not exactly a population pyramid, with 40% of patients over 65 Nutwood boasts more of a population parasol.
Below is his series of almost daily tweets over the two weeks since launch, and I think as the story unfolds you will be moved as I was.
Over to Hugh…
6/2/19 Day 1 AskmyGP. Wow – all today’s work done today. Online take up impressive for day1. Staff coped – 2 said it was best Weds ever! positive pt feedback. Drs slightly frazzled getting head round new system and strange only seeing f2f 30% of usual numbers 😀
7/2 Day 2 @askmygp 89 yr old sent me online message about her shoulder! Our salaried GP cleared all her admin & finished at 5.30-first time she’s left before 6.30 in 3 years. We had 62 new requests for help -phone and online-of these saw 15 people f2f. We’re cautiously optimistic!
8/2 Day 3 @askmygp GPs managed am and pm coffee breaks. 76 problems sorted – 32 f2f and one home visit. 89yr old who emailed yesterday sorted – one phone call and joint injection arranged next Tues. Old system would have taken at least 2 weeks! Next Monday’s rush the real test!
9/2 One of my partners told us of the incredulity and gratitude of a patient who was seen in surgery one hour after sending an email for a non-urgent problem.
Anyone that needs a physical examination we arrange to come in and see us – the same day they contact us , or visit at home. We now also get tests/xrays etc done first and then see people. Previously we phoned about 25% of pts and saw 75%, early results we see about 30% now.
Our access not bad at all but as you know continuity a real issue. Early signs are it could really help this.
11/2 Day 4 @askmygp – best Monday in 13 years at Practice. Gobsmacked! Pt with ?intracranial bleed after HI 10d ago-sorted CT-pt wanted routine appt, 10d wait on old system. Colleague spent 40 mins with pt who burst into tears at reception, she still left at 4.45pm with clear desk!
13/2 Week 1 @askmygp A revelation! 373 contacts of which 71% by phone and 29% online- this for a practice where 40% patients 65 or over. Of these we saw 30% f2f. Staff love it – no more telling pts no appt. Feedback from pts so far almost totally positive No downsides yet! I’m 😄
Pt feedback from pts at our Practice using online service @askmygp in week 1. Amazing Wonderful Excellent Brilliant Worked perfectly Professional Quick Instant Superb Astonishing First class modern service Time saver Reassuring Good technology. This is surely what it’s all about😀
14/2 Real test for new @askmygp system today. One GP sick leaving 1.5 GPs to do today’s work. Real benefit of no full surgery to rearrange-just one person booked in. At end of day all work sorted. One GP had 48 contacts 40% f2f, said still better than when crisis hit under old system!
15/2 No signif downsides as yet Peter. However have to make sure enough capacity available each day and understand the predictable demand for each day of the week otherwise the system will grind to a halt.
20/2 2 wks @askmygp. Getting used to system and love it. Pts seem to as well 34/37 online users think it’s better. 33% of all contacts coming in online and increasing by the day. More time to follow things up, phone people with results etc. Waiting time for a routine f2f appt <1 day!!
We still have work to do adjusting to a radically new way of working. Also fair bit of preparation beforehand. But so far gone better than we expected!
We book very little in advance now, starting the day with near empty schedule and as far as possible deal with today’s work today. At present we see f2f about a third of people who contact us and deal with rest either on phone or online.
Thanks Sam. Have never fallen out of love with general practice but was definitely very jaded. Now in my early 60’s and feel like the embers are starting to glow and real energy returning. Sounds a bit corny I know but true. This will keep me working – because I want to 😀
The Department of Health and Social Care published on 19/2/2019 its Code of Conduct for data-driven health and care technology.
Our response to the ten principles follows:
- Understand users, their needs and the context. askmyGP users are broadly two groups, patients and providers which includes all GP practice staff. Our design principles are for simplicity and ease of use, a difficult task when appealing to patients of all ages and abilities, both in general education and familiarity with online tools. We cater equally for proxies (parents and carers), all gender expressions, and keep language simple to help those with limited English. To assess our effectiveness we monitor age specific adoption by patients in each practice, and feedback from patients informs our development process.
- Define the outcome and how the technology will contribute to it. Our mission is to make it easier for patients to get help from their own GP, and easier for GPs to provide that help. We measure attainment against this outcome by volumes, response and completion times, and measures of efficiency through resolution mode by providers. We also collect and monitor patient feedback and present all measures to the provider organisations.
- Use data that is in line with appropriate guidelines for the purpose for which it is being used. We comply with all relevant legislation including GDPR, Data Protection Act 2018 and collect data only for necessary purposes. Personal data is processed on behalf of providers (the data controllers), stored and transmitted encrypted and over the secure N3/HSCN network. Anonymous data may be used for research and marketing purposes as allowed under the same principles.
- Be fair, transparent and accountable about what data is being used. All data is used in accordance with Caldicott principles, and the conditions are agreed by patients and providers.
- Make use of open standards. We support the use of open standards and wherever technically possible provide open links to others for legitimate interoperability reasons. We use standard NHS number coding for any authorised data transfers.
- Be transparent about the limitations of the data used and algorithms deployed. We collect and transmit plain text and other file formats between patients and providers, but we do not use algorithms to produce triage decisions or advice to patients.
- Show what type of algorithm is being developed or deployed, the ethical examination of how the data is used, how its performance will be validated and how it will be integrated into health and care provision. We do not develop algorithms. We do offer a third party service with Isabel Healthcare, which uses a machine learning approach. Our users may enter any number of symptoms, and be shown a range of possible conditions.
- Generate evidence of effectiveness for the intended use and value for money. Integral to our offer to all customers is standard reporting on usage, patient service, timeliness and efficiency through the use of askmyGP. We provide an economic model (Loadmaster), configurable by each customer, which demonstrates their value for money. We also conduct our own analysis of performance and value and may publish on this site and in other media from time to time.
- Make security integral to the design. From the outset of design, security has been built into askmyGP. Key features include:
- N3/HSCN access required for all live patient data by providers.
- Encryption of all patient data in transit and at rest
- Strength checked passwords required for all users.
- Separate code and database for live and demo systems
- Independent penetration testing and fulfillment of all comments raised.
- Define the commercial strategy. Our strategy is that self-funding customers should see a high rate of return from their investment, and do so from the date of launch (typically four weeks from engagement). Growth is therefore not dependent on taxpayer funding, but on efficiency and financial savings generated through the use of our services.
Harry Longman, 21 February 2019
“Private providers could grab unlimited share of GP consultations online” runs the heading in GP Online.
“Babylon GP at Hand given green light to expand NHS services into Birmingham” – to the usual outcry from BMA.
“All patients to have the right to video and online consultations by April 2020”. Have I got the right April? Why is it always April?
Let’s look at what GP at Hand have actually done in their 18 months of operation. At a cost of blanket advertising around the capital, they have recruited just 40,000 or one in 200 Londoners to their video-led service. I hardly think this merits the cries of barbarians at the gates.
But as we know people are led by feelings much more than facts, and all the headlines are designed to scare you.
They want you to feel threatened, that your livelihood is at stake.
They want it to “feel like” extra work – because anything ordered by the government must be extra work.
They want you to “feel like” you are being bullied into change, you’ll have to be different, and you don’t want it to be different, you didn’t sign up for this, and what do they know about your real work?
It’s a shame because very few GPs have considered the possibility that with the right design, digital first could enable you to be a better GP, providing a better service for patients with less work.
A practice we’ve worked with for eight months now is Witley and Milford, and some of their GPs were discussing the outcomes on Twitter this week. They are one of our fastest operators, with a median time to complete patient requests of 48 minutes (that’s all demand acute/routine whatever, and that’s completed, not just first response). They are also one of our highest for continuity, with 94% of patients who made a choice being helped by their chosen clinician.
All they have done is understood demand and flow and organised themselves around those principles. With over half their demand arriving online, they are a digital first practice, and it’s a joy to be a GP or a patient.
Many sage commentators tell us of the trade off that must inevitably be struck between Access and Continuity. I tell them Witley and Milford.
01509 816293 / 07939 148618
I’ve been reflecting recently on what we mean by personal care. NHS England’s Head of Digital writes of the NHS Long Term Plan this week:
”… sets out an exciting ambition for care that is more personalised and tailored around the needs of the individual, enabling people to have more autonomy over their health and wellbeing. It describes a future where people will be empowered to participate in their care using digital services that truly meet their needs, help them live better with long term conditions, target prevention and offer them a much more personalised experience.”
No doubt the intention is good but I’m concerned that what we design and build should be grounded in the everyday needs of patients, and I don’t hear them using that language.
We get over 500 patient feedbacks each week and one of the strongest themes is thanks to a doctor or nurse they name.
What we hear from patients if I could summarise in a sentence is: “I need help with my medical problem from someone I trust.”
For patients, personal care faces outwards, they are dealing with another person they know and trust.
“Personalised” seems to me inward facing, a digital experience where the technology is configured with my preferences and perhaps my medical history. It might be clever and it might have value, but I’m not hearing from patients that they want autonomy, especially those who are most in need of help.
“Personal” brings us back to that question of continuity of care. It’s well documented to have fallen in recent years, but we also know that this is not inevitable.
Some I think seem to view continuity as a kind of spiritual nirvana, or a lost golden age where the family doctor had all the time in the world for everyone who dropped in to see them.
Back on earth, right now, it’s a simple operational problem of “Can a patient needing help choose a named clinician?”
We’ve always made this possible with a validated list shown to patients, of all clinicians working today, and around 20 – 30% of patients make a choice. But we’ve just introduced three improvements to make it easier both for patients and practices, since ease of use is the biggest driver of any change.
- While the patient may only choose someone working today, they can now look a week ahead to see when their chosen GP is available (they always have capacity same day)
- With our One Click Assign feature, a GP if named is starred so unless there’s a reason not to, the assigner will, with one click, put that patient request in front of said GP.
- Any patient can have a “Usual GP” set, if the practice wishes, so even if the patient doesn’t choose, the assigner can see that GP tagged with an icon in the One Click Assign list.
The outcome is that we are hearing every day from GPs and patients who feel empowered.
There’s a growing conversation on Twitter (follow @askmygp) from all sides, do take a look.
Some years ago I heard former RCS President Clare Marx speak and I have often quoted her words, “We must make the digital, personal”. So true, and yet I wonder whether she has been heeded?
Perhaps to make this work we should look at it the other way round.
“We need to enable the personal with digital”
That’s the task for NHS England’s Head of Personal.
PS Data geeks, this is fascinating. We’ve just published a study showing the age-specific adoption of online consultations. Covering 10 practices in the period 1/1/19 to 8/2/19, n = 37,634 requests, it shows that for young adults 70% are now seeking help online rather than by telephone, and even up to 65 it’s over half. These are normal regular local digital first practices.
PPS 4 new practices and another 30,000 patients covered last week, with Weston-super-Mare reaching half way in its project for the whole town.
The latest data from our chief analyst Dr Steve Black (@sib313) shows remarkable adoption of online consultations across all ages and 10 diverse practices. n = 37,674 requests, date range is 1/1/2019 to 8/2/2019.
The context is all askmyGP practices operating in “total flow” mode where all patient demand goes through the system in two modes. Online, patients submit a request for help from their NHS GP practice either for themselves (dark blue) or as a proxy (light blue), mostly children but also vulnerable adults, most over 75. They may also telephone the practice, and a receptionist creates the request on their behalf (orange).
The key point is that all demand is covered in the chart, not from a self-selected subset of patients, and these are regular GP practices where there is no change in registration.
What the data shows
For infants and children, over 60% of parents chose to send their request online.
For young adults aged 20 – 40, over 70% submitted online.
With increasing age, the proportion online falls slowly, but even at 65 – 70 it is 40%.
Over 70 the proportion falls more steeply and significant numbers are by proxy.
It is clear that when designed for ease of use and universality in respect of patients and their medical problems, coupled with rapid response by providers, the online offer is highly attractive to patients.
The vision for “digital-first” providers who are at the same time traditional, local GP practices is achievable and already being achieved.
Founder, Chief Executive, askmyGP
I’ve had a bit of time to absorb the new GP contract – there’s an excellent summary on GP Online if you don’t want to read it all. While some of the digital notes are a tad off key, I suspect they are a nod to our technophile SoS while the real action is elsewhere.
The centrepiece is Primary Care Networks, PCNs, and we are going to hear lots and lots more about them. Notice how the language has changed, as until quite recently it was all about “GP at scale”, a phrase absent from both BMA and NHS England texts.
Hats off to Richard Vautrey and team.
While the numbers “30 – 50,000” are the same, rather than large scale providers for which no convincing evidence was ever produced, networks of existing providers with no change of scale could make sense.
Steel mills need economies of scale, but GPs don’t, and diseconomies of scale soon show up with loss of continuity, local accessibility and lower patient satisfaction all well known.
But some AHP resources don’t really work at smaller practice level, and it’s clunky to employ for example a pharmacist for 7 hours a week and a physio for 12. At the network level they could work well, and indeed this could rebalance the funding model in favour of smaller practices as funds and resources will be based on list size.
The DES incentivises all practices join a network, and there will be a dash to join up with “people we like” at the local level. Expect a few funny shaped contiguous groups, some larger and some smaller than prescribed, but with a little pushing and shoving the money will ensure it happens.
The labels don’t all say this, but a very large proportion of the new money will effectively go into core funding, and will strengthen GMS partnerships as indeed the Watson review said they should be strengthened. This is a good thing for GP, for the NHS and the population as a whole.
The new and interesting questions arise over how the networks will operate. 22,000 new primary care staff is a lot to take on board, considering only how they are recruited, trained and managed.
Any shared resource raises the problem of “the freedom of the commons”. Currently, the design of A&E, urgent care centres, 111 and so on means they soak up demand from poorly performing GP practices. The reward for failure is for someone else to take your work.
How will the the new AHPs be shared fairly, so quality is rewarded as it should be? (by the way, fair is not the same as equal. Consider the student practice in the seaside town)
Practically, how will GPs make best use of them, appropriately referring the right patients at the right time? What is the patient view?
How will network performance be measured? How soon will patients get the right help? How will outcomes show we’re getting value for money?
No doubt we will return to these themes.
Cogitate as well as celebrate this weekend.
PS No network yet, but already there with 100% of patients offered online and video consultations, Dr Barry Sullman talks about Balaam St Surgery and astonishing return on investment.
He’s a traditional, local, digital-first practice. Fabulous.
Hurrah! NHS England and the BMA GPC have agreed a new contract covering the next five years.
Apparently there’s lots more money, funding for 22,000 addtional health workers in primary and community care, and everyone seems very happy with it. I couldn’t possibly digest the whole lot but will concentrate on what we know best.
This is going to increase GP workload and cut patient access.
How so? See the fine print in the IT and digital section.
1. NHS111 will have the right to book directly into 1 appointment slot per 3,000 patients (rounded down) per day.
Leave aside the technical issues, problems of policing the scheme and arguments over unused slots, late booking and so on, what would happen even if it did work perfectly?
In a traditional practice with more patient demand than available slots, they tend to be all booked up within minutes of reception opening. You know, we know, everybody knows.
So now what does the savvy patient do? Call NHS111. Go through all the palaver of identifying themselves, answering dozens of irrelevant yet scary questions, eventually landing with “I need to see the GP. And I have a right to one of those 2 appointments in my practice of 8,999 patients, today.”
Boom, they got it. But they got the second one and there is no way of telling the other 23 patients who were turned away by the practice, so all of them go through the NHS111 palaver again, but get the same message: all slots gone.
So we’ve wasted NHS and patients’ time, added a bunch of complexity, and increased GP capacity by precisely zero.
And by the way, what do GPs think of the ability of NHS111 to triage a patient and provide concise and relevant detail of the conversation? Do ask one.
2. Make 25% of appts bookable online?
It is now such a commonplace that we kind of assume everyone knows this: only about one third of patients seeking help from their GP need a face to face appointment.
Which means that if GP capacity is reserved for patients to decide for themselves to take a slot, two thirds will be wasted. So that’s 17% of GP capacity to be wasted by design. Maybe they will include telephone appointments, which would be less wasteful but still may not be appropriate.
Reserving any proportion for a single channel reduces equity of access: those with no online capability, often the most vulnerable and needy, are shut out of 25% of available capacity.
It could be so much better, simpler and cheaper.
Here’s what our practices are already doing:
1. When they are open, there is always capacity, so no need to call 111 to try for reserved slots. They won’t be used, but neither will the GPs waste the time, they’ll just crack on.
2. Make 100% of capacity available online – that’s normal, it’s what we do. But 100% of capacity is also available for patients who phone in – there is complete equity of access.
It’s the same capacity. But how it is used for each patient is up to the GP to decide, which they do in seconds through digital triage – they don’t even need to phone many patients.
It takes two to tango, and the tragic missed opportunity here is that both GPC and NHS are stuck in supply thinking: it’s all about pushing services at patients, wrapped up in complex funding rules.
Demand led thinking does exactly the reverse, understanding in great depth and detail the incoming demands and designing services around them. We’d get bucketloads of efficiency as well as astonishing performance if they did that. (Do call, best rates for hard up government departments)
Well, I always say that when they’ve tried everything else that doesn’t work, they’ll be back. Maybe before I’m dead.
Why take the risk, start now!
01509 816293 / 07939 148618
PS We’ve been amazed by the views on our new video, Dr Barry Sullman talking about Balaam St Surgery.
He’s a traditional, local, digital-first practice. Fabulous.
“Oft as by winding Nith I, musing, wait”
Given the day I couldn’t resist a line of Burns (the river Nith rises in Ayrshire), and this one captures a favourite mood of mine, musing, waiting, the moment rich with possibility.
Then something happens.
Dr Barry Sullman is one of those infectiously enthusiastic people who is an absolute pleasure to work with. As you will see, he has gathered around him an equally joyful body of staff. We just couldn’t stop them talking and the hardest part has been editing this down to just under three minutes. It could have run for hours.
He talks about quality, service and sustainability.
He talks about the calm, relaxed atmoshere, going home smiling.
About efficiency, saving the first year costs two or three times over (and that’s in only nine months).
I showed this to a visitor who said others might think it’s a spoof – why would people say that and who is paying them?
The truth is very simple, Barry is a regular paying customer, the same as anyone else. What’s more, he has turned down a competitor product offered by the CCG, for free.
Yes, there is a select band of GPs who are capable of making their own business decisions as independent contractors. When they see something which gives their patients better service, at lower cost to the practice, and with a return on investment of 300%, they know what to do.
Are you one of that happy band?
Just check again whether you really want what Barry has.
Right now, free, see how GPs such as Barry run their day, with 50 randomised, anonymised patient requests. It takes about 15 minutes.
Apply for your Digital Triage Experience and then invite your partners.
What are you waiting for?
PS Barry wrote to me last Monday: “Had a really hard day today. Made breakfast for 2 children. Took them both to school. Got back and did some work. Went to the chippy for lunch with the wife. Relaxing cup of tea and started my face to face 3pm.”
Then on Thursday: “I have been listening to what makes a job fun or awful. I think the constant interuptions at work make it so stressful. With askmyGP I can stay at home – a place of zen like peace and tranquility. Then come to the surgery for a short focussed session. This is a great system – and it’s getting better.”
Do you ever wonder about that phrase “local needs”?
It made me wonder whether say Facebook had ever been asked to do a local needs version.
It’s just that we are responding to tenders issued by different CCGs, which are remarkably different given that I thought patients had roughly the same range of diseases wherever they live.
Essential requirement A: “Is able to fully triage the patient and signpost to the most appropriate service with no GP intervention”
Essential requirement B: “The system should not perform an automated triage that gives a disposition”
Imagine a pharma procurement where A specifies that it shall raise the patient’s blood pressure, and B that it shall lower it.
There’s a national specification for online consultations and question of what the computer actually does with the patient request seems central to the whole scheme… you couldn’t make it up.
Whether it’s more surprising or saddening I don’t know, but there is now a subastantial body of evidence of what doesn’t work in online consultations, and it includes much of what is being specified:
– no safe & economic automated triage has been invented
– lengthy questionnaires lead to very low usage, under 1%
– there is no evidence of online channels reducing oveall demand.
Despite all this, specifications are full of wishful thinking which will simply result in more taxpayers’ money being flushed down the toilet.
But perhaps what’s less well known is the evidence of what does work.
We’re just about to release a new video case study which is an inspiration. Final checks are being done, and I’ll tell you all about it tomorrow.
PS the GP in question wrote to me yesterday “I am laughing and dancing” When you see the video you might assume we paid them for it. No, they pay us from their own partner income, just a regular customer.