Witley & Milford Surgery serves 11,200 patients in the rural Surrey commuter belt. Yet the partners felt under pressure, not in control.
They weren’t providing the service their patients deserved. Dr Dave Triska and colleagues explain what happened from June 2018. Below the video, see the numbers.
Charts on demand volumes, patterns, response times, channel of demand and response, continuity and patient satisfaction:
Witley and Milford charts to 14 May 2019
It seems pretty clear that the main plank of government policy towards patients is: let them book their GP appointments online.
The new contract says that 25% must be available online, and they are investing £6.3m in the NHS App with appointment booking the headline feature.
Yet we all know that anything which requires compulsion or bribery is probably a BAD IDEA. The badder it is, the bigger the bung. Good ideas have a life of their own and no government can stop them.
Online appointment booking has been a contractual item for years, and yet while everything travel, banking or retail is online, only about 4% of GP appointments have gone that way. The technology is there already – it’s the GPs who don’t want to release appointments for self booking.
They know that without reception as the intermediary, many will be taken by patients who don’t need them, reducing equity of access for those in greater need. They are even paying receptionists from their own profits to suffer all the stress of turning patients away, rather than put everything online and leave the phone off the hook.
Yet we know that when they trust the practice to give them the help they need, patients don’t even want appointments. We ask them how they would like to be contacted and were astonished to find the average at only 25% by face to face, some down at 11%, GPs begging them to come in.
“Super service thank you for implementing it. Much easier than an appointment” wrote a lady in Somerset today.
So we turn to the Pilot Evaluation of the NHS App. Credit for publishing this for comment within 3 months, but let’s look at the detail:
- 34 practices, given lots of on site support and training over 3 months to 21/12/18
- 3,192 patients used it
- 337 appointments booked, and 106 cancelled.
Now I’m “just saying”, as they say, but in the same period and with only 28 practices we had 100,000 patient submissions on askmyGP. No appointments were booked directly, but they all got help and about 30,000 had a face to face.
We’re coming up to eight years old as a company and I’ve found it necessary many times to do the opposite of the zeitgeist. There’s never any guidance on being counterintuitive and it’s very costly, but what keeps me going is that it works.
I was at a Leicester practice this week for their training and the enthusiasm they have is infectious. Next week a couple more launch in Sheffield and Glasgow. They are all paying for themselves, taking control of their own workload. It’s becoming unstoppable.
Two quick things to do now so as to see the difference:
1. Do the patient demo and get how easy it is, without being able to book an appointment at Bramley Demo Surgery.
2. See how easy it is to respond by signing up to the GP Demo, triage 50 real patient requests.
Summer is coming, don’t spend evenings in the practice.
New financial year, new contract – the rush to put QOF to bed is replaced by the rush to absorb the new implications of Primary Care Networks.
“Who do we want in our gang?”
Or is it, “Will anyone pick me?”
Anxieties from the school playground resurface. I was never any good at ball sports.
Already there’s a deluge of advice from all kinds of bodies, leadership development offers, model contracts and so on. Some of it is bound to be contradictory given the scale of change and I have to say a July start seems, er, courageous. Then again delay to anticipated fundamental change seems to be in fashion, so we’ll see.
I have a different question: how will PCNs work, from a patient’s perspective? In simple terms, patient presents with a need, GP decides the need is best met with a shared network person or service. How are they assigned, how long will they wait, who owns the case?
For the PCN, more questions arise. How will they predict demand, by type and volume? How will they manage capacity and measure performance? How will they allocate resources fairly between members?
I would love to hear your views. Please drop me an email with a few lines, or comment on the blog. No promises, but we’ll try to help.
PS It has been a pleasure to work with our highly talented videographers this week, at a simply astonishing practice. Very soon we’ll have the result, from prosperous Middle England. It’s just so hard to cut several hours down to 3 minutes.
Meanwhile the same team has made a short, just over a minute, from the other end of the spectrum in multi-ethnic East London. Before it goes out on social media your can sneak a look at Be More Barry. Just lovely to brighten up your weekend.
We’re delighted to inform you today of the open access publication from Abi Eccles et al:
It’s the first independent study of askmyGP and it’s well worth reading in full. I will quote the conclusion briefly:
“Patterns-of-use and patient types were in line with typical contacts to GP practices. Though the age of users was broad, highest levels of use were from younger patients. The perceived advantages to using online triage, such as convenience and ease of use, are often context dependent.”
What comes through for me is the very ordinariness of the online demand. It’s the same as normal demand, same patients, same conditions, same frequency by day of week and time of day.
There’s more on patient feedback too, with themes extracted which are very familiar to us. We’ve quantified the age question in our study on “Age specific adoption of online consultations.”
What this study adds is online usage orders of magnitude greater than any previous paper, with 5447 patient episodes from 9 practices in 10 weeks. Data collection was May to July 2017, which was our previous version 2 platform. Since then the same principles have been carried forward to v3 with a new design and many more features. Growth in usage means that we are now collecting the same volume of data roughly every two days.
The scope for further research is increasing daily with an anonymised database of some 300,000 episodes, unique in general practice. If you’re an academic in the field, we welcome the opportunity to collaborate, particularly on studies of the GP practice as a whole, not just online components.
Benefits for patients and GPs are the product of system change.
PS See how patients interact with askmyGP on our Bramley Demo Practice.
To experience the GP side, start with our free online demo.
It was a tweet from a regular GP partner (yes, they’re all special).
It was last Sunday lunchtime. Why then? For fun. For sharing. For sheer joy and pride in work. For having something to say.
It had the image of a runchart, that simple device which is still the best way to show what happens to some characteristic over time, this one monthly from Feb 17 to Feb 19.
Now what’s remarkable about the characteristic is that it’s “Average days waiting to see GP”. That may seem obvious enough to a patient (oh yes, we’re all patients) but this was from a GP.
If you’ve noticed in all the medical press, Pulse, GP Online, BMJ, NHS England and so on they all harp endlessly about the pressures of workload, stress, burnout, early retirement of GPs and so on, but nairy a word about patients.
Now here’s a GP doing data about what matters to patients. How long to get help.
I can almost feel that defence welling up inside you “It’s not the only thing that matters to patients!”. Yes, we know it’s not the only thing, what also matters is the professional care they receive, and for many relational continuity with a named GP. But there’s no point in praising the wonderful professional care which patients can’t actually get.
Everyone knows the single biggest theme in the general media concerning GPs is the time waiting to get help, and in our own surveys of practice staff, the dominant theme is the difficulty in giving patients the help they need soon. Equally, the dominant theme by far in our patient feedback is gratitude for the speed of response.
Yet nobody is measuring the waiting time, what matters most to patients. Where are you NHS England, Scotland, Wales and NI?
We must turn to the story in the data. From Feb 17 to May 19 it starts with a range between 2 and 5 days wait, variable in such a way that stats geeks call “out of statistical control”. Others would say it’s all over the place.
Then it changes completely to a new mean of 1.5 days with random variation of +/- 0.3 days. This is in statistical control.
If you aren’t curious yet, there’s more. Discussion follows where the author Dr Dave Triska of Witley & Milford Surgery is asked what extra resources he needed to achieve this. “Mmmm we didn’t recruit anyone, in face we lost 6 sessions as we changed over due to retirement”
There’s no shortage of GPs here – they’ve saved a whole one.
What about personal care, stress? “It’s a pleasure most days to give people what they need – rarely overrun now even with 30mins with people dotted through the day”
So some patients are getting half an hour. And by the way, we know they achieve 91% continuity, choice of named GP.
People, this is history in the making, I don’t know how it will be looked on in the future but I’m calling it:
Be the witnesses.
01509 816293 / 07939 148618
PS Welcome to see how patients interact with askmyGP on our Bramley Demo Practice.
To experience the GP side, start with our free online demo.
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.