After peeling 3.5kg of potatoes in just ten minutes for Burns Night, I’m grateful again to Sam Farber, creator of the OXO Good Grips peeler. Motto “Make everyday living easier.”
His wife Betsey had arthritic hands and he saw how hard it was for her to hold a peeler. The new model came after hundreds of design ideas and iterations, but despite being four times the price of its bent metal predecessor, it’s now the choice of millions of able bodied sous-chefs around the world. I would never use anything else.
What’s the connection?
My time with patients on launch day in Hyson Green, Nottingham on Thursday was fascinating. Dozens of languages are spoken among this deprived population, making it one of the most challenging places in the country to deliver high quality primary care. I submit that this is the NHS at its humane best, universal and free at the point of care for the patient in need, whether from UK, EU or anywhere else.
I watched as a Polish man created his login to make a request on behalf of his girlfriend, trying not to “help”, rather to see where there might be the slightest trip or friction. His smartphone is set to translate, but the translate bar covers one of the text windows. He needs to click “Please accept the end user licence agreement” but his fingers are fat and he misses the small checkbox. Why not have a bigger box and shorter text, “Accept the terms”?
Next I sat with a Romanian interpreter, the lady next to her not the patient but her sister, working out how to send a request by proxy, then to be able to arrange a face to face with the interpreter present.
Patient situations are endlessly complex, and we must learn how to do better for all.
It is so much harder to build something simple than something awkward to use, and it is these extreme but everyday situations that drive us continually to fine tune the patient experience.
We’d had the usual comments from the staff that askmyGP would not work for all their patients (most practices tell us why their patients are different and won’t use it). In the event 69% of requests arrived online in week one, higher than our median 63%, and the feedback has been 100% positive.
I hope the title makes sense. Design “for the few, not the many” means everyone’s life is easier.
The staff room looks out over fields, a couple of hens pecking in the long grass over the fence. We’ve driven Lincolnshire’s challenging roads and arrived through quiet village streets and bungalows. Think everything Salford isn’t: elderly, stable, families and retired.
The new record set by Ruskington Medical Practice was to abolish the old and launch a completely new system from receipt of order in just ten days.
It’s the last place in the UK you’d expect to see this, but from day one they have got 80% of demand online.
They know that almost everyone under 65 has online access, and a large proportion of much older patients. The patients haven’t yet realised there’s an easier way to get help, so if they ignore the GP recorded message, the receptionist asks:
“Do you shop online?”
That simple question, almost always answered yes, means they can be directed to the website (or sent a welcome email) and off they go. Request arrives online, it’s sorted to the appropriate person, and completed within a median 91 minutes. Only 23% need a face to face or visit.
Credit to practice manager Jules for that phrase – we love simple. She’s happy, staff are happy, GPs happy, and patient feedback shows 78% say the new system is better (one aged 90), only 12 days in.
Jules tells me demand is below prediction, which I find slightly annoying as we do like to get this right.
I’ve counted and “Do you shop online?” has exactly half the syllables of “Patient Communication Strategy”. It would be funny if it wasn’t sad, but NHS England’s Patient Online programme has taken 8 years and spent countless £millions of taxpayers’ money on telling patients to book appointments online, and they’ve reached 4%.
It hasn’t worked and it will never work because GPs are smart enough to realise that allowing patients to book all their time will waste a good 2/3rds of it.
Here’s the offer that works for patients:
Tell us who you are and what is your problem, and we’ll work out how to help you. Boom.
You’d be amazed how many times GPs tell me “this wouldn’t work for our patients” – perhaps because they’ve tried something which didn’t work. That is why simplicity is so important, and why Computer Must Never Say No.
Ruskington at 80% still welcome those with no online access. Suburban Hounslow is another new launch, 86% online, Salford remain highest at 98%.
We’re looking forward to a Surrey commuter practice making the last launch of 2019 on 23rd December, and a Lincs seaside town the first of 2020 on 2nd January.
Never know who might set a new record…
PS Often a fear of “opening the floodgates” leaves people torn about the risk of change. In the recorded webinar Understanding Demand we examine the evidence of what happens. Free to register.
For an idea of how the askmyGP could put you in control of your day, click here to get our four user stories.
The walk down from Manchester Piccadilly is a fascinating cityscape, and then crossing the river Irwell into Salford it seems everything is in flux.
Here, between the £180/night Lowry Hotel and the £35/night Salford Arms Hotel, lies Blackfriars Medical Practice. Perhaps that’s a metaphor for the patients Dr Babar Farooq and his team serve: young, mobile, diverse and with fortunes right across the spectrum.
It’s free to join his list and free to get help – the NHS is a great leveller.
What’s unique is that when Blackfriars launched askmyGP three weeks ago they moved 97% of their patient demand online, from day one.
There’s no messing about – Linda on reception simply tells the patients what they need to do. They send online, they get sorted within a few hours (median time to complete the episode is 193 minutes). Computer never says no.
Inside the practice with the phone not constantly ringing the drop in stress and pressure is palpable. They are bouncing. Babar keeps telling me how happy he is, and he’s resolving 38% of requests simply by message.
Patients? 86% say the new system is better. “I was surprised at how quick my question was responded to. Much faster than calling.” is a typical response, female 29.
Their demographic is young, mostly 20s and 30s, so we wouldn’t expect every practice to get this many online, 80% would be more reasonable for the average normal digital first GP.
Blackfriars in week 3? They’ve just ticked up to 99%.
Pictured, between the yellow sign and the railway bridge, ground floor.
If you’re a GP you will by now be familiar with the NHS England requirement for “25% of appointments to be bookable online”. If you’re a commissioner you may be fretting about how to measure it. Anyone else is most likely bemused by another arbitrary number of little relevance.
But there’s a dark side to arbitrary requirements, and with this one it is faced by the digitally disadvantaged. We instinctively know that those least capable of booking online, for reasons of age, deprivation, mental capacity or simply being ill, are disproportionalely most in need of help from their GP.
The good Dr Julian Tudor-Hart called it the “Inverse Care Law” and it can only be overcome by deliberate policy. By carving out GP capacity for a relatively advantaged group, this policy stokes and promotes that law. Shame.
You may look to BMA guidance on how to dance around the policy: in essence, 25% can be for any clinician, at any time, so it could be all the HCA appointments bookable 4 weeks hence. That ensures the box is ticked, but do we really want to manage compliance by frustrating policy?
Regular readers would expect me to offer a radical and practical alternative, and I’ll try not to disappoint.
We believe that 100% of patients should be able to get help online. And we believe that 100% of patients should be able to get help by telephone. Same goes for walk-ins.
How so? It’s all the same capacity, none is reserved for any group or mode of contact. The point is that a patient can’t reserve any GP capacity, it’s up to the GP to decide what is the best way to help. Patients can request help by any mode, but all requests go into the same flow at the same time, managed by the GP according to need: none has an advantage.
We are concerned to make life easier for both patients and GPs, and we know that online requests are much faster for GPs to deal with so we encourage patients to go online. It turns out that the 25% figure is unambitious. The lowest rate of online requests for any of our total flow practices is 35%, and the average 56%. I visited one in a perfectly ordinary part of Wigan last Wednesday which gets 75% online. That’s Wigan, not Westminster.
Median time to complete a requests at the practice, Shakespeare Surgery, is 31 minutes (if they need to be seen it will be later the same day).
– patients will do what works for them, not what they are told
– online requests can work for all ages and conditions (though usage is lower with greater age)
– online is more efficient for GPs and receptionists, freeing up time for those who still need to use the telephone.
In order to deliver the outcomes we all want, system change not arbitrary targets are needed, and suddenly it makes sense to abolish the existing assumptions and methods.
We’ve added a criterion by which we judge progress with askmyGP:
The service must benefit non-users.
“The patient journey…” We are fond of that phrase in the NHS, aren’t we?
That’s in the parallel universe of politics and pipedreams. The reality when we become patients is often very different. As one GP tweeted last week “Have to say being stuck in a trolley queue for over 3 hours got me thinking about patient flow”
At a practice on Wednesday a receptionist told me of the time she had a patient across the counter and had just explained they had no appointments left. He pulled out a pink screwdriver and started waving it at her. In that situation you would remember the colour of the screwdriver, though I was unable to see why a screwdriver would change the availability of appointments.
Wherever you enter the system, it can be deeply frustrating, when you know what you want and just can’t seem to get it. The patient journey we all want is one that works, and if it did, the NHS would be far cheaper to run.
We have a shockingly radical thought: “Make it easier for patients to get help”.
In general, most of us now start looking for local services online. That means the GP practice website is the very start, and what could be more important than getting this right?
Having looked at hundreds, they fall into three main groups:
1. Standard commercial offerings – low cost templates, everything included, ticks all the boxes.
2. Boutique designs – beautiful graphics, videos and moving images, where what you want must be somewhere…
3. Push-you popups – wherever you go on the site, they tell you what you want and it’s very hard to find a way around.
The problem we felt with all of them is that they don’t help the patient find and do what they want to do.
We don’t do websites, but we found someone in Tim Green at GPSurgery.net who does, and starts with patients. He tells me that most patients click on:
– how do I get an appointment?
– repeat prescriptions
– meet the team.
Aha. So that’s exactly what we put on the home page of our patient demo site Bramley Surgery.
Do try it, and we would love your feedback on the patient journey. Send in a request and we might even reply (sorry, no actual medical help).
Here’s the news: we have bundled one of Tim’s wonderful websites free with our Transform and Improve Pro packages. You can stay with your old site, but making it easier for your patients turns out to have a beneficial side-effect.
With 57% of demand now online, they make life much easier for you too.
Delighted to share a surprise with you which I first heard on Wednesday.
Many of you will know Ben Gowland of Ockham Healthcare and his regular podcast.
This week he interviewed Dr Hugh Reeve of Nutwood Medical Practice in Grange-over-Sands, Cumbria. It’s 25 minutes of straight-talking on why they implemented askmyGP and what happened.
I’ve learned a lot from it too, about the importance of continuity for GPs as well as patients. As Hugh says, it pained him when patients had to wait days to speak to him, or were then passed around to others. Rework was bound to follow.
I love the bit where he says it’s not a bolt on, and where he says after 6 months each GP has shaped it for themselves. This is one of the most elderly populations in the UK, and they are now at 40% online. Quite a story.
PS Do sign up to get Ben’s regular blogs.
How did you feel about the incoming prime minister’s pledge in his very first speech outside Downing St?
“My job is to make sure you don’t have to wait three weeks to see your GP”
Every PM I can remember from Blair to now Johnson has said as much, and what have they done?
– the 48 hour target
– the contract giveaway of 2004
– the Prime Minister’s Challenge Fund
– the Vanguards
– training 5,000 extra GPs
– the GP Forward View
– recruiting 2,000 foreign GPs
– the online consultation fund
I’ve probably missed a few, do fill in the gaps.
Every PM has watched waiting times increase and continuity of care fall. I’m picturing the ships they launched now a line of rotting hulks…
Nothing wrong with the ambition, what’s missing is method. METHOD, how, based on evidence, are they going to do it?
Practices we help measure their patient service in minutes not weeks, and with a choice of named GP, and in fewer GP hours. They’ve got there quickly and at low cost.
On Wednesday I met another practice in Lincolnshire for their Pathfinder diagnostic, they decided to go ahead on the spot and in three weeks time, they will prove it all over again.
We have found over the years that it’s best to ignore the fads, fashions (and indeed the funding streams), and pursue relentlessly what works.
Our approach doesn’t win friends in high places, so I’m not going to sit by the phone. Perhaps some of our happy GPs would get in touch with the PM, give him one less thing to worry about.
Does F2F frequency affect patient satisfaction in digital first primary care? SAPC Exeter ASM poster
Many have wondered whether patient satisfaction is affected by their chance of seeing a GP face to face. The study done for the Exeter Annual Scientific Meeting of SAPC (Society for Academic Primary Care) analysed 14,009 patient feedbacks from 423,143 episodes managed through askmyGP from 1 January to 26 June 2019.
Presented by Ian Barratt and Steve Black at the conference. Download pdf here.
Read this NHS Digital press release and shudder: “NHS 111 online hits one million triages mark”
You will be very familiar with the quality output from NHS111 sent to GPs from the standard version, where a human reads a list of questions from a computer to a patient, and based on their answers tells the patient what the computer tells them to do. Data shows the disposition is 8% to ambulance with a further 7% advised to attend A&E.
That process has now been fully automated into NHS 111 Online, and the number advised to attend A&E has reached 24.7%. Yes, almost one in four patients seeking help “when it’s not an emergency” is told that after all it is an emergency.
Over many years we’ve run audits, n>200k, where GPs labelled just 0.4% or 1 in 250 consultations as emergency. So we can estimate the proportion of false positives in the NHS 111 online dispositions at around 98.4%.
As you would expect, I have tested the system myself, in the interests of science. During a break in the weather we managed a cycle club run this morning and after 53 miles I am shot to pieces, so I tried “aching legs”. Answering just 6 questions, all truthfully and all negatively, except that the aching was all over, sure enough I got the result in big red letters: “Phone 999 now for an ambulance”
Folks, if you read the press release they are actually proud of this. I put the figures to Simon Stevens at a Reform meeting last week. Earlier he had spoken of the benefits of machine learning in assessing images, an application which makes sense as computers are good at comparing similar things and looking for differences. When it came to 111 he assured the room that results would improve when the algorithms had more cases from which to learn. They’ve had a million, how many do they want?
247,000 innocent patients have been advised by this abominable software to call an ambulance or attend A&E. Tariffs vary but if we take an average of £200 (ambulances much more) that’s around £50m, almost all of it overtreatment. We are told that ambulances and hospitals are under pressure and want to reduce demand… is anyone in Skipton House paying attention?
Suppose these million patients had been diverted to a qualified human to assess their needs and respond appropriately, that £50m could have been invested in front-line services so beloved of politicians.
My only hope is that most patients had the good sense to ignore the advice. But what have we come to when the NHS is spending money to make people afraid?
We get asked to bid for contracts with CCGs to provide online consultations through the intriguingly named “Dynamic Purchasing System”. Most of the specifications require an algorithm to triage patients automatically to an appropriate disposition. We explain why we won’t do that because it would be both wasteful and dangerous. We don’t win any DPS contracts.
It doesn’t have to be like this. Public money could be spent on evidence based interventions. Ploughing our own evidence based furrow can be lonely but we’re going to keep on doing what works. As far as we know at 20,000 per week we’re already the largest provider of online consultations, mostly from practices self-funding because they make such a difference to their workload and profitability. They absolutely love it.
Cheer up, believe that better is possible, right now, and smile with the staff at Witley and Milford practice.
PS Barry Sullman showed me the numbers from his CCG this week, Balaam St winter A&E attendances fell by 24% in his first year with askmyGP. That’s the power of human intelligence.
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: