Today I return to that long term plan and a piece of it which has so tickled the national consciousness that it made the News Quiz.
To touch quickly on “Skype consultations”. Skype for various reasons is problematic – it requires both parties to have a login, whereas our video solution works with a one time link. But headlines have been overblown. We now know that when offered the choice, only about 1 in 1000 patients are choosing video. It may grow a bit, but I don’t see it becoming a huge channel.
Let’s move on to the NHS App.
I will share a little of my medical history, and I hope you don’t find this too much information, but I get fungal nail infection.
So in the interests of science I wanted to test how the NHS App would help with my condition, using its 111 online algorithm, and my presenting symptoms of “brown and broken toenails”.
You can see the whole process in this 3 minute video, which is how long it took.
It asked me 12 questions, of which 1 was possibly relevant, 10 irrelevant and 1 frankly embarrassing. The outcome was self care, but with absolutely no specific advice on what to do.
I have tried the same input with the Babylon AI chatbot, which couldn’t find anything relevant and asked whether I had any more symptoms (as if the waiter told me the fish option was off).
I have tried the same input with EMIS Patient.info. Its first option was “Fibre and Fibre Supplements” on which I clicked, and they tried to sell me a hearing aid.
I have tried the same input with NHS Choices, and the first option was sepsis, that well known affliction of toenails, though it did have Nail Problems as the fifth item, which does have relevant information on fungal nail.
I gather about 10% of the population has this, and whenever I mention “brown and broken toenails” to a doctor, the first thing they say to me, without even looking, is “fungal nail”.
If the might of government, of major corporations and £millions of venture capital can’t get toenails right, what hope have they when conditions are complicated and serious? I must leave the question with those qualified to assess them.
On Twitter Dr Dave Triska writes:
“I consulted with 3 people today with a near identical ‘cough’ presentation, recognised the ill one (whom I knew to be stoic and was concerned they had contacted me). Guess what? Sick. As. Algorithm would have missed that.
I just tried my sick patient will all big 3 symptoms checkers. All falsely reassured. From an algorithm point of view, they were right. Likely URTI. Except it wasn’t…
How would I program into an algorithm that the barn door URTI I did also bring down needed to be seen because I knew they’d lost someone to lung cancer and would be worried? That a visit and chat helped them in ways that aren’t measurable against outcomes?”
All falsely reassured.
No doubt you find that very concerning, but consider the specification on which we were invited to bid by a CCG yesterday:
Essential criterion: “Is able to fully triage the patient and signpost to the most appropriate service with no GP intervention using a solution where indemnity lies with the supplier and not the practice”
PS. We do offer self care help with askmyGP, but we don’t claim that it reduces demand or diverts patients. We aim to make it as fast and simple as possible. Please try it yourself, with “brown and broken toenails” or anything else. This is exactly what your patients would see.
Did we meet the aim?
So the NHS long term plan has landed and it’s a techie one. Should we be happy?
As a part-time nerd myself I can’t help but feel the enthusiasm with the word “digital” appearing no less than 14 times in this single page on primary and outpatient care.
“Over the next five years every patient in England will have a new right to choose this (digital first) option – usually from their own practice or, if they prefer, from one of the new digital GP providers.”
I’m going to describe it with three words you wouldn’t normally put together.
Encouraging – Matt Hancock has clearly recognised how far behind the NHS is in patient service, and how new technology can help. I agree on tech enabled, but tech driven is something else.
Dangerous – shifting the ground rules to move patients away from their own local NHS GP will do immeasurable damage to the long term continuity of care integral to the registered list system, and in so doing undermine the professional careers of GPs. Test this idea against Prof Chris Salisbury’s Mackenzie Lecture – the transcript now with illustrations is a must read.
Lackadaisical – with many patients forced to wait three weeks for an appointment, why make them wait five years for change? We’re turning regular NHS practices into digital first practices overnight (well, with four weeks preparation, then overnight). Digital first because all patients are welcome online, but not forced online, and we’re seeing over 60% from day one.
Day one feedback, today: “Seeing its a new introduction, I think its fantastic. The helpfulness, the speed, and the results. Thank you.” Gentleman, 71, Weston-super-Mare.
Come on Matt, keep up!
What a year it has been already. First NASA’s New Horizons discovers a snowman at the edge of the solar system, then Chang’e 4 lands in a crater on the far side of the moon.
What are your dreams for 2019?
I learned this week from the little museum in Grantham that Margaret Thatcher’s father inspired her with the idea that “if you can think it, you can do it” (Love her or loathe her, there’s no question that she changed Britain. Yes, it was a small grocer’s shop, away from the town centre and no indoor bathroom).
So our dream for 2019 is that as we bring about happier patients and happier GPs, we help the profession to be more of what it is meant to be.
What is general practice meant to be?
My discovery of the week was the RCGP James Mackenzie Lecture given on 20th December by Prof Chris Salisbury. What better title than “Designing healthcare for the people who need it.”?
Christmas and New Year are past, we’re getting the house straight again, and have more time to reflect. So I have a little work for you today:
In under 50 minutes you will need to think, you will be challenged, you will laugh, and yet you will know it makes sense. You will contrast the conceptual strength of GP with the failures of implementation.
You will hear the most comprehensive and cogent critique of recent policy I’ve come across. If you are an optimist, you will nonetheless come away with hope that while change is necessary, if we can think it, we can do it..
We’ve had an exciting start to the year with a practice launch on 2nd January in Lincolnshire (clue!), two more next week in Somerset and an accelerating programme through the winter.
I don’t know where we’ll be at the end of the year but I know it will be absolutely focussed on implementation. Thank you Chris for helping us understand what it’s for.
Have a bolder and happier New Year,
PS I’m ambivalent about Thatcher but she was right about a lot of things. A banner in the museum, “I want to turn us from a nation of “Wait until it’s given to you” to one of “Do it yourself””.
People of every political stripe can sign up to that. By the way, we’re looking for GPs with that attitude.
PPS The response has been huge already for our free Digital Triage Experience, and we have now enabled the first user in each practice to invite their colleagues. Compare notes on how you triaged each of the 50 cases and the time you saved.
The “Flaw of Averages” was I understand first observed when a trainee statistician drowned while fording a river which he calculated had an average depth of 2 feet.
You can tell he was American. A British trainee would have made the average depth 0.945m.
We are seeing 7,000 online consultations per week through askmyGP, from about 250,000 patients covered. At 2.8% of total list, that would be about a third of total demand on average, right?
You know I’m going to say “wrong” and the flaw explains very simply why.
It turns out the practices divide into three cohorts, which I’ll call the swimmers, runners and rollers.
The swimmers see under 5% of demand online. There may be a lot of splashing, but speed over the ground is quite low, benefits are hard to measure and an adverse current may even sweep them away. An askmyGP icon decorates their website, leaflets and posters are all over reception but for any patient using it, service is slow and frankly, the telephone seems a safer bet.
Runners are in the range 20 – 40% online, it’s a main mode of access with good service and generally high patient satisfaction. Benefits for the practice are significant and they can handle all patient demand on the day. But they are still running two systems, with mixed messages to patients. While they know online is more efficient, they may still limit access, so patients revert to telephone.
Rollers are putting 100% of demand through askmyGP, between 50 and 80% online from patients, the rest by telephone into reception. In this total flow mode, GP digital triage means they manage all their workflow with an efficiency simply impossible by any other means.
What does this mean for us?
We want to increase usage because, while we incur some volume related costs, it’s much more valuable to us when customers and patients get the most benefit from askmyGP, and that is after all our vision.
But while it might be tempting to persuade, cajole or incentivise practices to push up their average % usage by a few points, it would be a waste of everyone’s time.
Quite simply, we need to get them all rolling along in total flow mode. They’ll experience the benefits all for themselves with no pushing and shoving from us.
Here’s the thing: all our customers have exactly the same software, and the same advice. They are just making different choices, and seeing radically different outcomes as a result.
The great news is that all our new launches are rolling from day one. It works best that way.
Any triathletes will have spotted the analogy but there’s an added twist: transition between the modes seems to be remarkably difficult. People settle into a mode of operation and to shift seems just, well, a bit of an effort.
It’s not impossible, with Witley & Milford shifting three weeks ago and immediately doubling their speed of flow. After one week, someone briefly went back to the old system and was very quickly corrected!
So while new practices are all getting the max, how do we move the others?
PS What about the spectators? Very simply and with no commitment, you can be the GP managing the incoming total demand. It’s real, randomised and anonymised patient data, and when you have your login it will take about 15 minutes to rattle through 50.
Register for our free Digital Triage Experience.
We’re delighted to have reached a milestone today, just over four months after launching version 3. Steve Black our chief analyst told us:
“At 08:31 this morning Aisha at Balaam Street closed the 100,000th patient episode.”
Wonderful to know that in the absence of a functioning government, some things keep rolling along.
History is informative but I’m even more excited about the present, as we announce today the launch of video consulting through our askmyGP platform.
- No app to download
- No need to change surgeries
- Works on any device with a camera
- Your own NHS GP initiates the call
The first ones have happened already, one GP telling me of a child he could see happily running around- saving a visit, and a mole he could tell was benign – giving reassurance. Another tells me of checking on a wound and saving a whole morning off work for a patient.
The experience was easy for both parties, with high quality pictures over wi-fi, and no cumbersome pre-booking arrangements.
Video consults are driven by what is clinically appropriate in the GP’s view, and it’s going to be so interesting to see how this mode affects practice. My guess is it will be around 5 – 10% of consults, but this is the thing: we don’t know.
Have a lovely evening.
Good news has a hard time getting heard.
This week we’ve seen new, comprehensive data from NHS Digital on the wait to see a GP, splashed across all the papers:
It’s all “true”, though I’m afraid the spin is not. The argument that “40% are seen the same day” rings hollow with anyone who has hung on the telephone for half an hour, to be told that all the same day slots have gone. Many of those 40% have been trying for several days just to get through.
Blame the patients, blame the government, blame whoever else we can think of. Or take a different look.
These tiny stories from the last few days are just a handful of the hundreds we see each week from patients grateful to their GP:
Your service and reliability are amazing. Thank you! (f 85)
Amazing fast system thank you (m 41)
Amazingly swift and very easy process than trying to jugggle around work – thank you so much! (f 24)
Amazing…More personal…Super speedy (parent, boy, 3)
Love how easy it is to speak to your own doctor . Amazing (parent, girl, 4)
Love this new system…so easy and quick , and have the problem solved without having to sit around at the surgery. (f 49)
Love ‘askmygp’. Making it so much easier to get info and solve problems whilst holding down a full time job! (f 40)
Wow. I am impressed! (m 69)
Wow, just wow. Have been in terrible painall night…absolute godsend… Thank you so much for your skills and innovations (f 65)
WOW, great system, quick easy, and no need to travel. Many thanks (m 63)
We’re now over 4,600 feedbacks from 80,000 episodes since August, and the trend is better and better. Please do have a look at the live rolling 7 day summary chart. We ask patients whether it’s better or worse and the ratio as I write has moved up to 9 which is so exciting.
These patients are getting an outstanding service from their own regular NHS GPs. The GPs have no extra funding (they pay us), and no complicated extended hours 8 to 8 hubs (that didn’t work)
Patients didn’t have to switch to an out of area GP. They could name their own GP. They were seen same day if needed.
And the GPs are happier too – happier professionally to be giving such a service and bringing the joy back into their working lives.
If you haven’t yet watched the Burnbrae video, please do and click for the demo at the end. This is one of her 5,000 patients last week, helped within 2 hours:
“fantastic service and Dr Arnott is an amazing doctor, Shotts is lucky to have all these new changes.”
How do we get this into the headlines?
Looking up Eric Berne’s classic “Games People Play” I was surprised to find it was published in 1964. He calls it “a way of predicting people’s behaviour.”
It would be pleasing to say we have learned more as time has passed. I doubt it would be true.
Without going into the great psychiatrist’s theories too far he was clear that destructive games caused a lot of pain not only to his patients but to all of us in our daily lives.
I was reminded of these ideas when joining in a Twitter conversation about DNAs (did not attends), a GP complaining that 4 out of 7 patients hadn’t turned up – blame the patients for wasting GP time, NHS resources and slots which someone in need could have taken.
It all makes sense, until you realise that these were Saturday morning “extended access hub” slots. We know that very few patients want weekend slots, and they don’t like to travel away from their own surgery or see someone they don’t know. They were sent there and then as their own practice gave them that option or nothing.
We know that the longer the gap between the booking and the date of the appointment, the higher the DNA rate. On the same day, DNAs all but vanish. Our practices don’t talk about them any more. If changing the system with the same patients eliminates the problem overnight, it follows that DNAs are a system problem, not a patient problem.
The blame game is very simple: “We tell you when and where you will be seen, by whom. We blame you for not turning up.”
We find the same things happening with all kinds of variation. The most common game for appointments is “Nothing left today, you’d better call tomorrow but make it early as they all go around 8 am”. A friend of mine had the whole family of six call the surgery at 8am to increase the chance of one of them getting through.
Another game is “We’re very busy so we allow booking up to six weeks in advance for routine matters”. The mother would take the slot, and would turn up herself or with whichever child or frail elderly relative was most in need on the day.
A new one on me recently was “If you phone in the morning a nurse will triage you. Phone after 12.30 and a GP will triage you for the next day”. In seven years this is the first ever practice I’ve met which has more “demand” in the afternoon.
Whenever we start work with a practice we ask them how the appointment system operates, and we look at their website. So often they summarise it in the two words, “It’s complicated.”
We’ve reached the point that we know from the rules what games patients will play. Then we get the data on demand patterns and it turns out exactly so.
It’s really “Games providers play”, and the cost they and their patients pay is rework. Everyone gets locked into the game, working like stink, deeply frustrated, achieving little.
I love what Eric Berne says in his field:
“Everybody has a hunger for intimacy, a game free zone where people are straight with each other.”
The alternative for practices is to rewrite the rules very simply:
“Let us know your problem, whenever you like. Tell us who you would like to help you, if not anyone, how you’d like us to contact you, and any issues with timing.
“We’ll work out very fast how to help you. No promises, but we’ll do our best to meet your preferences too.”
What happens is quite astonishing. Not only do patients almost always find their needs met, but because there’s so little rework, it’s less effort for providers.
This week from a Bristol patient: “So much easier as I have time to think what I want to say, and it frees up staff to do what they need to do.” We get dozens every week on the same theme.
Shotts, North Lanarkshire. Small town and surrounding areas, ex-mining community. Traditional, somewhat deprived area.
Dr Sue Arnott, full time single hander GP. Team consisting of 8 session ANP, practice nurse.
“We were looking to do things completely differently”
As well as hearing the story, you may like to see the data. Best in full screen, then slideshow.
Innovation is risky, and change is risky, so it should come as no surprise that we have failures. Perhaps we have more to learn from failure than success, which means we must reflect.
Since launching askmyGP v3 in August we’ve had three practices turn it off. I won’t name them, suffice to say they differ widely in size, demographic and location, but you all want to know why they gave up.
The common theme in what they told us was that they felt unable to cope with patient demand.
Yet patient demand was very close to predicted, within 10%, as it has been with the great majority of successful practices.
We do point out that unmet need is uncovered when limits are removed, which may appear to be a rise in demand in the early weeks. A small number of patients will abuse the new system, as they did the old one, but we’ve found from our Datalog audit that in the GPs’ view this is around 3% both before and after launch.
We don’t say it will be easy. We do say that with perseverance both patient service and GP working lives improve. But those that start from a strong patient service ethos seem to do best for their own working lives too.
The commitment to fast and appropriate response from the whole team puts them in control and minimises rework. That doesn’t mean saying yes to what every patient “wants” – that way lies madness. It does mean sufficient breaks around GP and staff needs. Indeed the day can be much more flexible, with many opting to work from home part of the time.
While failure means a return to the previous state with all its frustrations and stresses, success is a journey not an endpoint. It’s all about flow, measured continuously:
- Patient demand, by type, mode and timing over weeks, days and hours. This matters for designing the service.
- Elapsed time to complete requests. Usually the chief concern of patients.
- Continuity, where appropriate. Often key to patient satisfaction, GP job satisfaction and quality of care.
- Efficiency, a chief concern of providers as it drives workload, quality of working life and profit.
- Patient satisfaction, for which we publish summary charts in real time:
The benefits from wholly embracing system change are orders of magnitude greater than from any hybrid system, and a large part of our work is giving practices the confidence to do so. Followng that is an enchanting journey of learning, experimentation and refinement.
We too are continually learning, often finding we can help the flow with new features, better measures, or working with practices to solve unique problems. Sometimes we change our advice,
While change cannot be absolutely risk free, for many businesses, staying the same may be the most risky strategy. We only have to walk down our high streets to see the consequences. For most GPs, protected as they are by permanent contracts, staying the same and offering a service no worse than others locally may not seem too bad, though it hardly inspires.
Our greatest challenge, and by far the greatest cause of failure, is failure to overcome fear, to reach consensus and therefore failure even to start. Let’s re-iterate our purpose in undertaking this work:
We make it easier for patients to get help from their own GP.
We make it easier for GPs to provide that help to their own patients.
Sometimes the way may seem hard, but reward comes through perseverance. We have a mantra to take us through those times:
“First for our patients, then for ourselves.”
PS After the rain, sunshine. I’m about to share some of the most moving patient feedback we’ve had, just from the past week.