Like many of you I’ve joined in the clap for key workers on Thursday evenings, and very well deserved it is too.  There’s little doubt in the public mind that the NHS has performed better in the pandemic than the government overall.

But working in the health sector we have every reason to feel not just pride but relief, as we are in relatively secure jobs while we see others all around lose their livelihoods in everything from hairdressing to aerospace.

This week another survey comes out from the BMA, GPs bemoaning their lot for one reason or another.  In the eleven years I’ve been working with GPs, something like this appears almost weekly, predicting the end of the profession as we know it.  Yet the GPs we work with are more secure than ever, loving the job and have never been better off.

Adding to the conundrum is disturbing data on numbers.  As reported in GP Online, GP ftes are down 712 in the year to March 2020, and GP partners down 1,023.  Yet in the same issue, GP locums bemoan the sudden loss of work in the pandemic, 81% seeing a drop in income.

I’m sure that, like me, you have many friends and relations in the medical profession and I’m sure that considered overall you wouldn’t disagree with what one observed to me, “We’ve never worked less hard since we left medical school.”

It’s amplified by leaders saying “We’re not going back to the working life we faced before the pandemic”.

I can’t wait to be rid of the restrictions on all our lives, but there’s little doubt that general practice will not return to the working format pre-covid.  RCGP reported that face to face had dropped to 25% of consults, which seems high to me as our practices dropped from 30% to 2%.  It has now crept back to 5%, while total demand is nudging up towards pre-covid levels.

Having discovered the efficiency of telephone triage overnight, partners will not offer face to face to everyone again, rehire all the locums and take the hit on their profits.  We’ve been saying this for ten years, a few pioneers have said so for twenty years.  Our latest askmyGP data, live here, shows 37% of requests are now resolved by message alone, no need even to telephone and much more time saved, while patient feedback is up too.

Practice after practice is discovering the same, but they all seem to go through a ritual of catastrophisation before they launch.  At one this week the GPs were very adamant that Friday would be the busiest day, and I said they would remain very adamant until Friday.  It came in with less than half even my predicted volume.

Another due to launch next week did the staff survey, and the biggest fear of the partners was higher workload.  The biggest fear of all the other staff was losing their jobs because of lower workload.  It’s a GP thing, and it goes with the territory.

With the huge extra resources now going into Primary Care Networks, I foresee very good times ahead for GP partners.  If you’re a locum or salaried, apply as soon as you see a good opportunity.  If that translates into better patient service, better quality and continuity of care, and more fulfilled professional lives, we all win.

So I’m very optimistic, but honestly, I’m bored with lockdown.  I haven’t quite reached the point of sorting out my sock drawer, but I’m close, and that’s serious.  Okay okay, “There’s never been a better time to sort out my sock drawer.”

Harry Longman

With the passing tomorrow of the deadline to sign up to the Primary Care Network DES a Rubicon will have been crossed for PCNs.  The rehearsals are over, real money and commitments are at stake.  But I want to know, how will they work?

A funding model is in place, a set of PCN duties and payments is agreed, no doubt controversially for some but that’s how it is.  A list of professions is now 100% funded by the delightfully named Additional Roles Reimbursement Scheme.

But still I ask, how will they work?

Everything we do in the NHS needs to relate to its purpose which, however it is worded, amounts to helping patients overcome or manage their various medical needs and diseases.

The additional roles must be to help patients, who have needs.  Which patients, what needs, when, with what measurable outcomes?

Forgive me if I’ve missed something, but the debates on funding, roles, governance and so on seem to be very far removed from these practical questions.

Consider the patient journey: present to GP practice, GP considers they would benefit from referral to a PCN employed clinician, say a pharmacist.  How easily do they refer them?  How soon can the patient be seen?  How does the pharmacist manage demand from multiple practices?  What is the right capacity for each kind of role?

A PCN I spoke to had a pharmacist one day per week in each of the five member practices.  Neat, being five, but others will have 3, 4 or 7, and all different sizes.  One may be mostly students, another elderly and with very different needs.  What if our patient gets referred on Tuesday, just missing the pharmacist who calls at her practice on Mondays?  And work or family commitments mean Monday never suits her?

Managing the workflow, demand and capacity for shared roles could be orders of magnitude more difficult than the same within practices.

I would love to know your thoughts on how, or ideas from your PCN.  Yes, we are going to try and make it easier so you can make the most of the new resources, do let us know what you would like and watch this space.

Harry Longman

PS Last week’s blog looked at return on investment in askmyGP.  David Evans replied to me that following their £35k investment in year one, they were saving £100k pa in locum costs.  Not bad, indeed typical.  Sujit Vasanth commented online “I can honestly say the change to askmyGP has been the most important (and positive) change in our practice in the last 10 years.”  Thank you!

A number asked about spreading payments and I’m pleased to announce that we have responded with just that, it’s on the bottom of our Transform Express and it is now standard.

Today I want to talk about a problem for us and for GP partners.  We’ve always supported the GP partnership model as the most effective (while not the only) way to deliver high quality primary care, locally and with long term relational continuity.

Forgive me if you’re not a GP partner, no need to read on, but if you are I hope we can share some of your thinking as we are a small business with a turnover similar to a medium sized partnership.  We value our independence and we want to help you use yours.

Throughout England GPs are able to access one of several suppliers free which enable them to comply with the edict to offer online and video consultations.  We chose not to participate in this tender, as the allocation is random by CCG, no evidence of outcomes was required to participate and therefore it is impossible for GP partners to make an informed choice of supplier.

Not only are we competing with free, bluntly our service is around three times the price of others over 3 years.  It’s a job to explain to people that it’s very different from bolt-on technology, as askmyGP enables system change like no other.  We are not competing with point solutions.

This means that in addition to helping you comply with regulations, we need to sell on the concepts of “value for money” and “return on investment”.  It has to be worth it for GPs making decisions as owners, those with skin in the game (I loved the wonderfully provocative book of that title by NN Taleb).

In the whole UK just four CCGs and one Welsh health board are fully funding askmyGP for all their practices, and they are flying, but let us face facts:  the rest of you are going to have to pay directly.  Which puts you in exactly the same position as thousands of other businesses, including ours, where investment is a decision you make to save time and money, improve your life and increase profits.

Now here is the good news:  our customers are our greatest fans, and we are very grateful to them for their public support.  Some recently set up a facebook group (I’ve applied to join).  They are all over Twitter – last week @simondevial wrote “We’ve been using it for 8 weeks. In 28 years no other change delivered “what it says on the tin” like this.”

I was talking to Barry Sullman on Friday.  He’s happier than ever after 2 years. “Using askmyGP has given my practice extra resilience, allowing us to easily cope with clinical staff shortages due to Covid, and sustain a high level of care dealing with every clinical patient the same day” He goes on to add “Last year was our best QOF year because of askmyGP. We were able to identify long term condition patients at the triage state and bring them in for care of their long term condition as well as the problem being triaged. As a result last year I reached virtually all my QOF targets before New Year’s Day!”

We hear lots like this.  As a result we’re seeing the highest ever rate of enquiries from GPs, many of them unhappy with the free software imposed by their CCG with no consultation and no evidence.

However, many get stuck at the point where they need to pay, and when they are used to having everything for free, it seems odd.  Yet the same people wouldn’t think twice about buying a holiday (a cost) or replacing the car (a wasting asset).

Last week my bank wrote to tell me the interest on my savings account is 0.01%.  Compared with keeping £1000 under the mattress for a  whole year, that’s just 10p extra, and they are threatening to charge us for looking after it soon.

I’m happy to report that increasingly partnerships are realising the very high rates of return they will make with askmyGP and deciding to invest, based on evidence, putting themselves in control of their destiny.  Our practices managed 98,050 requests last week, 96% of them remotely, 69% of them received from patients online.

It’s not only the savings on locums (you will have noticed that locums are struggling to find work at present), so many echo @catiebagel’s tweet “Hope we can continue to deliver remote assessment and treatment where possible & if clinically appropriate. Often more convenient for patients and less travel has co-benefits for the environment. Agree, am so glad we had @askmygp in place before COVID hit. #greenergp”

You may have enquired with us a day, a week or a year ago.  If you’re not convinced of the evidence, crawl all over our website, study our live data, ask your friends who are customers and look for independent views.  If you don’t understand it yet, spend an hour on the webinar “How, but first Why, askmyGP works”.

If you’ve seen and heard enough, and you don’t want to waste a year on something free but with tiny usage and no savings, then now is the time to act for three simple reasons:

• the barriers to change have disappeared
• current workload is lower than ever
• money has never been cheaper

So many practices have got this far and then decided to hang on for taxpayer funding.  They are still hanging on, six months, a year, two years later.  Don’t be another disappointed hanger-on, be another delighted user, within a week.  We’ve now launched close to 3% of UK practices – that’s enough to start a revolution.

Kind regards

Harry Longman

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).

In summary:

– 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.

Harry Longman