Another week, another specification thumps onto the floor in front of my inbox. NHS Blithering CCG* has copied down the questions from the last lot, added the requirement to integrate with local place-based cloud-enabled remote home visits by Longstay (Vietnam) NHS Telecare plc, and there, ta-da, is the blueprint for online consultations.
As I read through the same tired wishlist, my heart sinks. Must have:
- red flags (unsafe and cut patient use by around 60%)
- symptom checkers to divert patients away (unsafe and patients hate them)
- ability to book GP appointment (wastes GP time as 70% of patients don’t need a face to face)
It goes on, and of course we aren’t going to rewrite our software to meet this specification and thereby ensure it doesn’t work. What’s missing from the list are many of the features which really do matter to patients and GPs, let alone any serious understanding of the journey of change which is much more expensive to deliver than software.
If the CCG has decided on a tick box procurement process, we’ve put ourselves at a serious disadvantage. We run a permanent policy of not lying about evidence, rather presenting the raw data and letting the customers talk about the outcomes. Worse still, we don’t promise the moon unless we have clear technical and economic means of reaching the moon. Overall disastrous.
So I’m going to ask you a genuine question, if you’re in an English CCG, or a GP affected by the DPS procurement process through the ringfenced £45m online consultations fund, set up by Arvind Madan, former eCONsult chief executive: should we pull out of the DPS?
CCGs can still procure askmyGP or any competing product via G-Cloud, and draw on the same £45m fund. We are fully compliant on patient safety, information governance, security and so on. But our product development is driven by the simple question “what works?” rather than “what is specified?”.
It’s a philosophy that has enabled orders of magnitude greater usage and value for patients and GPs.
What those tick boxes and essay writing competitions can never ask is whether it will do this. Copied to me yesterday by Dr Barry Sullman, writing to another GP and he’s delighted to share:
“AskmyGP is a revolutionary system, that has transformed my work/life balance. It is now normal for me to have breakfast, and tea with my family. It has also transformed care at the surgery, empowering patients, and creating efficient SAME DAY care.
But I don’t want to talk hyperbole. I want you to come and see this on a live system, where you can see this really happening. I have recovered the cost of the system in 3 months, and I will continue to recover the cost many times over indefinitely until I retire. Let me show you the math when you visit.
This is the future – and doctors need this sorely as do patients.”
So what do we do? Advice welcome or if you like put it in public and comment online.
PS Wales and Scotland do not suffer the same procurement blight as England and they are pulling ahead, as are English GPs investing in their own businesses for the return Barry mentions above.
*Blithering and its staff are an unregistered trademark of the great @jtweeterson, used without permission. The genuine article is here.
At the end of a week of “fun” on the NHS at 70, I want to contrast two views of what it’s about.
Matthew Parris is always thought provoking and he writes today in the Times, “The NHS guarantees second rate healthcare”
In case you don’t have access through the paywall I’ll summarise his thesis. Transport in London is slowed by congestion to the point where people would rather walk. When it speeds up, they will get back in the car/bus/tube. NHS Healthcare is like transport, keeping the waits long and the service cumbersome is a crude way of rationing. If we made it faster, more patients would jump in to the point where it slowed again.
“We’re getting a second-rate health service for the price of a third-rate one. I see no other way.” Meh, as my daughter would say.
The theory is impeccable, just spoiled by an inconvenient fact: it’s not true of healthcare. Easier access doesn’t increase my number of diseases. If the theory were true, lowering the effort to access the GP as close as we can to zero would see demand escalate.
It doesn’t happen. Demand is flat. Patients don’t even need to wait for the phone to be answered, and they are getting a personal response within minutes.
Witley yesterday: “our waiting time for routines is now half an hour. And we’re a partner down this week, unplanned.”
You may have heard of the death last week of Julian Tudor-Hart. So much has been written about him and by him on the NHS, I’m grateful to @mellojonny for a 9 tweet summary (click Show this thread). He starts with “1. A united national service devoted directly and indirectly to care, fully available to all citizens.”
We never met but at 85 he wrote to me in 2012 and I quote:
“So I count on you & others like you to carry whatever is useful from my torch, which I in turn got from my predecessors – my father, Len Crome, Hugh Faulkner, Alistair Wilson, Jerry Morris and a small handful of others.
I wish I could get more people to read the 2nd of my Political Economy of Health Care, especially the final chapter. To act effectively and sustainably throughout their lifetimes, people must have a comprehensive big picture of society, and how fundamental social change actually works. So far, very few people have that. Until they do, we and our descendants will be in mortal danger, worse than 1933-45.”
Matthew Parris or Julian Tudor-Hart: choose your vision.
I’m fortunate rarely to need the NHS, so when I do as this week there is so much to learn. And it touches directly on why we can routinely make life changing efficiency gains in the order of 40%.
Where could that possibly come from in practices who tell us the whole time they are bursting, sinking, drowning or whatever hyperbole they choose? They can only see one way out, recruiting more GPs, and they can’t recruit.
So here’s my story. I need a blood test for schistosomiasis after swimming in Egypt, as another member of the group tested positive. While I explain what happened, tot up in your head the waste…
Weds 27/6 I check online to book an appointment, next available is Friday 29/6, HCAs only this week, but I think, blood test, will be OK, and clearly state the reason.
Friday 29/6 Three phone calls around 8am, all of which I miss, but get a message and call back. HCA can’t do this one, could I see nurse instead, and she’s free at 11.30. I grumble, shorten a meeting and agree to go at 11.30. (wasn’t available to book online)
I’m on time, but she spends the next 15 minutes explaining how unusual this blood test is (me: “but I’ve only got one kind of blood”), nips out to refer to GP. Can’t take the blood, but GP will call me today at 4.30 to explain what needs to happen. (slot wasn’t available online)
4.30pm GP calls and spends 4 minutes explaining what the nurse told me, and that I now need to book another appt with an HCA to take the blood. (what really creased me up was seeing the note online for my 10 minute call: “This was a difficult pt earlier”. Not intended for my eyes!)
Monday 2/7 I book another appt with HCA for Friday 6/7. Today I turn up at 11.50 and the HCA takes my blood, I’m out in 4 minutes and the actual value work is done, at long last. I was a very brave boy and got a badge.
I did everything by the book, all online as Jeremy Hunt wishes, but did you tot up all the waste? 4 receptionist phone calls, only one connected. 15 minute nurse appt, including an interruption to the GP. 10 minute GP slot, achieving nothing.
You missed something – over an hour of my time.
I can hear you whispering that this was a special case but do you know, for the patient every episode is a special case? Other family members get a similar run around pretty much every time they need help from the GP. Then they try going around the system, just because they are human beings, just like all the other human beings who tell me daily about their frustrations.
But have you seen how the magic works?
All we need to do is take out the waste and rework.
I’d go online with askmyGP, answer a few questions to explain exactly what I needed and send. Looks complicated, receptionist assigns to GP who in total peace and quiet looks up the procedure in seconds and messages me to say come in for the blood test, today. Done.
Multiply hundreds of times per week for each practice and millions of times per week for the UK.
Jeremy Hunt wants to automate the waste, creating more waste. Andy Burnham pops up to tweet “This lazy line that the NHS is inefficient annoys me.” That’s not lazy, it’s caring. I counter with Don Berwick: “Efficiency is a moral imperative”
Most of us will be born, live and die cared for by the NHS. That doesn’t make it a religion, just a jolly useful health service. Britain has sadly become one of Europe’s most unequal nations, and the NHS does a little to level opportunities at least in one sphere of our lives.
The NHS at 70 doesn’t need reverence. It needs principled leadership, critical friends, and no-nonsense doers with method.
PS If you’re sick of all the hearting, @jtweeterson’s blog is guaranteed to cure you. Simply brilliant. Sit down first.
PPS My story above shows why our first question in Pathfinder is “What is it like to be a patient? The data we capture make that pretty clear, and it helps to focus on purpose, good preparation for the next step of eliminating the rework.
I’ve no doubt Jeremy Hunt meant well by what he called his birthday present to the NHS, a new NHS app. But as W Edwards Deming said, “Best efforts are not enough, you have to know what to do.”
“I want this innovation to mark the death-knell of the 8am scramble for GP appointments that infuriates so many patients.” says Hunt.
He’s right that innovation is needed, right that there’s an 8am scramble and right that patients are infuriated. One phoned me this morning, absolutely fizzing about her practice, but not one of ours and there was nothing I could do. She told me she could book online, but there were never any GP appointments soon enough so she physically went this morning and still no joy.
The gap is in understanding the problem: it’s the system. It’s not lack of online access, standard for some years. Bad news, it’s the system, meaning the operating system of the practice. Good news, it’s the system, meaning it can be changed. By whom? The GPs who run the practice.
Even better news, it isn’t a matter of resources. The BMA is right that Hunt’s NHS app won’t create any more appointments, but their knee-jerk reach for the begging bowl so lacks imagination.
I won’t bore you with how we are helping practices to achieve 30 – 40% efficiency gains, and help patients within minutes, because you’ll tell me it’s too good to be true.
But I’ll share with you a brand new chart which astonished me this week, and it goes to the heart of Hunt’s problem definition. A month ago we started asking every patient when they send in from askmyGP how they would like the GP to respond, whether email, phone or face to face. This is from 12 practices who have done Transform, online varies from 15% to 80% of demand, average 35%.
Even though around 30% of patients need a face to face, only 15% are asking for one. GPs are having to persuade some patients to come in.
It seems obvious after all: patients don’t want an appointment, they want help with their medical problem from someone they trust.
But if you make it a thing to book appointments online, then that’s what they will do, and take 10 minutes of GP time, even though neither party wanted it.
The BBC listened, thank you, and we have been saying this to NHS England for a long time, but they aren’t listening. Can you help?
PS #GarethSouthgateWould not mention that 6 out of 9 England goals have been scored by a Harry, so neither would I.
PPS All the above practices started with Pathfinder – Could you be ready to change? It’s normally quiet in summer but we are surprisingly busy and it is actually the best, quietest time so do get in touch today.
In this third instalment on Babylon/GP at Hand the cards are on the table, and you’ll see why.
I’ve looked at what they are getting right, patients’ desire for speed and convenience (don’t blame the patient, think of the last time you were one). I’ve looked at their AI claims, partial, unproven but fundamentally a disease based rather than demand led model.
Now the nub of it: GP at Hand is disrupting traditional practice with a city wide (London only for now) service attracting young, fit, male and mobile adult patients – your most profitable demographic. The exclusions effectively mean
- it’s not whole person
- it’s not whole life
- it’s not whole family
- it’s not whole community
Even a normal healthy female would go through four changes of GP to use this service during her lifetime.
Infant – no. Young adult – yes. Mother – no. Older adult – yes. Elderly – no. “All the world’s a stage…” but only bits of it are covered by NHS Babylon. (Kudos to them for getting Malcolm Grant onto their stage on Wednesday night btw. What was he thinking?)
Let me be absolutely clear where we stand: for high quality general practice covering the whole person, life, family and community. Sounds rather like the RCGP, indeed the NHS. It has to be local to do that (and unit size is irrelevant, except to patient satisfaction which goes up as size goes down).
But to compete against the likes of GP at Hand, and to be profitable in ever more squeezed circumstances, you have to work much more efficiently. Not lilttle 3% tweaks, but 30% leaps. That is exactly what we do.
That kind of efficiency gain (Dr Sue Arnott, single hander, has 4,600 patients) is changing the economics.
The normal experience of askmyGP patients is to send a request online, get a response within minutes and for the 30% or so who need to be seen, it’s today. The record posted last week was a feverish child seen within 12 minutes of sending. GP at Hand can’t touch that.
Safety must be paramount, and two features of the system design are crucial. Firstly it enables you to be responsive, easier to contact by phone as well as online, and we know the average practice should expect a couple of emergency presentations each week. I would never have made this claim, but Dave Triska tweeted on Wednesday, “so far I can count 3 lives saved in 4 weeks by this method.”
Secondly, it enables and encourages continuity by allowing patient choice of GP, and giving GPs total flexibility within the day to provide. Here is today’s BMJ paper, better continuity reduces mortality.
Increasing numbers of practices are asking us where to start, without leaping into the unknown (really not unknown, the once familiar delight of being a doctor) and that’s what we do wtih Pathfinder – Could you be ready to change?
It’s the kind of change which is necessary to stay the same. Don’t give in. Don’t see decline as inevitable. Don’t expect bungs or contract changes to bail you out – not this five year plan.
Use the power you already have over your own destiny.
PS Please don’t believe me. Believe the GPs doing it, and if you haven’t yet, hear the amazing interview with Dr Dave Triska.
PPS This tweet from Dr Lis Flett moved me: “One of the two patients who wanted a face to face appointment this morning (that’s right, 2) sat with me for half an hour. Many problems solved, patient felt listened to: Medicine the way it should be.”
PPPS Just had an email from Babylon “Babylon’s AI is on par with doctors”. You. Could. Not. Make. This. Up.
With all the debate going on it seemed right to tackle the question of AI and in particular Babylon’s grand reveal yesterday.
The stage show was to accompany the latest marketing, not peer-reviewed and published, but designed to look like a scientific paper. The point is that they have trained a computer to pass an exam, for MRCGP.
Exams are necessary but not sufficient to be a GP, as I’m sure they would agree with RCGP, but what have they really achieved with 100 made up vignettes and patients played by GPs? Others will answer much better than me on the safety of the process (follow this brilliant thread by @DrMurphy).
I’ve done my own trial of the AI chatbot based on two diseases I’ve personally had in recent months.
“Toenails brown and broken” I start. “Please rephrase…”
“Brown and broken toenails”, and so on. Absolutely no idea from Babylon, who end up asking, “Do you have any other symptoms?”
So I move on to my next trial:
“Wrist pain”. At least they recognise this, and there follows over four minutes a series of 39 questions, of which only 3 seem to me to be relevant, and the diagnosis comes out as:
“8/10 broken bone in the lower arm. Go to A&E”. I answered everything honestly. What I really had was tenusynovitis, tendonitis of the wrist, and I guess rather more common than a broken arm.
The way we do this with askmyGP is to let the patient type in on the very first screen whatever they want, then search for self-care advice. Try it yourself on
Try anything, medical, colloquial, badly spelled, phrases, anything. It’s not perfect but for example my trials above got me in two clicks to fungal nail infection, and the other to wrist pain where tendonitis was one possibility.
I could dress this up as AI and call it the answer to everything, but really it’s just our own algorithm to search NHS Choices better than its own search. It works, and crucially it’s very fast, much faster than having to register wtih all the details and answer 39 questions one after the other. Remember that most patients’ first concern is speed and convenience and this search costs nothing.
We had a clever history taking algorithm in our version 1 software, and very good it was too, but not good enough. Patients got bored and GPs got fed up with too much irrelevant information.
The much simpler interface, respectful of patients’ ability to express themselves, has proven hugely more popular and that has enabled us to move over half the demand online with practices that really understand the benefits.
You have no doubt heard of Elon Musk, technology billionaire and founder of SpaceX and Tesla motors. On that company’s calamitous production problems, flowing from their overambitious automation, he said last month, “My mistake. Humans are underrated.”
You probably haven’t heard of Dr Ellen Stofan, former NASA chief scientist, who said last year they are sending a human to Mars because they’ll get more information, sooner and cheaper than by sending a robot.
I’m an engineer, as keen as anyone on the benefits of technology for humankind, but to get benefits we have to understand how computers can help, not pretend with smoke and mirrors. They are good at searches, communications and analytics, simple and repetitive tasks. For the tricky stuff, we need HI, human intelligence.
Who knows what they might do in some unknown future, but we have a problem right now in general practice, and it’s not a lack of intelligence.
There’s a fundamental difference between Babylon’s start point and ours. They work from DISEASE and have put together an algorithm to try to convert Q&A into diagnoses.
We work from DEMAND and very simply get it to the right clinician to triage in seconds and decide how to care.
That is only the start and tomorrow I’ll discuss our Systems Thinking approach to intervention, in which we’ll see that technology is but a small part.
Time will tell which gives the greatest benefit. but for a taster of how much can change in only a couple of weeks just listen to this interview with Dr Dave Triska .
PS If you’re on Twitter, click to follow Dave @dave_dlt for some moving reports of the change they have undergone.
PPS Did you hear about the latest AC – Artificial Caring?
You might be surprised to see the title, and unless you’ve been on a different planet recently you can’t have failed to notice the PR. Babylon/GP at Hand (their NHS service) are brilliant at finding the limelight.
The chief reason is: they offer something that people want, speed and convenience in getting medical help. Who knew?
The sites are very nicely designed, and if you think that’s easy, you haven’t tried. At present they are nicer than ours (watch this space) and looking attractive is important – people buy on emotion even if we kid ourselves that we’re logical.
People of all ages expect to do everything online, and with younger people a huge majority expect it to be on mobile. The experience must be seamless and beautiful.
A colleague of mine told how a complete stranger struck up a conversation while shopping last week. He told in amazement how he got help within an hour from GP at Hand.
But how? The business model is fantastic too. Low cost of service, with low estates overheads as so much is done remotely, and low usage from a largely fit, young, male demographic. As you all know they’ve been able to exclude children, the frail, elderly, chronically ill and women in danger of pregnancy – most of the people who need a GP.
NHS England pretty much told them to, incredible as it seems, undermining the shared risk model of local general practice. Malcolm Grant speaking today doesn’t seem to understand what this is doing to existing practices who are left with the rest. Anyway, the theme has been so well rehearsed elsewhere I won’t say more, but the reaction from GPs led by the BMA has been as pathetic as it has been predictable.
“Foul!” “Placards!” “Marches!”. Anyone would think the whole lot of them were a cartel bent on nobbling the competition with their newfangled ideas. But we know better. GPs are a fine upstanding profession who embrace innovation to improve their service to patients.
And that vote at the ARM to put a cap on daily contacts? The perfect gift for Babylon/GP at Hand, who will pick up more of those patients they have turned away. Only the profitable ones mind.
Next time I’ll look at what you can do to reverse the slide, and it won’t involve marching on Richmond House.
This was launch week at Witley and Milford Surgeries, serving 11,200 patients in Surrey. Dr Dave Triska is their change leader and it seemed best to record it in his own words. All I’ve done is copy everything he put in the public domain, on Twitter @dave_dlt:
He starts on Weds 6th June:
Currently in the middle of the best working week of my career with @askmygp
Third day with @askmygp . Every single person who wanted to see me did. Had lunch, tea breaks. Saw colleagues. More relaxed seeing patients. Held fort alone for PM, no dramas.
Day 4 with @askmygp . Demand easing off now, clear slots throughout the day. No one turned away
Day 5 of @askmygp. Demand dealt with (its Friday!) by 0920. Oldest user 91.
@askmygp day 5. Quickest response 30s today, having mid morning catch up with my team. Patients happy, staff happy. No wait.
Day 5 @askmygp . Patient seen and sorted for painful condition within 30 mins contacting surgery. “I didn’t believe it could be true, I’m converted”
Day 5 @askmygp . Lunch eaten. Catching up with patients I need to, because I have time.
End of 1st week with @askmygp. Busy but manageable, all patients helped. New way of working to get used to but thrilled practice team and thrilled patients
Usually it gets better so things are looking pretty good so far!
We keep talking about a (very short) journey of change, and immediate benefits, so it’s very encouraging to us when people tell their own story like this – though there are bound to be bumps too.
Funny how GPs are always asking us whether they can visit somewhere or speak to someone and we do our best but… there are limits.
So I’m doubly delighted that Dave has agreed to join us for the webinar next Thursday 14th June at 1pm.
I’ve scratched the previous agenda on (boring but important) return on investment and we’ll hear about how it feels on the front line at the head of the peloton.
Sorry to mix metaphors but I’m trying to combine former Army medic and mad cyclist references!
Anyway, it will be real, immediate, warts and all. Lots of folk have told us they get most value hearing direct from GPs.
Click below to book now:
Webinar Thursday 14/6 1pm: Witley and Milford Launch – as it happens, with Dr Dave Triska.
PS Now much more detail on a 45 minute webinar recording
Want to get started now? Pathfinder: Could you be ready to change?Practices in the north west, Wales and London have started the process this week.
Last week’s webinar, Dr Chris Thompson pres to Leics CCG
This time yesterday I was in Plaistow, East London and while Cockney rhyming slang is spoken in these parts, you are as likely to hear any of a dozen East European or South Asian languages on the street. It’s quite deprived and extraodinarily diverse.
I was visiting Balaam St Surgery. As anyone knows in general practice, it is pandemonium first thing in the morning when the phones go over. So here’s what Nihul on reception told me:
“We only had three phone calls between 8 and 9 this morning”
That dog and bone just lay there.
Practice manager Divya came out to ask what was not going on. This is week 7 and the numbers have subsided as they keep giving out the same message:
“Do you have an email address?” – yes
“Do you have a smartphone or internet?” – yes
“Can I tell you about a shortcut to get help from the GP?” – yes
Then they show them the practice website, click askmyGP and take it from there. 80% of demand is now online.
Barry Sullman the GP was working from home that day for family reasons, had all 25 askmyGPs directed to him via VPN and messaged or called them from the home office, bringing some in to see the GP on site.
He tells me Monday – Tuesday are hard work, Weds was fine, he looks forward to Thursday – Friday. This has never happened before. He’s saving money, doesn’t need locums any more, takes the kids to school.
While Pulse moans on about GPs turning patients away, Barry is recruiting patients. He keeps telling me “It’s digital triage. There isn’t the strain of telephone triage. This is the future of the NHS.”
The thing I find difficult is that when I report what they are telling me in their own words, people say it’s too good to be true therefore it isn’t true.
That’s really sad, because while GPs are sitting there moaning and disbelieving, their most profitable patients are turning to GP at Hand to get a service far worse than what Barry and his team are providing from their own local surgery.
Spend 5 minutes in reception when it opens tomorrow morning and see what you could say goodbye to.
Looking out on the rain, memories quickly fade of, for once, that glorious bank holiday weekend.
In GP land you may have noticed a lighter week too, because demand is predictably sensitive to weather – whether warm sunshine or heavy snow.
We need to qualify the effect however, because if your system is book ahead and wait, lower demand only shows up as a smaller backlog and maybe less pressure on reception. You will still see the same number of patients who have patiently waited whatever the urgency of their need, and it will feel like a treadmill.
The point of a demand-flow system is that there’s always plenty of capacity for the predicted demand, and if it comes in below prediction, you can enjoy the sunshine. A colleague of mine visited one practice we work with on Thursday lunchtime and there were just no patients, time for chat.
Now with summer on the way it is of course the perfect time to put that demand-flow system in place but let me tell you about a real problem we are struggling with.
I can name three practices right now where they are very clear on the challenges they face, they can’t cope with the workload, they know the service is terrible, and their receptionists are getting abuse every single day.
They’ve done a thorough analysis, all the surveys, know exactly what to do, and four GP partners can hardly wait to get going. But one, or perhaps two, partners have dug their heels in.
I’m a great fan of the partner model for a host of reasons, and I haven’t seen a better one, but it has its drawbacks. One partner can veto any change. They are condemning the others to live with the same or worsening situation. Why isn’t there a veto on doing nothing?
Fundamentally I think this imbalance in favour of inaction is holding GPs back, perhaps the whole profession, even if a majority can see what needs to be done.
Are you in this situation or do you have any suggestions?
Meanwhile two north east practices launch on Monday and let’s hope they enjoy the summer.
PS: One who did act was Dr Sue Arnott and she joins us for this Thursday’s webinar at 1pm.
Some background on how she came to be running a 4,700 practice as a single hander here.
Many have asked for the first in the series recorded, so it’s here, 45 minutes, “Exploding the myths of online consultations”