You cannot have failed to notice Babylon’s GP at hand service all over the media this week. As a PR exercise, on the Today programme, You and Yours, TV, front page of the Times and an almost unheard of positive story in the Daily Wail, it was SIMPLY BRILLIANT.
What you may not have appreciated is the existential threat this makes to regular NHS GPs. While presenting it as “the NHS has suggested that the service may however be less appropriate for…” the list of exclusions is in fact the engine of profit for Babylon. Read the list. It’s 90% of a normal GP workload. It begins with women (twice the consult rate of men in middle years), who are or may be pregnant (more work. And babies – lots of work). All the usual suspects, the elderly, sick, frail, confused and multi-morbid are there. They are work. Babylon doesn’t want them.
Babylon has got something spot on: patients are fed up with the often abysmal service from their current GP.
They want the young, fit and healthy, especially men, who rarely need a GP but when they do, want help fast, and don’t want to bother with going to a surgery unless they have to.
All these patients carry the same capitation. Think: what if you lost half your income and the easy half of your population? But kept 90% of the work? If it isn’t obvious yet, GPs will go under. That may not be you, but your neighbouring practice, whose list will be dispersed… to you… and you know those dispersed will be high demand. Nice.
They are in London so far, but Babylon’s ambition is limitless and I fear a multiplier effect from the mechanism above. They have the law (practice boundaries abolished), the funding model, the technology, the demographics and clearly the PR on their side. No doubt BMA is dreaming up legal challenges as I write, but they are no match for weasel words backed by £60m of VC money, while changing the law takes years, at best.
If it were simply about better GP services, I would be cheering. But the inevitable consequence is to stoke the Inverse Care Law. Those who most need help will find it most difficult to obtain. General practice will be dramatically less profitable in the hardest areas, and will suffer even in the most privileged. This undermines nothing less than the core principles of the NHS, universal, accessible and free at the point of use.
I will end on a note of hope, because this is not hopeless if we act fast. I founded GP Access & askmyGP with the vision “to transform access to medical care” and some might say Babylon have achieved that.
But our vision is universal. We have no exclusions. We understand the quality and safety from relationship continuity, to say nothing of the professional joy in work.
Although Babylon’s offer is getting the PR, it’s actually not that great. 2 hours for a video? So slow. 48 hours to be seen? So long. Travel within zones 1 – 3? So far to go.
You can beat it. Faster, easier, closer, with the GP you know.
As @stevekellGP tweeted yesterday, “All patients contacting the surgery today for GP help have spoken to GP & been seen if needed. No DNAs, clean start tomorrow. No videos needed” – most of them spoken to within half an hour.
If you haven’t seen his 2 minute interview you really must.
Our vision is of a transformed general practice that you own and you run for the care of all your patients. It is not a transformation done over you by the power of money.
I’ve been saying this for six years. Now wake up GPs, before it’s too late.
“We’ll get the information a lot sooner and for a lot less money by just sending a person.” I was dumbfounded. Dr Ellen Stofan, outgoing Chief Scientist of NASA, was talking to Jim Al-Khalili on the Life Scientific about no less a task than finding life on Mars.
It’s a fascinating interview from the start, or jump to the quote at 19 minutes in. So that’s why they want to send a person, not for the ultimate ego trip, but the simple purpose of finding life. Jim pushes her on the reason, doubtless at a cost which is telephone numbers cubed, and it’s simple: humans are creative, flexible and mobile.
All they have to do is break open rocks and look for fossilised microbes. With NASA’s vast resources and access to the world’s best brains, their secret weapon isn’t AI and robotics, but human intelligence.
I’m an engineer and a technophile. I read Wired online and I have three bicycles, one of them all carbon. But I’m ever so wary of the claims made for AI chatbots revolutionising healthcare any minute now.
At Best Practice show last week half a dozen companies were offering some clever algorithm to make your patients go away. They are so seductive, even plausible. But when I ask, “How many patients have actually used them?” I get stonewalled.
Substantial wedges of venture capital say “It must work”. Rather different from asking, “What works?”
What humans are good at:
- searching huge databases in milliseconds
- communicating instantly and securely
- organising and analysing information
What computers are good at:
- solving tricky problems through experience
- building relationships of trust
- caring for people in need
Our philosophy with askmyGP is very clear: we get the computers to do the boring easy bits they do so well, so the humans can get on with the real hard work of looking after patients.
We’re proud to call it HI and we’re on the same track as NASA.
PS Did I get that the wrong way round? Doh! Must get a new proof reader.
Launch day at a practice is something I always look forward to, yet not without a twinge of nervousness – things can go wrong and a difficult day dents enthusiasm which takes time to recover.
Special circumstances at Larwood in Worksop, Bassetlaw were that they had a two week average wait to overcome, and at 32,500 patients were the largest single practice we’d worked with. Their patients were also used to a walk-in service which was abolished with 1 week’s notice, on the same day (simple message, this is the one system now, it has to work).
Well the phone system fails to go over at 8.30 as it always has… 25 patients turn up unaware of the change… but it would have been 100. A small team from management is in the waiting room guiding patients, being helpful and kind, explaining the system.
The start feels a bit chaotic, with queries from GPs trying out their view of online demand for the first time. But work is being done, and by lunchtime we have the first patient surveys – 81% say the new system is better (27/33) and smiles are breaking out.
I hand over the blog to Dr Steve Kell, because he can communicate and all I can do is watch with humbled awe as the week unfolds in tweets.
Steve Kell @SteveKellGP
Quite a day. Changed practice systems today, introduced @askmygp and all patients who contacted the practice dealt with today. Great team.
Hi. AskmyGP – online and telephone access, huge change but great feedback from staff and patients.
Massive change management task but all patients dealt with yesterday, blank screen again today. Fingers crossed.
2 days into full system change to @askmygp:
Really impressed. Different feel to day
Job satisfaction and service ⬆️
Wait – gone
Day 4 of @askmygp – all patients seen so far if needed. Skin problem for 2 years, seen within 20 minutes of submitting message online. ?
Week 1 of @askmygp. Exceeded all expectations. Job satisfaction, responsive and one of the best weeks I’ve had as a GP in 18 years.
Have been doing @askmygp 1 week and never had better access AND better continuity. All my patients can speak to me and see me if needed.
The last word is from an anonymous patient, one of 417 who got help online with askmyGP, about 20% of demand in week 1 at Larwood. It surprised me:
“I like this service as it is more personal between me and the doctor . Also it gives the doctor more chance to look at records so they know what has been done in the past . This means I don’t have to wait time trying to explain.”
Relief. The humans are in control, not the computers.
If GP workload is your prime concern I’ve got great news: you can cut it by 10% without fail in just four weeks. Simply take 3 appointment slots off your daily template. Boom.
You can even claim some high-minded motive, reducing GP burnout, decision fatigue, keeping away the worried well, timewasters and so on. Your receptionists will have to turn away a few more patients, but they are used to that.
Don’t worry, you’ll be no worse than some other local practice and the CQC won’t notice – they have no way of measuring what you’ve done.
The only folk who will suffer are some of your patients, the unlucky ones, but they don’t have a voice anyway.
If so please unsubscribe, we can’t help you.
There are plenty of others who promise to reduce your demand, divert your patients, make them wait longer, travel further, see someone they don’t want to see at a time they don’t want to go. Much of this is taxpayer funded. Links on request – they just don’t have any evidence that it works.
Want something better for your patients?
Before we begin any change programme we ask the partners a few questions, one of the most revealing of which concerns their ambition for patient service.
Very few admit to “Never mind, it’s all about the money”. A few say “No worse than others locally”, “A bit better than we are” or even “Top quartile performers”. The vast majority go for “The best we possibly can be.”
We can work with them, because they have the inner fire to carry them through what could be tough in the early weeks, as you get used to dealing with true demand.
You will be much more efficient from day one. Typically you will deal with 60% of demand remotely and we measure this (though below 50% the efficiency change is marginal, many are soon even higher. The latest hit 65% in month one.)
Don Berwick, mindful of the need to provide excellent care with finite resources, says “Efficiency is a moral imperative.” It’s far more important to study efficiency than workload, because you can do something about it, now, without waitiing for handouts from someone else, or worse taking it out on patients.
But what about the workload? It’s related but a different question. A big factor is the amount of unmet need pre-launch. We measure this too, with the average at 14%.
The highest we’ve ever seen is 32%, and before that practice launched last week I warned that it was going to be tough. Talk about inner fire – Sue the GP principal told me on Thursday at 5pm that something wasn’t right, she had free appointments right now and time to do other things.
We can’t make absolute promises on workload because of the variables, though GPs continually tell us that they feel more in control.
Our laser focus is on efficiency, never a final answer, always improving, sometimes in leaps like the one from telephone triage to digitial triage, sometimes in tweaks like the half day session plan (ask me how it works, very neat).
Our promise is to help you become as efficient as possible, so you can give the best possible patient service.
Dr Chris Peterson of The Elms, Liverpool, 5 years on:
“It’s more efficient, but it exposes unmet demand.
It’s completely liberating!
We are delivering demand lead care, not capacity constrained. We have no one waiting to see us.”
Can you say that every night when you go home?
With the publication in this week’s BMJ of the Tele-First study into the telephone first model of general practice, you would expect me to read carefully and respond. So here are the headlines:
- 65% of patients report being phoned by a GP in less than one hour.
- 56% of patients find it more convenient vs 22% less convenient
- Large improvement in length of time to be seen, 20% move in GPPES survey.
At a time when we are told repeatedly that patients are having to wait ever longer to see a GP, often measured in weeks, these are quite astonishing figures, all quoted direct from the report. But, dear reader, these are not the headlines you have seen in Pulse or the BMJ Editorial are they? Studies, and the interpretation of studies, are political. We have an interest, and so does everyone else.
Therefore the first thing I want you to do is read the full text so you can make your own mind up independent of headline writers. It is much more detailed than the print version, framed by an angry looking GP model and a scared looking patient model, giving more space to a commentary piece than the actual study.
There is much to absorb but for brevity I’ll comment on the summary section.
What is already known on this topic
- GPs are struggling with the current demands on general practice and looking for effective ways to manage patient demand
- Claims have been made, reproduced in NHS England literature, that a telephone first approach, in which all patients wanting to see a GP are asked to speak to a GP on the phone first, results in major cost savings for primary care and reductions in secondary care costs
We do not make those claims, they were made on the home page of PPC Doctor First, a 20% drop in A&E and £30,000 saving per GP per annum. I’m grateful to the authors for proving these false. *
What this study adds
- In general practice, many problems can be dealt with by a GP on the phone
- The new telephone first approach resulted in more phone calls, fewer face to face consultations, and, on average, more time spent consulting
- There was wide variation between individual practices, including large increases and large decreases in workload after adoption of the telephone first approach
- There was no evidence that the telephone first approach would reduce costs of secondary care
In a way it is disappointing to see no secondary care effect, but not unexpected and unless the evidence changes, that is what we accept.
But what has really got GPs aerated is this finding of “more time spent consulting”. This was derived from data sent by us to the study, which we have not used to make a calculation on workload for several reasons: much of it is missing (and as the authors state, had to be imputed), it shows wide variation, and it cannot account for total workload. Let’s consider:
Workload = demand/efficiency + non-clinical work + waste
We do not have a reliable way to measure the total, and given that the study used only one of our three datasets, I don’t see how they can make this assessment. Just one example: many practices have told us of the drop in home visits, each one saving the time for many surgery consultations. This is not measured. It may be a good thing to have more recorded time consulting, if less time is wasted. Not only does this finding seem to me unsafe, it also brings us back to the question of purpose, for the study and indeed for the NHS.
If the purpose is to minimise GP workload, we can do so very simply: design the working day so you see 4 or 5 patients in the morning, take a good lunch and a nap, then spend a little time in personal reflection and development before heading home., purpose achieved.
I’ve worked with a lot of very hard working GPs and they would not be satisfied with that purpose. No, the purpose of general practice and therefore the purpose of change must be to improve patient care.
There’s a missing term in the workload formula, and that is “unmet need”. Behind those words lies untold suffering and frustration of patients, heard perhaps by a receptionist (one wrote last week, “I dread having to tell the patients there’s nothing left”) while others do not even get through on the phone. This is the dirty secret of general practice, and over many years we’ve measured it in practices we’ve helped, variable around an average of 14%.
One in seven patients is told to go away. Although we offered this data to the study team, they didn’t want it and took no account of it.
Their figures cannot distinguish between the workload of one GP helping 30 patients in a day, who had all waited two weeks, and another helping 40 patients in a day, on the same day they called. It could be life changing for those 10 patients, indeed all 40 of them for not having to suffer two weeks of disease, pain, or anxiety.
Both GPs may have equal skill and compassion, but the difference comes from efficiency.
By framing the question on workload rather than efficiency, the study misses a huge opportunity. It offers no help on how to become more efficient, and while it found wide variation in performance, the data were munged into averages rather than investigating in detail why the best ones worked better.
I’ll tell you a secret: we’re in this for the patients. To help the patients we have to help the GPs be more efficient. There is never a final answer to the method, there is only “the best we know for now, while we look for the still better way”.
We’ve helped around a million patients so far, with another 50,000 to be added in the next month. and as telephone triage (done well) is more efficient than pre-booked face to face, digital triage is already proving to be the next step. Sometimes we fail, but we press on.
Every day over 100,000 patients are told by practice receptionists “Nothing left, call another day”. Not on any basis of clinical need, just because the GPs have no slots.
It’s my personal mission to eliminate that phrase. What’s yours?
* The 20% A&E effect came from my 2011 study, based on pioneer practices with up to 10 years running the model, and promising at the time. The figure was copied by Dr First but never attributed. We could not show that the effect was reproducible, and therefore stopped making any specific claim about A&E 3 years ago. £30,000 saving? We make no such claims, although if GPs tell us about savings we are happy to report them. Why did NHS England swallow this?
Hypothesis: efficient operation of primary care depends on clinical triage of all demand, to optimise the use of scarce consulting resource – GP time.
The faster and simpler the system, the more patients will co-operate.
Who does what, when and how?
Patient “I need help…” Make it easy to provide enough detail for triage. Online, anytime.
Reception ”I’ll assign you to a clinician, unless I can help you myself” (within minutes, verify patient, choose clinician)
GP “I’ll work out how to help, usually phone, may see you, send a message, or refer” (take seconds, within minutes, from online entry)
Consult & complete – precisely appropriate for the patient and episode.
Presented at EFPC European Forum for Primary Care, Annual Conference Porto 24-26 September 2017
Download the poster here:
Known since before Tudor times, named Gresham’s law in 1860, thoughtful observers have realised that “Bad money drives out good”. When two forms of currency are in circulation, the debased version quickly replaces that of true value. It’s happening now, paid for by the NHS, in general practice.
Oxford CCG proudly trumpets the big numbers, “15,000 extra GP appointments in £4m scheme.” Divide £4m by 15,000 x 12 months and we find the cost per appointment is £67. That’s over twice the fully absorbed average cost of a regular GP appointment.
It gets worse: regular GPs are funded by capitation, not by activity (per appointment) and their contract means they are already responsible for their registered patients who are or believe themselves to be ill. The CCG is paying £6 per patient for a service already fully funded – it’s paying twice. But not the CCG – it comes from an NHS England pot, descended from a GP Access fund which covered less than 10% of England – a lottery as to whether your area is included.
It gets worse: a GP federation officer says it’s for those patients having to wait 2 to 3 weeks to see their own GP. These GPs are failing their patients with an appalling service. They are being rewarded for failure, incentivised to fail more as worse access will move more of their patients into the “extended service hubs”. Patients at GPs offering an excellent service, such as Oak Tree Didcot which we helped over 5 years ago, have no need and no desire to travel further to see a doctor they don’t know.
It gets worse: my Didcot GP friend tells me “it is virtually impossible to find GP locums or recruit GPs because many are now working in these hubs seeing relatively straight forward problems, with 15 minute appointments, whether the patient needs 15 minutes or not.” [and we know that utilisation of slots is low, many will be left empty]
All right thinking people can see this. So why is it happening? Control of the money lies with those who don’t want to see: NHS England, who knows why, Oxford CCG who think they have a “nice” headline, and the GP federation owners so happy to take up the offer of highly profitable light duties. £4m will get soaked up in a year with no difficulty at all, and when the money stops, so will the service. This is the very antithesis of sustainable continuous improvement.
What can you do? Fight this debasing of general practice with every bone in your body. The RCGP, BMA and all in leadership positions should be calling this out. Local GP Dr Helen Salisbury says, “It might be better if we could just fund GPs properly,’ Too right. NHS funding must go to where it is of highest quality, most effective and productive, core general practice.
I don’t like to end without hope, because we need hope, and Gregory Bateson’s analogue is worth noting: “the oversimplified ideas will always displace the sophisticated, and the vulgar and hateful will always displace the beautiful. And yet the beautiful persists.”
Fight for the beautiful.
PS last week’s launch in Surrey has gone well, GPs dealing with all demand on the day, patients amazed. A couple of examples stood out for me on day one: the lady who walked straight to the desk at 8:35 expecting a queue of 10 and a rammed waiting room: nobody. Look of total bewilderment – “are you open?” And the patient late in the afternoon who, on the way out, stopped at reception to thank the whole team for the wonderful service she’d had. Gets me out of bed every morning.
I do hope you are thoroughly refreshed and have enjoyed the break from my blog. I mean your work. Oh, whatever, I’ll stop digging.
But I wonder how you view the thought of a 10 hour working day? Horror or relief? It’s relative isn’t it, because to some that would be 2.5 hours over the regulation 7.5, to others it might bring sanity at last to a regime which has been 12 or even 14 hours. People aren’t made for that and whatever you earn, it can make life not worth living.
So I was struck when a GP partner recently said she had this burning ambition for a 10 hour day, when completing our Could you be ready to change? (we do this with everyone thinking about system change. Nothing matters more than having a burning ambition).
Reducing GP workload has been number one topic in Pulse, BMA, RCGP and goodness knows where else, and the bad news is that we can’t wave a magic wand to reduce it. There are lots of factors. One is patient demand, which is remarkably constant, whatever we do. It isn’t going up, though revisiting a Liverpool practice we first helped five years ago is encouraging – demand is down 10%.
But what we can do, and to some this does seem like a miracle, is dramatically improve efficiency. It’s intense, and getting it right means careful analysis of consultation times, modes, referral and resolve rates, but it does work. Unmet demand is a factor, and simply meeting this can soak up a proportion of time freed up by a 20% efficiency gain, but almost always there’s plenty left over for getting the hours down.
Efficiency is our absolute laser focus – how you convert that to your benefit is up to you.
Overwhelmingly GPs tell us “I feel more in control”, as another partner did last month having launched in June, and it’s the control that makes work satisfying, even though it can be intense.
We love what we do and those kind of comments get me out of bed every morning. It will be an early start Monday to be at our first autumn launch in Surrey – I can hardly wait.
Are you enjoying the Proms? I’ve only been a couple of times but I love the wealth of music on offer, some familiar, some challenging.
David Sawer’s “The Greatest Happiness Principle” and the Proms Extra talk got me thinking last Saturday. We put “Happier GPs” on our askmyGP home page, because it’s a direct quote from GPs. But what might that mean? A non-stop cheesy grin, I think not.
The evidence is that we don’t consciously think of ourselves in a state of happiness (the strong conscious emotions are the negatives), but we are living in the moment. Contributors include:
- doing something good for others
- flow, being totally absorbed at the limit of our capability
- control of our own time and efforts
It isn’t the same as an “easy life”, pleasures with which we may relax but too much of which don’t give us meaning. So we aren’t saying to GPs, put your feet up, but reflecting the kind of things they say. Last week I was in a practice where one partner reflected “I feel so much safer now” (they are dealing with all demand same day, where it had been only 40%).
In another, the manager said last Thursday they had all finished by 4pm so they went home except for the one on duty, who dealt with five calls before 6.30. That’s not every day, but most GPs would have a clinic full of patients booked three weeks ago who may or may not turn up. In contrast, knowing you are providing a fabulous service and can have that flexibility is enormously liberating.
You don’t need me to tell you that the narrative in the medical press is so different, and BMJ front page last week has BURNOUT in big capitals. But the editorial is right on the mark: “Solutions have traditionally focused on individuals and their resilience.” whereas, they continue, “A systems level approach is imperative…”
We couldn’t agree more. It’s the system.
PS this makes me a little bit happy, the first askmyGP feedback at 8 this morning, “I really like this new service and I cannot say enough how much easier this is to access medical treatment. The surgery is fantastic.” This theme is so often repeated that it’s getting boring. The meaning for me comes in asking, “How can we multiply it by ten thousand?”
When I was five I used to love asking my farmer uncle how he counted his sheep. “Count the legs and divide by four” he was sure to reply, and I was sure to giggle. Thanks Ray, for the laughter and learning you sparked.
Measurement, a kind of counting with maths, is a huge part of what we do and we are always trying to make it simpler and clearer.
The simplest, most important measure in general practice is demand – by month, week, day, hour.
Then comes the service response – how fast, how soon? That’s what matters most to patients. Why isn’t anyone else doing this?
Then comes efficiency – how long does it take to deal with all those demands? That’s what matters to GPs and staff – they want a reasonable working day, and without harming patients improving efficiency is the surest way.
All these are operational measures we derive on an industrial scale with minimal effort and immediate visibility.
So It grieves me to see hundreds of £k spent on fiddly little “improvements” which make no attempt to measure benefit for patients. They trumpet thousands of hours saved – which turn out to be approximately 17 minutes per GP per week.
It grieves me to see the vast expense on poor substitutes for measures, postal surveys with small samples and smaller response rates, reported months later. Counting legs.
It grieves me to see the BMA making threats to close GP lists, unable or unwilling to frame questions of capacity in terms of efficiency.
When you make a step change in efficiency, lots more becomes possible in ways we can’t measure with numbers.
Read in Pulse how Dr Steve Edgar describes “Taking back control”, using terms like autonomy, mastery and purpose, with time for the simple team huddle.
If you’re heading to the hills this week you’re sure to see a few sheep. Yan, tan, tethera…
PS Reminder of the poster study of online consultations at Concord Medical Centre. Another step on the efficiency road.