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.

Harry Longman

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.

Harry Longman

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.

Regards,

Harry Longman

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…

Regards,

Harry Longman

PS Reminder of the poster study of online consultations at Concord Medical Centre. Another step on the efficiency road.

Summer may be a-coming in, we will see beaches and I promised to take a look at that pattern of patient tidal flow.

GP demand is like a rolling wave.  Or quite like a skijump, or one side of a volcano, but let’s stay with the wave for the purposes of surfing.

We’ve analysed hundreds of practices and when you allow patients call any time in working hours the pattern is strikingly similar across the board.  The calls start high when you open at 8, stay there for a short time and from 9 fall rapidly through the morning.  They flatten out through the middle of the day and early afternoon, then tail off from around four down to very little by 6.

Aha.  So how to respond?

• Tidal deniers:  “We hold our partnership meetings at 8.30 on a Monday morning.  Works well for us as everyone is in, perfect start to the week”.  If only they spent five minutes in reception.
• Tidal self harmers:  “Sorry, what do you expect, it’s already 8.17 and there’s nothing left.  Call back tomorrow but make it early I should to be sure of an appointment”  Funny how every day is the same.
• Dudes:  we’re ready, on it as the demand comes in, phone or online first response, deal with it now, decide to see some later when incoming is quieter.  Stay on the wave, take a break, mentally prepare for face to faces, back for next session.  It’s a full on day, but we feel in control.

Someone accused me on Twitter this week of common sense and I strenuously deny all charges, but really, is it that hard?  So why do patients wait an average of 5 days to get help from their GP?  And why do GPs end the day shredded?

One practice we’re working with has hit a median response time by a GP to any patient demand of 17 minutes.  Within five weeks of launch.  17 minutes.  Surfin’

Harry Longman

askmyGP & GP Access Ltd

PS Delighted to see that Matthew Swindells, new Director of Operations at NHS England, is starting to call out NHS111 for the monstrous waste that it is.  Sad to say that it’s taken a change of personnel to admit the truth, while those four years have seen hundreds of £m wasted, never mind the frustrations for patients, GPs and staff.  So will he actually do the necessary?