With those lines from the terraces of Murrayfield ringing in our English ears, it’s a night to celebrate north of the border. And there’s more to celebrate for a handful of Scotland’s GPs.
Why are patients flocking to register at Newarthill Medical Practice in North Lanarkshire?
Very simple, the access is brilliant. Where neighbouring practices are making patients wait three weeks, Dr Ashish Vijayan can sort them out the same day.
You know what I’m going to say next, but there’s a surprise to come. Yes, he launched askmyGP as a whole system just three months ago and loves it, along with his patients evidently.
The secret is to have time for the patients who need it, just the right time for the right patients.
If you’ve followed this blog for long you’ll know that’s only about one in three, while the others still need help, but it can by remotely and much faster by phone, and now faster yet by secure message.
When Ashish first got in touch in the autumn he was swamped, not knowing what to do with his high demand population, many quite deprived in the ex-mining and steel area. (you might have seen that North Lanarks is the only place in Britain to offer free school meals at weekends).
But they’ve really gone for it, with a fantastic reception team helping patients to go online, and if they can’t putting them on the system too for the doctor.
They are doing 170 online requests every week, the vast majority of all their demand. It’s the most unlikely place to be leading the digital revulution in general practice.
While this week’s BMA News is a cover to cover Moanathon, Ashish is positively bursting with optimism.
The surprise: he’s a single hander, and from 2,900 patients in December, he’s gained nearly 200 since then.
So that’s 50% more than the average fte GP list. Think about the national shortage of GPs, then think again.
I guess that like me a lot of your time is spent grinding through one (damn) thing after another. In the short days and long nights it can seem like more grind than ever.
So when plans struggled over for years suddenly work it’s a very special day. It feels like the sun coming out on the brilliant white of fresh snow.
Dr AV, a single hander GP in Scotland with 2,900 patients emails me: “Best Friday I have had in 2 years!😊”
The reason? He’s in control, he’s reached 50% of demand online, the rest by phone, and he and the team are dealing with everything as it comes in. In the middle of December he writes “We have free slots – many in fact – on any given day !😀”
Sorry I don’t even know how to write emojis but I think that means a cheesy grin.
Actually, he’s not the only one, Dr SA has done the same, and she has even more patients. I’m using initials because they don’t necessarily want you all to ring them up at once.
What was it that suddenly made the difference? Last week I promised to tell you if it continued. Well it’s so ridiculously simple that I’m almost embarrassed to say.
We’ve had this idea on one of our powerpoint slides for months, but never really pushed it because no one had tried it so we didn’t know it would work.
The receptionists guide the patient to the practice website and get them to try askmyGP. They are even more effective than the GP giving a telephone message. They love it – they feel empowered too, and when the requests come in they are better equipped to deal with them – many are answered by secure email.
The GPs love it because every single one is saving minutes, and when you’ve 3,000 patients to manage, and preparing for Christmas too, that counts for a lot.
One terribly important point I must make: there is no forcing patients online. You may hear of other case studies where the telephone option has effectiively been removed.. We refuse to condone such an approach – in fact, telephone service improves.
Look, the vast majority of things that we try, fail. You don’t hear about them, and we try a lot, and some of the failures are painfully costly. So when something works, we might as well 😀 about it.
Anyway, you can see what the receptionists and GPs are directing patients to do on Bramley Demo Surgery.
askmyGP & GP Access Ltd
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PS You might even say the struggle goes back to 1981 when the electronics lecturer is trying to explain to thicko engineering undergraduate why asynchronous communication is so much more efficient. He wins.
How is your Monday going? If you’re a GP, I already know the answer, it’s busy, because 28% of the week’s demand arrives on Monday, and 3/4 of that in the morning. It’s not news.
News last week was that GP numbers have fallen by 1,300 over the last two years. A bit of a problem when at the half way point to Jeremy Hunt’s election pledge of 5,000 more GPs, we’d have expected growth of 2,500.
We need happier GPs.
The Dutch have happier GPs. Listen to Jako Burgers tell the RCGP conference why (20 minutes or so). Students compete for their GP training places, they recognise it as a top choice.
There are differences in funding and so on, but a lot about the system is similar to ours and they are paid about the same. Practices are smaller, there’s no obsession with scale, and they love the independence.
Let me float this idea for the UK: GP opening hours are too long. For many years now more women have been joining GP, but 8am is too early to be family friendly, and a 6.30 finish is too late. While we’re there, why shouldn’t fathers be at breakfast with their school age kids? Of course they should.
6.30 finish? “You’d be lucky” I hear partners say. Yes, many GPs are working very long days, I’ve heard 12 – 14 hours. Then taking days off. Working with hundreds of practices we almost never come across a full time GP.
I’m not proposing to cut GP working hours, though we should cut pointless overwork. But to spread them out evenly. Operationally it’s much better to work a regular five days, reasonable, family friendly hours, offering better continuity to patients.
I’m not proposing to cut access to GPs, but improve it (clue’s in the name). The difference in pushing back opening from 8 to 9 is an hour – compare with the three week wait forced on many patients. (by the way, the Austrian health department is trying to get GPs to open in the afternoon). Extending hours to 8pm and opening weekends for routines is catastrophic – sucking GP capacity into low demand periods, destroying continuity and burning money.
Understanding demand and flow means help for patients within the hour is not just normal, it’s easy. Minor problems we have with the Transform programme are firstly, we know that GPs starting work at the same time as reception is crucial for daily flow, and 8 is too early for many. Secondly, part time working causes uneven capacity through the week.
While our policy makers focus on inputs, number of GPs, number of hours, we need to look the other way. How do we make GP more professionally rewarding and practically possible?
Jako Burgers: “Happy GPs will do a better job than unhappy GPs.”
It’s not rocket science is it?
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.
A quick note with exciting news, we’ve just had our poster published at the Society of Academic Primary Care SAPC Annual Scientific Meeting in Warwick.
askmyGP has now passed over 50,000 patient episodes, 4,000 of them on the all new platform launched just two months ago.
The case study with Concord Medical Centre, Bristol, is here:
What took demand to 30% online? In a nutshell, it’s:
– Personal (“Hello, I’m Dr Bradley…)
– Universal (all patients, all problems)
– Responsive (we’ll get back within the hour)
– Simple (“Easy to use” main theme of feedback)
We took the decision in version 2 to take OUT the clever technology we’d put in v1.
It’s much simpler, with the aim of putting patients in faster, easier, touch with their GP, and vice versa. It builds trust by allowing patients to express exactly what they mean.
The result? Positive feedback has shot up, both from patients and GPs.
Dr Simon Bradley comments:
“The thought that goes into putting something into writing often helps the patient to have reflected on their problem prior to initiating a request.
Then for the clinician to have reflected on the request and reviewed relevant elements of the record means we can be more aligned with the patient’s agenda.
Online communication is asynchronous which allows both patient and practice to use their time more effectively.”
Aha. Time. The only absolutely finite resource.
Time for recreation too – enjoy the weekend.
Download pdf: What makes patients use online consultations?
This week’s blog was written by a patient to his local paper, and I loved it so much I’ve copied it here in full:
My local doctor’s surgery, Audley Mills in Rayleigh, has changed its appointment system.
When you call for an appointment you will be called back by a doctor. The doctor will then either deal with your query over the phone or ask you to come in to the surgery.
I used the system today, and I must say that it worked for me. I was asked to come in, and got to see a doctor within minutes. The waiting room was almost empty, and the consultation did not feel rushed at all.
I expect the majority of queries can be dealt with quite adequately over the phone, and doing so allows for quicker and less rushed appointments for patients who really need a face-to-face meeting with a doctor.
I was very impressed.
Simon Bishop, Rayleigh
What I most love about his letter, sent the day after Audley Mills launch on June 12th, was this phrase “the consultation did not feel rushed at all” It recalled the fourth principle of consultations from John Launer’s article last week – unhurried.
Like you, I’m suspicious of anecdotes unless they illustrate a body of evidence. But here’s the survey data from Audley Mills week one: they called 46 patients at random, of whom 39 said the new system was better, 5 same and 2 worse. A staggering 85% say better, and only 21 of the 46 had seen the doctor.
I spoke yesterday to lead GP Dr Luke Whiting who said Monday had been very busy but demand had tailed off over the week and now they had free slots, unused. It’s so predictable. We allow 15% for random variation in our plans, so it’s not uncommon to have free time.
Luke: “We’ve been tearing our hair out for years. Now suddenly the place feels relaxed, the building is so quiet, we’re on top of the work.”
So what made the difference at Audley Mills? Why could they do this when others all around are still tearing their hair out? Are they larger, smaller, younger, older, more urban, more rural, whatever, than the rest?
No, just one thing: they made a decision.
PS The data shows no change in average face to face consultation time before and after launch. But the range increases as GPs have more flexibility to give the appropriate time to each patient.
PPS I’ve been speaking at NHS England and CCG events in the last month. There is no doubt about the appetite for change. What’s needed is evidence, method and frankly, a sense of urgency.
“A year ago in February 2016 we took the plunge and embarked on GP Access. The time between making that decision and going live was barely 4 weeks, but in that time Harry and his team analysed our data, gave us information about staffing levels, leaflets and publicity for our patients and training for staff.
Since then we haven’t really looked back. It is fair to say that some of our patients have taken longer than others to get used to the system, but now mostly they all understand how it works and comply. We do still get the occasional walk-ins, but manage these effectively. Our DNA rate has also dropped dramatically.
We have developed our own way of using the system, which is unique to us – but that is the beauty of the concept.
From the point of view of our patients, in particular those who ring in the first couple of hours of the working day, by mid-morning most will have spoken to the Doctor of their choice and be coming to the Surgery either to have a face to face consultation with a doctor, nurse or to have investigations carried out prior to a GP appt… Or at the other end of the day, those phoning after 4pm have been called back and seen by 6pm if that is what is needed!
We often get remarks about the lack of patients lingering in our Waiting Room and it was interesting that when the CQC came to inspect us only a couple of months after we had embarked on the new way of working, they were most disappointed not to find anyone who had waited ‘hours’ in the Waiting Room to interview opportunistically. I think it came as quite a shock to them!”
Michèle Hole, Senior Receptionist, Millbrook Surgery, Castle Cary, Somerset.
See what a Millbrook patient wrote in the local paper in June 2016.
Play the top 70 charts as fast as you like – there’s a picture surprise at the end.
Greenway Practice in Belfast launched a demand led system on 26 April 2016, initially with GP telephone response, adding the askmyGP online channel in July. We look at the operational effects and quote GPs, staff and patients before and after the change.
Presented for RCGP Annual Conference, Harrogate, 6-7/10/16, but not as an official poster – the abstract submission date was months before the events took place.
All quotes are verbatim, either written or verbal. My favourite is from Dr Andrew Courtney, “My stress has gone from one hundred to zero”.
GPs, staff and patients from four practices in Northern Ireland explain how they have transformed their working lives through adopting a demand led system.
“Patients were angry because they were waiting so long.” turns to “They’re loving it now” – receptionist.
“From being very skeptical… I’m very positive” Donna Casey, manager
“Our big concern was that demand would increase… It’s been a revelation” Dr Tom Black. “The GPs are more relaxed… we have improved our continuity of care.”
They can now respond to patients within minutes, from demand either by telephone or askmyGP online, offer a choice of GP and see those needing a face to face consultation on the same day. They tell their own story.
The Northern Ireland Department of Health have committed to further rollout of askmyGP in their plan, Health and Wellbeing 2026: Delivering Together page 25.