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

How did you feel about the incoming prime minister’s pledge in his very first speech outside Downing St?

“My job is to make sure you don’t have to wait three weeks to see your GP”

Every PM I can remember from Blair to now Johnson has said as much, and what have they done?

– the 48 hour target

– the contract giveaway of 2004

– the Prime Minister’s Challenge Fund

– the Vanguards

– training 5,000 extra GPs

– the GP Forward View

– recruiting 2,000 foreign GPs

– the online consultation fund

I’ve probably missed a few, do fill in the gaps.

Every PM has watched waiting times increase and continuity of care fall.  I’m picturing the ships they launched now a line of rotting hulks…

Nothing wrong with the ambition, what’s missing is method.  METHOD, how, based on evidence, are they going to do it?

Practices we help measure their patient service in minutes not weeks, and with a choice of named GP, and in fewer GP hours.  They’ve got there quickly and at low cost.

On Wednesday I met another practice in Lincolnshire for their Pathfinder diagnostic, they decided to go ahead on the spot and in three weeks time, they will prove it all over again.

We have found over the years that it’s best to ignore the fads, fashions (and indeed the funding streams), and pursue relentlessly what works.

Our approach doesn’t win friends in high places, so I’m not going to sit by the phone.  Perhaps some of our happy GPs would get in touch with the PM, give him one less thing to worry about.

Harry Longman

Read this NHS Digital press release and shudder:  “NHS 111 online hits one million triages mark”

You will be very familiar with the quality output from NHS111 sent to GPs from the standard version, where a human reads a list of questions from a computer to a patient, and based on their answers tells the patient what the computer tells them to do.  Data shows the disposition is 8% to ambulance with a further 7% advised to attend A&E.

That process has now been fully automated into NHS 111 Online, and the number advised to attend A&E has reached 24.7%.  Yes, almost one in four patients seeking help “when it’s not an emergency” is told that after all it is an emergency.

Over many years we’ve run audits, n>200k, where GPs labelled just 0.4% or 1 in 250 consultations as emergency.  So we can estimate the proportion of false positives in the NHS 111 online dispositions at around 98.4%.

As you would expect, I have tested the system myself, in the interests of science.  During a break in the weather we managed a cycle club run this morning and after 53 miles I am shot to pieces, so I tried “aching legs”.  Answering just 6 questions, all truthfully and all negatively, except that the aching was all over, sure enough I got the result in big red letters:  “Phone 999 now for an ambulance”

Folks, if you read the press release they are actually proud of this.  I put the figures to Simon Stevens at a Reform meeting last week.  Earlier he had spoken of the benefits of machine learning in assessing images, an application which makes sense as computers are good at comparing similar things and looking for differences.  When it came to 111 he assured the room that results would improve when the algorithms had more cases from which to learn.  They’ve had a million, how many do they want?

247,000 innocent patients have been advised by this abominable software to call an ambulance or attend A&E.  Tariffs vary but if we take an average of £200 (ambulances much more) that’s around £50m, almost all of it overtreatment.  We are told that ambulances and hospitals are under pressure and want to reduce demand… is anyone in Skipton House paying attention?

Suppose these million patients had been diverted to a qualified human to assess their needs and respond appropriately, that £50m could have been invested in front-line services so beloved of politicians.

My only hope is that most patients had the good sense to ignore the advice.  But what have we come to when the NHS is spending money to make people afraid?

We get asked to bid for contracts with CCGs to provide online consultations through the intriguingly named “Dynamic Purchasing System”.  Most of the specifications require an algorithm to triage patients automatically to an appropriate disposition.  We explain why we won’t do that because it would be both wasteful and dangerous.  We don’t win any DPS contracts.

It doesn’t have to be like this.  Public money could be spent on evidence based interventions.  Ploughing our own evidence based furrow can be lonely but we’re going to keep on doing what works.  As far as we know at 20,000 per week we’re already the largest provider of online consultations, mostly from practices self-funding because they make such a difference to their workload and profitability.  They absolutely love it.

Cheer up, believe that better is possible, right now, and smile with the staff at Witley and Milford practice.

Harry Longman

PS  Barry Sullman showed me the numbers from his CCG this week, Balaam St winter A&E attendances fell by 24% in his first year with askmyGP.  That’s the power of human intelligence.

It seems pretty clear that the main plank of government policy towards patients is:  let them book their GP appointments online.

The new contract says that 25% must be available online, and they are investing £6.3m in the NHS App with appointment booking the headline feature.

Yet we all know that anything which requires compulsion or bribery is probably a BAD IDEA.  The badder it is, the bigger the bung.  Good ideas have a life of their own and no government can stop them.

Online appointment booking has been a contractual item for years, and yet while everything travel, banking or retail is online, only about 4% of GP appointments have gone that way.  The technology is there already – it’s the GPs who don’t want to release appointments for self booking.

They know that without reception as the intermediary, many will be taken by patients who don’t need them, reducing equity of access for those in greater need.  They are even paying receptionists from their own profits to suffer all the stress of turning patients away, rather than put everything online and leave the phone off the hook.

Yet we know that when they trust the practice to give them the help they need, patients don’t even want appointments.  We ask them how they would like to be contacted and were astonished to find the average at only 25% by face to face, some down at 11%, GPs begging them to come in.

“Super service thank you for implementing it. Much easier than an appointment” wrote a lady in Somerset today.

So we turn to the Pilot Evaluation of the NHS App.  Credit for publishing this for comment within 3 months, but let’s look at the detail:

• 34 practices, given lots of on site support and training over 3 months to 21/12/18
• 3,192 patients used it
• 337 appointments booked, and 106 cancelled.

Now I’m “just saying”, as they say, but in the same period and with only 28 practices we had 100,000 patient submissions on askmyGP.  No appointments were booked directly, but they all got help and about 30,000 had a face to face.

We’re coming up to eight years old as a company and I’ve found it necessary many times to do the opposite of the zeitgeist.  There’s never any guidance on being counterintuitive and it’s very costly, but what keeps me going is that it works.

I was at a Leicester practice this week for their training and the enthusiasm they have is infectious.  Next week a couple more launch in Sheffield and Glasgow.  They are all paying for themselves, taking control of their own workload.  It’s becoming unstoppable.

Two quick things to do now so as to see the difference:

1.  Do the patient demo and get how easy it is, without being able to book an appointment at Bramley Demo Surgery.

2.  See how easy it is to respond by signing up to the GP Demo, triage 50 real patient requests.

Summer is coming, don’t spend evenings in the practice.

Harry Longman

New financial year, new contract – the rush to put QOF to bed is replaced by the rush to absorb the new implications of Primary Care Networks.

“Who do we want in our gang?”

Or is it, “Will anyone pick me?”

Anxieties from the school playground resurface.  I was never any good at ball sports.

Already there’s a deluge of advice from all kinds of bodies, leadership development offers, model contracts and so on.  Some of it is bound to be contradictory given the scale of change and I have to say a July start seems, er, courageous.  Then again delay to anticipated fundamental change seems to be in fashion, so we’ll see.

I have a different question:  how will PCNs work, from a patient’s perspective?  In simple terms, patient presents with a need, GP decides the need is best met with a shared network person or service.  How are they assigned, how long will they wait, who owns the case?

For the PCN, more questions arise.  How will they predict demand, by type and volume?  How will they manage capacity and measure performance?  How will they allocate resources fairly between members?

I would love to hear your views.  Please drop me an email with a few lines, or comment on the blog.  No promises, but we’ll try to help.

Harry Longman

PS  It has been a pleasure to work with our highly talented videographers this week, at a simply astonishing practice.  Very soon we’ll have the result, from prosperous Middle England.  It’s just so hard to cut several hours down to 3 minutes.

Meanwhile the same team has made a short, just over a minute, from the other end of the spectrum in multi-ethnic East London.  Before it goes out on social media your can sneak a look at Be More Barry.  Just lovely to brighten up your weekend.

NHS commentators specialise in gloom as I don’t need to remind you, and this week they have had plenty to moan about with the publication of the latest Nuffield/Kings Fund British Social Attitudes Survey.

Overall satisfaction with the NHS is down 3%, and for the fourth year running the principal reason cited, at 53%, is “It takes too long to get a GP or hospital appointment.”

As sad as it is predictable, the only response from all parties has been “Give us more, more money, time, resources, GPs”.  It’s not happening, GP numbers have shrunk this year.

Our latest practice launch this week was a middle of the road performer, with about 60% of demand “on the day” and a long spread thereafter leading to an average wait of 5 days.

In week one they dealt with almost all demand on the same day, achieving a median completion time (that’s completed, not just first response) of 49 minutes.  Patients have loved it, with 8 to 1 saying it’s better.  All done with no more resources – it’s only possible by saving time, managing 2/3 remotely.

I’ve had two contrasting conversations with practices this week.  One is in a prosperous market town, in a brand new multi £million health centre.  The GPs know they are making patients wait four weeks for a “routine” appointment, and they are quite happy with that, protected by their contract and local monopoly.

We can’t help them.

Imagine any normal company like us treating our customers like that – we’d be out of business in a minute. And that is why Babylon GP at Hand has a point, even if we don’t share their business model.

The other practice is in a decades old building, serving one of the poorest populations in their city, a minority having English as a first language, and dealing with huge problems of deprivation.  Yet they have an absolute passion to help their patients, already providing a superb same day personal service.  They just want to make their own working lives sustainable too.

We can help them.

Looking forward to more launches next week.  Glad to say that every one gets easier with new features, this week it’s the NHS Spine lookup for patients, improving accuracy and saving time on reception.

Regards

Harry Longman

PS GPs with that service ethos, don’t miss out any longer.  Start with our free online demo.

Dear colleague,

“Private providers could grab unlimited share of GP consultations online” runs the heading in GP Online.

“Babylon GP at Hand given green light to expand NHS services into Birmingham” – to the usual outcry from BMA.

“All patients to have the right to video and online consultations by April 2020”.  Have I got the right April?  Why is it always April?

Let’s look at what GP at Hand have actually done in their 18 months of operation.  At a cost of blanket advertising around the capital, they have recruited just 40,000 or one in 200 Londoners to their video-led service.  I hardly think this merits the cries of barbarians at the gates.

But as we know people are led by feelings much more than facts, and all the headlines are designed to scare you.
They want you to feel threatened, that your livelihood is at stake.
They want it to “feel like” extra work – because anything ordered by the government must be extra work.

They want you to “feel like” you are being bullied into change, you’ll have to be different, and you don’t want it to be different, you didn’t sign up for this, and what do they know about your real work?

It’s a shame because very few GPs have considered the possibility that with the right design, digital first could enable you to be a better GP, providing a better service for patients with less work.

A practice we’ve worked with for eight months now is Witley and Milford, and some of their GPs were discussing the outcomes on Twitter this week.  They are one of our fastest operators, with a median time to complete patient requests of 48 minutes (that’s all demand acute/routine whatever, and that’s completed, not just first response).  They are also one of our highest for continuity, with 94% of patients who made a choice being helped by their chosen clinician.

All they have done is understood demand and flow and organised themselves around those principles.  With over half their demand arriving online, they are a digital first practice, and it’s a joy to be a GP or a patient.

Many sage commentators tell us of the trade off that must inevitably be struck between Access and Continuity.  I tell them Witley and Milford.

Best regards,

Regards

Harry Longman