Like many of you I’ve joined in the clap for key workers on Thursday evenings, and very well deserved it is too.  There’s little doubt in the public mind that the NHS has performed better in the pandemic than the government overall.

But working in the health sector we have every reason to feel not just pride but relief, as we are in relatively secure jobs while we see others all around lose their livelihoods in everything from hairdressing to aerospace.

This week another survey comes out from the BMA, GPs bemoaning their lot for one reason or another.  In the eleven years I’ve been working with GPs, something like this appears almost weekly, predicting the end of the profession as we know it.  Yet the GPs we work with are more secure than ever, loving the job and have never been better off.

Adding to the conundrum is disturbing data on numbers.  As reported in GP Online, GP ftes are down 712 in the year to March 2020, and GP partners down 1,023.  Yet in the same issue, GP locums bemoan the sudden loss of work in the pandemic, 81% seeing a drop in income.

I’m sure that, like me, you have many friends and relations in the medical profession and I’m sure that considered overall you wouldn’t disagree with what one observed to me, “We’ve never worked less hard since we left medical school.”

It’s amplified by leaders saying “We’re not going back to the working life we faced before the pandemic”.

I can’t wait to be rid of the restrictions on all our lives, but there’s little doubt that general practice will not return to the working format pre-covid.  RCGP reported that face to face had dropped to 25% of consults, which seems high to me as our practices dropped from 30% to 2%.  It has now crept back to 5%, while total demand is nudging up towards pre-covid levels.

Having discovered the efficiency of telephone triage overnight, partners will not offer face to face to everyone again, rehire all the locums and take the hit on their profits.  We’ve been saying this for ten years, a few pioneers have said so for twenty years.  Our latest askmyGP data, live here, shows 37% of requests are now resolved by message alone, no need even to telephone and much more time saved, while patient feedback is up too.

Practice after practice is discovering the same, but they all seem to go through a ritual of catastrophisation before they launch.  At one this week the GPs were very adamant that Friday would be the busiest day, and I said they would remain very adamant until Friday.  It came in with less than half even my predicted volume.

Another due to launch next week did the staff survey, and the biggest fear of the partners was higher workload.  The biggest fear of all the other staff was losing their jobs because of lower workload.  It’s a GP thing, and it goes with the territory.

With the huge extra resources now going into Primary Care Networks, I foresee very good times ahead for GP partners.  If you’re a locum or salaried, apply as soon as you see a good opportunity.  If that translates into better patient service, better quality and continuity of care, and more fulfilled professional lives, we all win.

So I’m very optimistic, but honestly, I’m bored with lockdown.  I haven’t quite reached the point of sorting out my sock drawer, but I’m close, and that’s serious.  Okay okay, “There’s never been a better time to sort out my sock drawer.”

Harry Longman

With the passing tomorrow of the deadline to sign up to the Primary Care Network DES a Rubicon will have been crossed for PCNs.  The rehearsals are over, real money and commitments are at stake.  But I want to know, how will they work?

A funding model is in place, a set of PCN duties and payments is agreed, no doubt controversially for some but that’s how it is.  A list of professions is now 100% funded by the delightfully named Additional Roles Reimbursement Scheme.

But still I ask, how will they work?

Everything we do in the NHS needs to relate to its purpose which, however it is worded, amounts to helping patients overcome or manage their various medical needs and diseases.

The additional roles must be to help patients, who have needs.  Which patients, what needs, when, with what measurable outcomes?

Forgive me if I’ve missed something, but the debates on funding, roles, governance and so on seem to be very far removed from these practical questions.

Consider the patient journey: present to GP practice, GP considers they would benefit from referral to a PCN employed clinician, say a pharmacist.  How easily do they refer them?  How soon can the patient be seen?  How does the pharmacist manage demand from multiple practices?  What is the right capacity for each kind of role?

A PCN I spoke to had a pharmacist one day per week in each of the five member practices.  Neat, being five, but others will have 3, 4 or 7, and all different sizes.  One may be mostly students, another elderly and with very different needs.  What if our patient gets referred on Tuesday, just missing the pharmacist who calls at her practice on Mondays?  And work or family commitments mean Monday never suits her?

Managing the workflow, demand and capacity for shared roles could be orders of magnitude more difficult than the same within practices.

I would love to know your thoughts on how, or ideas from your PCN.  Yes, we are going to try and make it easier so you can make the most of the new resources, do let us know what you would like and watch this space.

Harry Longman

PS Last week’s blog looked at return on investment in askmyGP.  David Evans replied to me that following their £35k investment in year one, they were saving £100k pa in locum costs.  Not bad, indeed typical.  Sujit Vasanth commented online “I can honestly say the change to askmyGP has been the most important (and positive) change in our practice in the last 10 years.”  Thank you!

A number asked about spreading payments and I’m pleased to announce that we have responded with just that, it’s on the bottom of our Transform Express and it is now standard.

Today I want to talk about a problem for us and for GP partners.  We’ve always supported the GP partnership model as the most effective (while not the only) way to deliver high quality primary care, locally and with long term relational continuity.

Forgive me if you’re not a GP partner, no need to read on, but if you are I hope we can share some of your thinking as we are a small business with a turnover similar to a medium sized partnership.  We value our independence and we want to help you use yours.

Throughout England GPs are able to access one of several suppliers free which enable them to comply with the edict to offer online and video consultations.  We chose not to participate in this tender, as the allocation is random by CCG, no evidence of outcomes was required to participate and therefore it is impossible for GP partners to make an informed choice of supplier.

Not only are we competing with free, bluntly our service is around three times the price of others over 3 years.  It’s a job to explain to people that it’s very different from bolt-on technology, as askmyGP enables system change like no other.  We are not competing with point solutions.

This means that in addition to helping you comply with regulations, we need to sell on the concepts of “value for money” and “return on investment”.  It has to be worth it for GPs making decisions as owners, those with skin in the game (I loved the wonderfully provocative book of that title by NN Taleb).

In the whole UK just four CCGs and one Welsh health board are fully funding askmyGP for all their practices, and they are flying, but let us face facts:  the rest of you are going to have to pay directly.  Which puts you in exactly the same position as thousands of other businesses, including ours, where investment is a decision you make to save time and money, improve your life and increase profits.

Now here is the good news:  our customers are our greatest fans, and we are very grateful to them for their public support.  Some recently set up a facebook group (I’ve applied to join).  They are all over Twitter – last week @simondevial wrote “We’ve been using it for 8 weeks. In 28 years no other change delivered “what it says on the tin” like this.”

I was talking to Barry Sullman on Friday.  He’s happier than ever after 2 years. “Using askmyGP has given my practice extra resilience, allowing us to easily cope with clinical staff shortages due to Covid, and sustain a high level of care dealing with every clinical patient the same day” He goes on to add “Last year was our best QOF year because of askmyGP. We were able to identify long term condition patients at the triage state and bring them in for care of their long term condition as well as the problem being triaged. As a result last year I reached virtually all my QOF targets before New Year’s Day!”

We hear lots like this.  As a result we’re seeing the highest ever rate of enquiries from GPs, many of them unhappy with the free software imposed by their CCG with no consultation and no evidence.

However, many get stuck at the point where they need to pay, and when they are used to having everything for free, it seems odd.  Yet the same people wouldn’t think twice about buying a holiday (a cost) or replacing the car (a wasting asset).

Last week my bank wrote to tell me the interest on my savings account is 0.01%.  Compared with keeping £1000 under the mattress for a  whole year, that’s just 10p extra, and they are threatening to charge us for looking after it soon.

I’m happy to report that increasingly partnerships are realising the very high rates of return they will make with askmyGP and deciding to invest, based on evidence, putting themselves in control of their destiny.  Our practices managed 98,050 requests last week, 96% of them remotely, 69% of them received from patients online.

It’s not only the savings on locums (you will have noticed that locums are struggling to find work at present), so many echo @catiebagel’s tweet “Hope we can continue to deliver remote assessment and treatment where possible & if clinically appropriate. Often more convenient for patients and less travel has co-benefits for the environment. Agree, am so glad we had @askmygp in place before COVID hit. #greenergp”

You may have enquired with us a day, a week or a year ago.  If you’re not convinced of the evidence, crawl all over our website, study our live data, ask your friends who are customers and look for independent views.  If you don’t understand it yet, spend an hour on the webinar “How, but first Why, askmyGP works”.

If you’ve seen and heard enough, and you don’t want to waste a year on something free but with tiny usage and no savings, then now is the time to act for three simple reasons:

• the barriers to change have disappeared
• current workload is lower than ever
• money has never been cheaper

So many practices have got this far and then decided to hang on for taxpayer funding.  They are still hanging on, six months, a year, two years later.  Don’t be another disappointed hanger-on, be another delighted user, within a week.  We’ve now launched close to 3% of UK practices – that’s enough to start a revolution.

Kind regards

Harry Longman

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