I’ve been reflecting recently on what we mean by personal care. NHS England’s Head of Digital writes of the NHS Long Term Plan this week:
”… sets out an exciting ambition for care that is more personalised and tailored around the needs of the individual, enabling people to have more autonomy over their health and wellbeing. It describes a future where people will be empowered to participate in their care using digital services that truly meet their needs, help them live better with long term conditions, target prevention and offer them a much more personalised experience.”
No doubt the intention is good but I’m concerned that what we design and build should be grounded in the everyday needs of patients, and I don’t hear them using that language.
We get over 500 patient feedbacks each week and one of the strongest themes is thanks to a doctor or nurse they name.
What we hear from patients if I could summarise in a sentence is: “I need help with my medical problem from someone I trust.”
For patients, personal care faces outwards, they are dealing with another person they know and trust.
“Personalised” seems to me inward facing, a digital experience where the technology is configured with my preferences and perhaps my medical history. It might be clever and it might have value, but I’m not hearing from patients that they want autonomy, especially those who are most in need of help.
“Personal” brings us back to that question of continuity of care. It’s well documented to have fallen in recent years, but we also know that this is not inevitable.
Some I think seem to view continuity as a kind of spiritual nirvana, or a lost golden age where the family doctor had all the time in the world for everyone who dropped in to see them.
Back on earth, right now, it’s a simple operational problem of “Can a patient needing help choose a named clinician?”
We’ve always made this possible with a validated list shown to patients, of all clinicians working today, and around 20 – 30% of patients make a choice. But we’ve just introduced three improvements to make it easier both for patients and practices, since ease of use is the biggest driver of any change.
- While the patient may only choose someone working today, they can now look a week ahead to see when their chosen GP is available (they always have capacity same day)
- With our One Click Assign feature, a GP if named is starred so unless there’s a reason not to, the assigner will, with one click, put that patient request in front of said GP.
- Any patient can have a “Usual GP” set, if the practice wishes, so even if the patient doesn’t choose, the assigner can see that GP tagged with an icon in the One Click Assign list.
The outcome is that we are hearing every day from GPs and patients who feel empowered.
There’s a growing conversation on Twitter (follow @askmygp) from all sides, do take a look.
Some years ago I heard former RCS President Clare Marx speak and I have often quoted her words, “We must make the digital, personal”. So true, and yet I wonder whether she has been heeded?
Perhaps to make this work we should look at it the other way round.
“We need to enable the personal with digital”
That’s the task for NHS England’s Head of Personal.
PS Data geeks, this is fascinating. We’ve just published a study showing the age-specific adoption of online consultations. Covering 10 practices in the period 1/1/19 to 8/2/19, n = 37,634 requests, it shows that for young adults 70% are now seeking help online rather than by telephone, and even up to 65 it’s over half. These are normal regular local digital first practices.
PPS 4 new practices and another 30,000 patients covered last week, with Weston-super-Mare reaching half way in its project for the whole town.
I’ve had a bit of time to absorb the new GP contract – there’s an excellent summary on GP Online if you don’t want to read it all. While some of the digital notes are a tad off key, I suspect they are a nod to our technophile SoS while the real action is elsewhere.
The centrepiece is Primary Care Networks, PCNs, and we are going to hear lots and lots more about them. Notice how the language has changed, as until quite recently it was all about “GP at scale”, a phrase absent from both BMA and NHS England texts.
Hats off to Richard Vautrey and team.
While the numbers “30 – 50,000” are the same, rather than large scale providers for which no convincing evidence was ever produced, networks of existing providers with no change of scale could make sense.
Steel mills need economies of scale, but GPs don’t, and diseconomies of scale soon show up with loss of continuity, local accessibility and lower patient satisfaction all well known.
But some AHP resources don’t really work at smaller practice level, and it’s clunky to employ for example a pharmacist for 7 hours a week and a physio for 12. At the network level they could work well, and indeed this could rebalance the funding model in favour of smaller practices as funds and resources will be based on list size.
The DES incentivises all practices join a network, and there will be a dash to join up with “people we like” at the local level. Expect a few funny shaped contiguous groups, some larger and some smaller than prescribed, but with a little pushing and shoving the money will ensure it happens.
The labels don’t all say this, but a very large proportion of the new money will effectively go into core funding, and will strengthen GMS partnerships as indeed the Watson review said they should be strengthened. This is a good thing for GP, for the NHS and the population as a whole.
The new and interesting questions arise over how the networks will operate. 22,000 new primary care staff is a lot to take on board, considering only how they are recruited, trained and managed.
Any shared resource raises the problem of “the freedom of the commons”. Currently, the design of A&E, urgent care centres, 111 and so on means they soak up demand from poorly performing GP practices. The reward for failure is for someone else to take your work.
How will the the new AHPs be shared fairly, so quality is rewarded as it should be? (by the way, fair is not the same as equal. Consider the student practice in the seaside town)
Practically, how will GPs make best use of them, appropriately referring the right patients at the right time? What is the patient view?
How will network performance be measured? How soon will patients get the right help? How will outcomes show we’re getting value for money?
No doubt we will return to these themes.
Cogitate as well as celebrate this weekend.
PS No network yet, but already there with 100% of patients offered online and video consultations, Dr Barry Sullman talks about Balaam St Surgery and astonishing return on investment.
He’s a traditional, local, digital-first practice. Fabulous.
Hurrah! NHS England and the BMA GPC have agreed a new contract covering the next five years.
Apparently there’s lots more money, funding for 22,000 addtional health workers in primary and community care, and everyone seems very happy with it. I couldn’t possibly digest the whole lot but will concentrate on what we know best.
This is going to increase GP workload and cut patient access.
How so? See the fine print in the IT and digital section.
1. NHS111 will have the right to book directly into 1 appointment slot per 3,000 patients (rounded down) per day.
Leave aside the technical issues, problems of policing the scheme and arguments over unused slots, late booking and so on, what would happen even if it did work perfectly?
In a traditional practice with more patient demand than available slots, they tend to be all booked up within minutes of reception opening. You know, we know, everybody knows.
So now what does the savvy patient do? Call NHS111. Go through all the palaver of identifying themselves, answering dozens of irrelevant yet scary questions, eventually landing with “I need to see the GP. And I have a right to one of those 2 appointments in my practice of 8,999 patients, today.”
Boom, they got it. But they got the second one and there is no way of telling the other 23 patients who were turned away by the practice, so all of them go through the NHS111 palaver again, but get the same message: all slots gone.
So we’ve wasted NHS and patients’ time, added a bunch of complexity, and increased GP capacity by precisely zero.
And by the way, what do GPs think of the ability of NHS111 to triage a patient and provide concise and relevant detail of the conversation? Do ask one.
2. Make 25% of appts bookable online?
It is now such a commonplace that we kind of assume everyone knows this: only about one third of patients seeking help from their GP need a face to face appointment.
Which means that if GP capacity is reserved for patients to decide for themselves to take a slot, two thirds will be wasted. So that’s 17% of GP capacity to be wasted by design. Maybe they will include telephone appointments, which would be less wasteful but still may not be appropriate.
Reserving any proportion for a single channel reduces equity of access: those with no online capability, often the most vulnerable and needy, are shut out of 25% of available capacity.
It could be so much better, simpler and cheaper.
Here’s what our practices are already doing:
1. When they are open, there is always capacity, so no need to call 111 to try for reserved slots. They won’t be used, but neither will the GPs waste the time, they’ll just crack on.
2. Make 100% of capacity available online – that’s normal, it’s what we do. But 100% of capacity is also available for patients who phone in – there is complete equity of access.
It’s the same capacity. But how it is used for each patient is up to the GP to decide, which they do in seconds through digital triage – they don’t even need to phone many patients.
It takes two to tango, and the tragic missed opportunity here is that both GPC and NHS are stuck in supply thinking: it’s all about pushing services at patients, wrapped up in complex funding rules.
Demand led thinking does exactly the reverse, understanding in great depth and detail the incoming demands and designing services around them. We’d get bucketloads of efficiency as well as astonishing performance if they did that. (Do call, best rates for hard up government departments)
Well, I always say that when they’ve tried everything else that doesn’t work, they’ll be back. Maybe before I’m dead.
Why take the risk, start now!
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PS We’ve been amazed by the views on our new video, Dr Barry Sullman talking about Balaam St Surgery.
He’s a traditional, local, digital-first practice. Fabulous.
Do you ever wonder about that phrase “local needs”?
It made me wonder whether say Facebook had ever been asked to do a local needs version.
It’s just that we are responding to tenders issued by different CCGs, which are remarkably different given that I thought patients had roughly the same range of diseases wherever they live.
Essential requirement A: “Is able to fully triage the patient and signpost to the most appropriate service with no GP intervention”
Essential requirement B: “The system should not perform an automated triage that gives a disposition”
Imagine a pharma procurement where A specifies that it shall raise the patient’s blood pressure, and B that it shall lower it.
There’s a national specification for online consultations and question of what the computer actually does with the patient request seems central to the whole scheme… you couldn’t make it up.
Whether it’s more surprising or saddening I don’t know, but there is now a subastantial body of evidence of what doesn’t work in online consultations, and it includes much of what is being specified:
– no safe & economic automated triage has been invented
– lengthy questionnaires lead to very low usage, under 1%
– there is no evidence of online channels reducing oveall demand.
Despite all this, specifications are full of wishful thinking which will simply result in more taxpayers’ money being flushed down the toilet.
But perhaps what’s less well known is the evidence of what does work.
We’re just about to release a new video case study which is an inspiration. Final checks are being done, and I’ll tell you all about it tomorrow.
PS the GP in question wrote to me yesterday “I am laughing and dancing” When you see the video you might assume we paid them for it. No, they pay us from their own partner income, just a regular customer.
Today I return to that long term plan and a piece of it which has so tickled the national consciousness that it made the News Quiz.
To touch quickly on “Skype consultations”. Skype for various reasons is problematic – it requires both parties to have a login, whereas our video solution works with a one time link. But headlines have been overblown. We now know that when offered the choice, only about 1 in 1000 patients are choosing video. It may grow a bit, but I don’t see it becoming a huge channel.
Let’s move on to the NHS App.
I will share a little of my medical history, and I hope you don’t find this too much information, but I get fungal nail infection.
So in the interests of science I wanted to test how the NHS App would help with my condition, using its 111 online algorithm, and my presenting symptoms of “brown and broken toenails”.
You can see the whole process in this 3 minute video which is how long it took.
It asked me 12 questions, of which 1 was possibly relevant, 10 irrelevant and 1 frankly embarrassing. The outcome was self care, but with absolutely no specific advice on what to do.
I have tried the same input with the Babylon AI chatbot, which couldn’t find anything relevant and asked whether I had any more symptoms (as if the waiter told me the fish option was off).
I have tried the same input with EMIS Patient.info. Its first option was “Fibre and Fibre Supplements” on which I clicked, and they tried to sell me a hearing aid.
I have tried the same input with NHS Choices, and the first option was sepsis, that well known affliction of toenails, though it did have Nail Problems as the fifth item, which does have relevant information on fungal nail.
I gather about 10% of the population has this, and whenever I mention “brown and broken toenails” to a doctor, the first thing they say to me, without even looking, is “fungal nail”.
If the might of government, of major corporations and £millions of venture capital can’t get toenails right, what hope have they when conditions are complicated and serious? I must leave the question with those qualified to assess them.
On Twitter Dr Dave Triska writes:
“I consulted with 3 people today with a near identical ‘cough’ presentation, recognised the ill one (whom I knew to be stoic and was concerned they had contacted me). Guess what? Sick. As. Algorithm would have missed that.
I just tried my sick patient will all big 3 symptoms checkers. All falsely reassured. From an algorithm point of view, they were right. Likely URTI. Except it wasn’t…
How would I program into an algorithm that the barn door URTI I did also bring down needed to be seen because I knew they’d lost someone to lung cancer and would be worried? That a visit and chat helped them in ways that aren’t measurable against outcomes?”
All falsely reassured.
No doubt you find that very concerning, but consider the specification on which we were invited to bid by a CCG yesterday:
Essential criterion: “Is able to fully triage the patient and signpost to the most appropriate service with no GP intervention using a solution where indemnity lies with the supplier and not the practice”
PS. We do offer self care help with askmyGP, but we don’t claim that it reduces demand or diverts patients. We aim to make it as fast and simple as possible. Please try it yourself, with “brown and broken toenails” or anything else. This is exactly what your patients would see.
Did we meet the aim?
So the NHS long term plan has landed and it’s a techie one. Should we be happy?
As a part-time nerd myself I can’t help but feel the enthusiasm with the word “digital” appearing no less than 14 times in this single page on primary and outpatient care.
“Over the next five years every patient in England will have a new right to choose this (digital first) option – usually from their own practice or, if they prefer, from one of the new digital GP providers.”
I’m going to describe it with three words you wouldn’t normally put together.
Encouraging – Matt Hancock has clearly recognised how far behind the NHS is in patient service, and how new technology can help. I agree on tech enabled, but tech driven is something else.
Dangerous – shifting the ground rules to move patients away from their own local NHS GP will do immeasurable damage to the long term continuity of care integral to the registered list system, and in so doing undermine the professional careers of GPs. Test this idea against Prof Chris Salisbury’s Mackenzie Lecture – the transcript now with illustrations is a must read.
Lackadaisical – with many patients forced to wait three weeks for an appointment, why make them wait five years for change? We’re turning regular NHS practices into digital first practices overnight (well, with four weeks preparation, then overnight). Digital first because all patients are welcome online, but not forced online, and we’re seeing over 60% from day one.
Day one feedback, today: “Seeing its a new introduction, I think its fantastic. The helpfulness, the speed, and the results. Thank you.” Gentleman, 71, Weston-super-Mare.
Come on Matt, keep up!
What a year it has been already. First NASA’s New Horizons discovers a snowman at the edge of the solar system, then Chang’e 4 lands in a crater on the far side of the moon.
What are your dreams for 2019?
I learned this week from the little museum in Grantham that Margaret Thatcher’s father inspired her with the idea that “if you can think it, you can do it” (Love her or loathe her, there’s no question that she changed Britain. Yes, it was a small grocer’s shop, away from the town centre and no indoor bathroom).
So our dream for 2019 is that as we bring about happier patients and happier GPs, we help the profession to be more of what it is meant to be.
What is general practice meant to be?
My discovery of the week was the RCGP James Mackenzie Lecture given on 20th December by Prof Chris Salisbury. What better title than “Designing healthcare for the people who need it.”?
Christmas and New Year are past, we’re getting the house straight again, and have more time to reflect. So I have a little work for you today:
In under 50 minutes you will need to think, you will be challenged, you will laugh, and yet you will know it makes sense. You will contrast the conceptual strength of GP with the failures of implementation.
You will hear the most comprehensive and cogent critique of recent policy I’ve come across. If you are an optimist, you will nonetheless come away with hope that while change is necessary, if we can think it, we can do it..
We’ve had an exciting start to the year with a practice launch on 2nd January in Lincolnshire (clue!), two more next week in Somerset and an accelerating programme through the winter.
I don’t know where we’ll be at the end of the year but I know it will be absolutely focussed on implementation. Thank you Chris for helping us understand what it’s for.
Have a bolder and happier New Year,
PS I’m ambivalent about Thatcher but she was right about a lot of things. A banner in the museum, “I want to turn us from a nation of “Wait until it’s given to you” to one of “Do it yourself””.
People of every political stripe can sign up to that. By the way, we’re looking for GPs with that attitude.
PPS The response has been huge already for our free Digital Triage Experience, and we have now enabled the first user in each practice to invite their colleagues. Compare notes on how you triaged each of the 50 cases and the time you saved.
The “Flaw of Averages” was I understand first observed when a trainee statistician drowned while fording a river which he calculated had an average depth of 2 feet.
You can tell he was American. A British trainee would have made the average depth 0.945m.
We are seeing 7,000 online consultations per week through askmyGP, from about 250,000 patients covered. At 2.8% of total list, that would be about a third of total demand on average, right?
You know I’m going to say “wrong” and the flaw explains very simply why.
It turns out the practices divide into three cohorts, which I’ll call the swimmers, runners and rollers.
The swimmers see under 5% of demand online. There may be a lot of splashing, but speed over the ground is quite low, benefits are hard to measure and an adverse current may even sweep them away. An askmyGP icon decorates their website, leaflets and posters are all over reception but for any patient using it, service is slow and frankly, the telephone seems a safer bet.
Runners are in the range 20 – 40% online, it’s a main mode of access with good service and generally high patient satisfaction. Benefits for the practice are significant and they can handle all patient demand on the day. But they are still running two systems, with mixed messages to patients. While they know online is more efficient, they may still limit access, so patients revert to telephone.
Rollers are putting 100% of demand through askmyGP, between 50 and 80% online from patients, the rest by telephone into reception. In this total flow mode, GP digital triage means they manage all their workflow with an efficiency simply impossible by any other means.
What does this mean for us?
We want to increase usage because, while we incur some volume related costs, it’s much more valuable to us when customers and patients get the most benefit from askmyGP, and that is after all our vision.
But while it might be tempting to persuade, cajole or incentivise practices to push up their average % usage by a few points, it would be a waste of everyone’s time.
Quite simply, we need to get them all rolling along in total flow mode. They’ll experience the benefits all for themselves with no pushing and shoving from us.
Here’s the thing: all our customers have exactly the same software, and the same advice. They are just making different choices, and seeing radically different outcomes as a result.
The great news is that all our new launches are rolling from day one. It works best that way.
Any triathletes will have spotted the analogy but there’s an added twist: transition between the modes seems to be remarkably difficult. People settle into a mode of operation and to shift seems just, well, a bit of an effort.
It’s not impossible, with Witley & Milford shifting three weeks ago and immediately doubling their speed of flow. After one week, someone briefly went back to the old system and was very quickly corrected!
So while new practices are all getting the max, how do we move the others?
PS What about the spectators? Very simply and with no commitment, you can be the GP managing the incoming total demand. It’s real, randomised and anonymised patient data, and when you have your login it will take about 15 minutes to rattle through 50.
Register for our free Digital Triage Experience.
Looking up Eric Berne’s classic “Games People Play” I was surprised to find it was published in 1964. He calls it “a way of predicting people’s behaviour.”
It would be pleasing to say we have learned more as time has passed. I doubt it would be true.
Without going into the great psychiatrist’s theories too far he was clear that destructive games caused a lot of pain not only to his patients but to all of us in our daily lives.
I was reminded of these ideas when joining in a Twitter conversation about DNAs (did not attends), a GP complaining that 4 out of 7 patients hadn’t turned up – blame the patients for wasting GP time, NHS resources and slots which someone in need could have taken.
It all makes sense, until you realise that these were Saturday morning “extended access hub” slots. We know that very few patients want weekend slots, and they don’t like to travel away from their own surgery or see someone they don’t know. They were sent there and then as their own practice gave them that option or nothing.
We know that the longer the gap between the booking and the date of the appointment, the higher the DNA rate. On the same day, DNAs all but vanish. Our practices don’t talk about them any more. If changing the system with the same patients eliminates the problem overnight, it follows that DNAs are a system problem, not a patient problem.
The blame game is very simple: “We tell you when and where you will be seen, by whom. We blame you for not turning up.”
We find the same things happening with all kinds of variation. The most common game for appointments is “Nothing left today, you’d better call tomorrow but make it early as they all go around 8 am”. A friend of mine had the whole family of six call the surgery at 8am to increase the chance of one of them getting through.
Another game is “We’re very busy so we allow booking up to six weeks in advance for routine matters”. The mother would take the slot, and would turn up herself or with whichever child or frail elderly relative was most in need on the day.
A new one on me recently was “If you phone in the morning a nurse will triage you. Phone after 12.30 and a GP will triage you for the next day”. In seven years this is the first ever practice I’ve met which has more “demand” in the afternoon.
Whenever we start work with a practice we ask them how the appointment system operates, and we look at their website. So often they summarise it in the two words, “It’s complicated.”
We’ve reached the point that we know from the rules what games patients will play. Then we get the data on demand patterns and it turns out exactly so.
It’s really “Games providers play”, and the cost they and their patients pay is rework. Everyone gets locked into the game, working like stink, deeply frustrated, achieving little.
I love what Eric Berne says in his field:
“Everybody has a hunger for intimacy, a game free zone where people are straight with each other.”
The alternative for practices is to rewrite the rules very simply:
“Let us know your problem, whenever you like. Tell us who you would like to help you, if not anyone, how you’d like us to contact you, and any issues with timing.
“We’ll work out very fast how to help you. No promises, but we’ll do our best to meet your preferences too.”
What happens is quite astonishing. Not only do patients almost always find their needs met, but because there’s so little rework, it’s less effort for providers.
This week from a Bristol patient: “So much easier as I have time to think what I want to say, and it frees up staff to do what they need to do.” We get dozens every week on the same theme.
Innovation is risky, and change is risky, so it should come as no surprise that we have failures. Perhaps we have more to learn from failure than success, which means we must reflect.
Since launching askmyGP v3 in August we’ve had three practices turn it off. I won’t name them, suffice to say they differ widely in size, demographic and location, but you all want to know why they gave up.
The common theme in what they told us was that they felt unable to cope with patient demand.
Yet patient demand was very close to predicted, within 10%, as it has been with the great majority of successful practices.
We do point out that unmet need is uncovered when limits are removed, which may appear to be a rise in demand in the early weeks. A small number of patients will abuse the new system, as they did the old one, but we’ve found from our Datalog audit that in the GPs’ view this is around 3% both before and after launch.
We don’t say it will be easy. We do say that with perseverance both patient service and GP working lives improve. But those that start from a strong patient service ethos seem to do best for their own working lives too.
The commitment to fast and appropriate response from the whole team puts them in control and minimises rework. That doesn’t mean saying yes to what every patient “wants” – that way lies madness. It does mean sufficient breaks around GP and staff needs. Indeed the day can be much more flexible, with many opting to work from home part of the time.
While failure means a return to the previous state with all its frustrations and stresses, success is a journey not an endpoint. It’s all about flow, measured continuously:
- Patient demand, by type, mode and timing over weeks, days and hours. This matters for designing the service.
- Elapsed time to complete requests. Usually the chief concern of patients.
- Continuity, where appropriate. Often key to patient satisfaction, GP job satisfaction and quality of care.
- Efficiency, a chief concern of providers as it drives workload, quality of working life and profit.
- Patient satisfaction, for which we publish summary charts in real time:
The benefits from wholly embracing system change are orders of magnitude greater than from any hybrid system, and a large part of our work is giving practices the confidence to do so. Followng that is an enchanting journey of learning, experimentation and refinement.
We too are continually learning, often finding we can help the flow with new features, better measures, or working with practices to solve unique problems. Sometimes we change our advice,
While change cannot be absolutely risk free, for many businesses, staying the same may be the most risky strategy. We only have to walk down our high streets to see the consequences. For most GPs, protected as they are by permanent contracts, staying the same and offering a service no worse than others locally may not seem too bad, though it hardly inspires.
Our greatest challenge, and by far the greatest cause of failure, is failure to overcome fear, to reach consensus and therefore failure even to start. Let’s re-iterate our purpose in undertaking this work:
We make it easier for patients to get help from their own GP.
We make it easier for GPs to provide that help to their own patients.
Sometimes the way may seem hard, but reward comes through perseverance. We have a mantra to take us through those times:
“First for our patients, then for ourselves.”
PS After the rain, sunshine. I’m about to share some of the most moving patient feedback we’ve had, just from the past week.