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.
Last month we were at Best Practice conference in Birmingham and having a jolly good time until something really annoying happened.
We’d spent a lot of effort on our stand and if you’ve ever done these events you’ll know the few square metres cost £ thousands, never mind the little table and bar stools which are more to rent for the two days than they would be to buy.
We were dead opposite a mini theatre where every hour someone would roll up, no doubt having paid more £ thousands, to do their presentation on the latest dermatological cream or ear inspection widget. They’d pull in a couple of dozen delegates, grateful for the chance to sit down and fiddle with their devices.
Then all of a sudden we find custom has dried up and we are looking at the backs of a huge audience, filling all the chairs and spilling into the space around our stand. Everyone rapt.
The title: “How to Run a More Profitable Practice”
Sorry I have no idea what he was on about, I couldn’t see over the crowd, but he was one of the small army of advisors which serve general practice.
They are the accountants, solicitors, lenders, financial advisers and so on who make their crust knowing the many little levers of profit which independent contractors can play on to their hearts’ content. Good luck to them.
What amuses me is that when we ask GPs what are their priorities in undertaking change, 93% of them put “money” as the lowest (out of 5) of their concerns. Haha.
What amazes me is that these same GPs getting advice on how to reclaim VAT on rubber gloves are not even thinking about the dominant cost in their businesses, which is of course the GPs – their own time, their salarieds and especially their locums’ time.
The main cost of meeting patient demand is GP time. (by the way, this is why “GP at Scale” is doomed to have precious little effect on drawings. It’s no more efficient for consultations, and possibly worse because of lost continuity)
Therefore the best way to be more profitable is for the GPs to be more efficient. (I’m not including the option to turn patients away. No matter how much it happens, it’s plain wrong).
Bluntly, with askmyGP we enable GPs to be far more efficient in dealing with patient demand. How much, how fast, how that is balanced between fewer sessions, finishing earlier, running more patients or giving a better service, all those factors vary.
Just to get a sense of how that works out, watch our new three minute video, the Burnbrae story. Dr Sue Arnott is so cool and calm, as a full time single hander with her team running 5,000 patients.
You do the maths.
PS we’ve had a tremendous response from GPs signing up to the Digital Triage Experience even before we put it on the website, but click the link and we’ll create yours. You will make your own triage decisions on 50 cases within about 15 minutes, and see why this is the greatest lever on profit you’ll ever find.
I’m sitting here in my shorts, tee shirt and sandals and it’s the middle of October. Yes, I’m in Leicestershire, for those thinking laterally, and I have a jumper on, but I felt it worth dressing up to make the point.
Unless you’ve already settled on Mars, you’ve noticed that it’s significantly warmer than in your youth and while a fine warm week in October is weather rather than climate, we know the trend is one way.
The IPCC warned this week that our fossil fuel burn must fall more rapidly than we thought. Policy must change, and behaviour must change.
We link our work with askmyGP directly to lower carbon use, because it saves travel to the GP surgery. It’s hard to measure the numbers with telephone consulting, but we have much better data now with some 10,000 patient requests via askmyGP each week. Roughly 9,000 are for the GP, of which 6,000 are resolved remotely. Say half would have involved a car journey of say 1 mile each way, that’s 6,000 road miles saved – and we have only just started.
I’m optimistic that if we do the right thing, a lower carbon future can be a better one all round, and I’m glad to say the patients agree.
“Fantastic service, much easier to speak to GP whilst sitting in the comfort of your own home. Many thanks” f 53
“So much better than getting in the car and visiting. Personal chat with my GP at a time convenient to us both.” f 65
“I think the new system is excellent. Saves time and must give the doctor more time to see patients who actually need proper medical attention. Saves me from having to bundle my 1 year old son on a bus and come up for nothing. Love the new system!”
And why should patients have all the fun? One of our practices has instituted a work-from-home-day for all the partners. They are as productive as ever if not more so, one telling me she saves a 50 minute car commute each way.
GPs keep telling me they are terribly stressed, and I’m sorry we don’t do counselling or mindfulness sessions. All we can offer is to change the system, but consulting in slippers is quite nice.
Anyway, if you haven’t yet seen it, listen mindfully for 25 minutes as
PS. When each request is completed, we invite the patient to leave feedback and about 5% do so. The real time chart shows about 3 to 1 say the new system is better v worse, but one wrote this yesterday which was moving:
“It’s more than better. This is revolutionary. No waiting to see a GP and the speed at which the service delivered is outstanding.
I’ve switched practices to Central….the doctors are way above my previous experiences with another practice” m 67.
Another patient yesterday wrote the longest comment we’ve ever seen, an essay. I’m going to publish it tomorrow, do look out.
*Featured image is one I took in a GP car park, the environmental consequence of “GP at scale”.
Have to say it makes one a little queasy to see the Secretary of State take the platform at a competitor HQ and tell they world he wants their product to be offered to everyone. Taking a few shortcuts on procurement, open competition, evidence and so on, but then he’s new.
Two things I share with Matt Hancock are his enthusiasm for how technology can help, and his frustration with the glacial rate of innovation adoption in the NHS (plenty of innovation does not equal high rate of adoption).
But we absolutely must see technology within the whole system context, which is why we call what we do “Systems thinking applied to general practice.”
Mr Hancock might like to consider a few matters before handing over the jewel in the NHS crown to Babylon’s GP at Hand:
– their patient profile is skewed to younger adults
– they’ve traded access for discontinuity of care
– their exclusions, agreed by NHS England, cover children, pregnancy, many chronic conditions, those who can’t travel, pretty much most of the demand on GPs.
– taking out the above patients leaves remaining GPs with most of the work but much less of the income.
He’s right that a quick query on an acute illness from the back of the ministerial Jag could and should be dealt with online (if appropriate) by the patient’s own NHS GP. But from the GP side, that’s a very small segment of demand.
I fear a sinister side to the Babylon gig on Thursday: BMJ reports that Ali Parsa is lobbying NHS England not to cut funding for “digital first” GP providers out of area. Well he would say that, but having the SoS publicly tout your product is quite a nice negotiating gambit.
We aren’t just going to rail at the darkness. It would be lovely to have the endorsement of the SoS but until then, we’ll let the evidence talk.
- Practices running askmyGP serve about 8 times as many NHS patients as GP at Hand.
- Last week they did 6,600 online requests, probably 3 times as many as GP at Hand (and twice as many as eConsult, who claim 500 practices now to our couple of dozen)
- All patients had a choice of their own GP.
- They are digital first but never digitally exclusive – patients are able to use the channel that works for them.
- They get a faster service than Babylon can do, response in minutes and face to face same day.
- No patients are excluded from the GP list or turned away.
Call it disruptive innovation if you wish, but we’re disrupting the operating model, not the business or contracting model. That’s why GPs love it.
Parsa announced on Thursday another $100million investment into his company to be spent on AI, on top of the $60m already sunk. I don’t know whether this has been systematically reviewed, but it couldn’t recognise my fungal toenail infection. More seriously, @DrMurphy11 has shown how it misses a “barn door PE”.
I’m announcing today a secret weapon in askmyGP. We call it HI. It’s used for every single clinical diagnosis and decision, and even better, it does care. It can care for any patient, even one deaf, blind, lame, foreign, depressed and pregnant all at once. It understands context, nuance, subtlety, ambiguity, the importance of relationships. It even takes responsibility.
We work with over 100 GPs and I can tell you, each one is worth well over $1million. So much we can’t measure it.
Something else you need to know about GP at Hand, which is why they worry so much about funding per patient. Their Achilles heel is operating costs, sky high, compared with regular partnerships offering digital first. Drop me an email to find out how we know.
Our mission is to enable regular local GPs to outcompete Babylon, online, on quality, service and profitability. We’re showing how any practice can do it. We’re growing multiple times faster than GP at Hand, adding another 20,000 patients this week.
Someone will notice before long. A GP copied me yesterday her invite to Mr Hancock to come and see askmyGP in action.
Game on, Babylon.
PS A North East practice launched two weeks ago and has already blown my socks off as well as its own. They’ve gone from a median 5 day wait to see a GP to median completed request in 70 minutes, and demand went down in week 2.
One of their 91 year old patients commented, “Excellent, this service should have come earlier”
Do you glaze over when they report the latest A&E statistics? It’s all about what % of patients were seen within four hours. The latest figure for July is 89.3% and while it produces a lot of headlines, gnashing of teeth and calls for more resources, the saddest little note in the NHS England Statistical Commentary is where it says, “The 95% standard was last met in July 2015.”
Readers of this column know that I’ve been campaigning against the target culture that grips the NHS for many years. For me the personal journey was working in manufacturing in 1990 when I came across the work of W Edwards Deming, who said we must abolish all numerical targets. I fought against that thought internally as I tried to come up with ever cleverer targets for the factory, to cover all bases of timeliness, efficiency and quality. Until I crumbled – they could never work.
Nearly thirty years later we have this regime in the NHS which daily makes hard working professional people feel like failures. It has seen off a string of hospital chief executives who were either unlucky enough or failed to cook the books enough to keep their impossible jobs when the inspector called.
Measurement and accountability matter, but they are completely different from targets. Just briefly, let us suppose that the time to be treated in A&E matters – well I think it does – we can measure the median time, and chart it day by day, week by week, ever so simply. Everyone can be engaged in improving the system which will show in this and other appropriate measures. Fear of failure is replaced by pride in work.
I’m building up to some quite astonishing news but while we are on the theme, similar thinking is applied to ambulance response times. Red C1 and C2 calls have to get a response in 8 minutes 75% of the time, and there’s a vast bureaucracy, dreaming up and calculating the numbers and beating up the failures. Sigh.
Back in the GP world thankfully there are not so many high profile arbitrary targets (arbitrary ratings on arbitrary measures by CQC are another matter) but there is related anxiety about some of what we do. We get asked “How does your online askmyGP system handle red flags?” I assume on the basis that the patient may have something urgent wrong with them.
My answer is always the same: “Red flags are dangerous because algorithms cannot completely and safely cover all eventualities, yet they can give a false sense of security.”
Because we are very concerned about patient safety, we have a different approach, which is to understand that safety is a function of the system as a whole. Rapid response by a GP, appropriate to the patient and their condition, is a very safe system. Oh, and we make it very clear to the patients, “Do not use in emergency.”
We are also very clear on what they can expect, which is a next day response out of hours, or in working hours “usually within the hour.”
When GPs doing our Pathfinder diagnostic hear about this they often blanch and explain how they would water this down as it’s clearly impossible. And then we look at the data.
So here is the astonishing news from the first two practice launches with our new software (no, you didn’t miss anything, we haven’t announced it yet). In the first week of operation they achieved a first response average time respectively of 6.0 and 5.2 minutes.
That’s a personal response from a GP who has seen their request and triaged how to help (a face to face may come later). But it’s average, all demand, not just what someone considers urgent. No blue lights, no inspectors, no targets, no pressure, no overwork, no rework, just ordinary GPs, predictable demand and good flow.
Have an ordinary weekend.
PS Dr Simon Wade of Webinars for GPs has invited me to present this Wednesday 22nd August 8 – 9pm. Do join us on “Workload stress and burnout: can online access make a difference?” CPD points too!
No doubt your inboxes have been weighed down with the debate on the “2% pay rise for GPs”. Is it 2%, 1%, 3.4% or 4.2%? Of course it’s nothing of the sort.
It’s a contract uplift to independent contractors. If you buy a pencil, it comes out of your drawings. If you save a pencil, it goes into your drawings. I’m afraid the general public don’t understand this, but never mind.
There is no perfect model and of course it has its drawbacks, but I think the ability to run your own business is one of the great strengths of UK general practice. GPs have huge freedom to determine their own business performance, and therefore their profits and drawings.
Alongside improving patient service, one of our explicit goals is to make GP practice owners more profitable. Some of you seem rather coy about this, strangely, but I see it in very simple terms: why else would you pay us?
Because business owners take home the difference between income and expenses, they know that they can increase their incomes vastly more than 2% by investing in a machine to make pencils – I’ve over-extended the analogy.
Pencils are cheap but the expensive bit of the GP business is the GP. So the game is to make the GPs 30% or 40% more productive.
We are drawing near to Hancock’s Holy Trinity of “improving outcomes, helping clinicians and saving money”
Meanwhile there’s a monstrous failure: NHS England can’t persuade enough foreign trained GPs to come here. They wanted 2,000 no doubt at vast expense, and they are under half the target. They are looking in the wrong place. We already have the GPs. And by enabling them to be more efficient, and more profitable, we’ll have plenty.
It is a national scandal that a developed nation should steal the trained workforce from other countries who may have far fewer GPs per head than the UK.
We can do better.
PS I loved this tweet earlier today from @dave_dlt “Heck of a day, 4 sessions down then one partner needing to get away unexpectedly yet 1650 building calm and quiet”.
We are seeing partners shed locums and salaried sessions then still get away on time and enjoy the sunshine dividend.
Who’d have thought it before the Chequers meeting, but there it is, we have a new health secretary. I’ve put together some words from the very latest, and the first, of those at whose desk the NHS buck stops.
At the start of Matt Hancock’s term those interested hang on to every word, but to save time I’ve cut and pasted what I find most relevant here:
“as you may have heard I use an app for my GP. The discussion around my use of a Babylon NHS GP, which works brilliantly for me, has been instructive.
Some people have complained that the rules don’t work for care provided in this revolutionary new way. Others have said the algorithms sometimes throw up errors.
Emphatically the way forward is not to curb the technology – it’s to keep improving it and – only if we need to – change the rules so we can harness new technology in a way that works for everyone: patient and practitioner.
I want to see more technology like this available to all, not just a select few in a few areas of the country.”
A lot of positives. Sees the potential of technology (the NHS is so far behind, he could hardly not), brings in personal experience. Wants universal coverage, hear hear.
Steps into controversial territory with a commercial namecheck perhaps, but there’s a precedent. What I suspect he doesn’t understand is that GP at Hand while limited to the London area at present is not and cannot be a universal model. They exclude a long list of those most in need of a GP, as I don’t need to remind you, and they can’t offer continuity of care.
Our approach is rather to enable existing GP providers with local access and coverage for all patients, to give a much better service, much more profitably. We already serve about 8 times the number of patients covered by GP at Hand, but you might not think so by the volume of noise.
In recent week’s we’ve seen a growing body of GPs tweeting to let the world know that it’s really working. If you haven’t seen it do join the conversation, click to follow @askmyGP
Now to Aneurin Bevan, who wrote to the profession on 3rd July 1948:
“There is nothing of the social group or class in this: and I know you will be with me in seeing that there does not unintentionally grow up any kind of differentiation between those who use the new arrangements and those who, for any reason of their own, do not….”
We can say without fear of contradiction that all parties are agreed on that. The question is how, and what policies could threaten it. Bevan continues
“My job is to give you all the facilities, resources, apparatus, and help I can, and then to leave you alone as professional men and women to use your skill and judgment without hindrance.”
I’ve no doubt that 70 years later Bevan would be banging the table to say we had better get up to date with the means of doing so.
“Skill and judgment” – that’s human intelligence and in relating to, diagnosing and caring for patients, AI algorithm chatbots can’t hold a candle. Someone telll firstname.lastname@example.org.
PS Babylon’s recruitment page says its GPs “will see up to 5 patients an hour”. Jaw hits table. Our GPs tell us they would collapse with such a poor rate of producton. Looks even more like the Babylon business model can’t cope with anything but a fit and healthy demographic.
Did you hear the wonderful piece on Inside Health yesterday as Mark Porter interviewed Sir Denis Pereira-Gray? Listen on iPlayer from 4:40 minutes.
Sir Denis has been a tireless campaigner for relational continuity and his new paper published in BMJ Open. is the first systematic study linking better continuity with reduced mortality. Boom – the doctor knows the patient, they are likely to live longer.
But as he points out, continuity is actually falling, by an astonishing 27.5% between 2012 and 2017 as measured in this Leicester paper.
This is not inevitable.
It is the consequence of policies, system design and operational practice.
Therefore reversing the decline is a choice. The question is how?
Working with a huge range of GP practice structures and sizes, we have a very simple method.
- GPs set up their availability
- Patient chooses named GP
- Reception assigns patient to GP.
The data is interesting – only 25% of patients name a GP and quite often reception will look up the usual GP and assign to them. But most patients don’t mind and where it doesn’t matter, this gives enough flexibility to share the workload evenly.
It all happens within the normal flow of the demand led day, and crucially patients who feel their need is urgent are not faced with the dilemma of “You can see the duty doc today or that one you want in 3 weeks”
Now all of a sudden there’s a way to convert this into money. There always was, since continuity improves efficiency as GPs sort things out once properly, and patients don’t create rework.
The new time limited way is thanks to the Health Foundation launching a programme to increase continuity in general practice.
All excellent stuff and I wish you well.