We’re delighted to inform you today of the open access publication from Abi Eccles et al:
It’s the first independent study of askmyGP and it’s well worth reading in full. I will quote the conclusion briefly:
“Patterns-of-use and patient types were in line with typical contacts to GP practices. Though the age of users was broad, highest levels of use were from younger patients. The perceived advantages to using online triage, such as convenience and ease of use, are often context dependent.”
What comes through for me is the very ordinariness of the online demand. It’s the same as normal demand, same patients, same conditions, same frequency by day of week and time of day.
There’s more on patient feedback too, with themes extracted which are very familiar to us. We’ve quantified the age question in our study on “Age specific adoption of online consultations.”
What this study adds is online usage orders of magnitude greater than any previous paper, with 5447 patient episodes from 9 practices in 10 weeks. Data collection was May to July 2017, which was our previous version 2 platform. Since then the same principles have been carried forward to v3 with a new design and many more features. Growth in usage means that we are now collecting the same volume of data roughly every two days.
The scope for further research is increasing daily with an anonymised database of some 300,000 episodes, unique in general practice. If you’re an academic in the field, we welcome the opportunity to collaborate, particularly on studies of the GP practice as a whole, not just online components.
Benefits for patients and GPs are the product of system change.
PS See how patients interact with askmyGP on our Bramley Demo Practice.
To experience the GP side, start with our free online demo.
The latest data from our chief analyst Dr Steve Black (@sib313) shows remarkable adoption of online consultations across all ages and 10 diverse practices. n = 37,674 requests, date range is 1/1/2019 to 8/2/2019.
The context is all askmyGP practices operating in “total flow” mode where all patient demand goes through the system in two modes. Online, patients submit a request for help from their NHS GP practice either for themselves (dark blue) or as a proxy (light blue), mostly children but also vulnerable adults, most over 75. They may also telephone the practice, and a receptionist creates the request on their behalf (orange).
The key point is that all demand is covered in the chart, not from a self-selected subset of patients, and these are regular GP practices where there is no change in registration.
What the data shows
For infants and children, over 60% of parents chose to send their request online.
For young adults aged 20 – 40, over 70% submitted online.
With increasing age, the proportion online falls slowly, but even at 65 – 70 it is 40%.
Over 70 the proportion falls more steeply and significant numbers are by proxy.
It is clear that when designed for ease of use and universality in respect of patients and their medical problems, coupled with rapid response by providers, the online offer is highly attractive to patients.
The vision for “digital-first” providers who are at the same time traditional, local GP practices is achievable and already being achieved.
Founder, Chief Executive, askmyGP
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.
Good news has a hard time getting heard.
This week we’ve seen new, comprehensive data from NHS Digital on the wait to see a GP, splashed across all the papers:
It’s all “true”, though I’m afraid the spin is not. The argument that “40% are seen the same day” rings hollow with anyone who has hung on the telephone for half an hour, to be told that all the same day slots have gone. Many of those 40% have been trying for several days just to get through.
Blame the patients, blame the government, blame whoever else we can think of. Or take a different look.
These tiny stories from the last few days are just a handful of the hundreds we see each week from patients grateful to their GP:
Your service and reliability are amazing. Thank you! (f 85)
Amazing fast system thank you (m 41)
Amazingly swift and very easy process than trying to jugggle around work – thank you so much! (f 24)
Amazing…More personal…Super speedy (parent, boy, 3)
Love how easy it is to speak to your own doctor . Amazing (parent, girl, 4)
Love this new system…so easy and quick , and have the problem solved without having to sit around at the surgery. (f 49)
Love ‘askmygp’. Making it so much easier to get info and solve problems whilst holding down a full time job! (f 40)
Wow. I am impressed! (m 69)
Wow, just wow. Have been in terrible painall night…absolute godsend… Thank you so much for your skills and innovations (f 65)
WOW, great system, quick easy, and no need to travel. Many thanks (m 63)
We’re now over 4,600 feedbacks from 80,000 episodes since August, and the trend is better and better. Please do have a look at the live rolling 7 day summary chart. We ask patients whether it’s better or worse and the ratio as I write has moved up to 9 which is so exciting.
These patients are getting an outstanding service from their own regular NHS GPs. The GPs have no extra funding (they pay us), and no complicated extended hours 8 to 8 hubs (that didn’t work)
Patients didn’t have to switch to an out of area GP. They could name their own GP. They were seen same day if needed.
And the GPs are happier too – happier professionally to be giving such a service and bringing the joy back into their working lives.
If you haven’t yet watched the Burnbrae video, please do and click for the demo at the end. This is one of her 5,000 patients last week, helped within 2 hours:
“fantastic service and Dr Arnott is an amazing doctor, Shotts is lucky to have all these new changes.”
How do we get this into the headlines?
Shotts, North Lanarkshire. Small town and surrounding areas, ex-mining community. Traditional, somewhat deprived area.
Dr Sue Arnott, full time single hander GP. Team consisting of 8 session ANP, practice nurse.
“We were looking to do things completely differently”
As well as hearing the story, you may like to see the data.
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.
I’ve no doubt Jeremy Hunt meant well by what he called his birthday present to the NHS, a new NHS app. But as W Edwards Deming said, “Best efforts are not enough, you have to know what to do.”
“I want this innovation to mark the death-knell of the 8am scramble for GP appointments that infuriates so many patients.” says Hunt.
He’s right that innovation is needed, right that there’s an 8am scramble and right that patients are infuriated. One phoned me this morning, absolutely fizzing about her practice, but not one of ours and there was nothing I could do. She told me she could book online, but there were never any GP appointments soon enough so she physically went this morning and still no joy.
The gap is in understanding the problem: it’s the system. It’s not lack of online access, standard for some years. Bad news, it’s the system, meaning the operating system of the practice. Good news, it’s the system, meaning it can be changed. By whom? The GPs who run the practice.
Even better news, it isn’t a matter of resources. The BMA is right that Hunt’s NHS app won’t create any more appointments, but their knee-jerk reach for the begging bowl so lacks imagination.
I won’t bore you with how we are helping practices to achieve 30 – 40% efficiency gains, and help patients within minutes, because you’ll tell me it’s too good to be true.
But I’ll share with you a brand new chart which astonished me this week, and it goes to the heart of Hunt’s problem definition. A month ago we started asking every patient when they send in from askmyGP how they would like the GP to respond, whether email, phone or face to face. This is from 12 practices who have done Transform, online varies from 15% to 80% of demand, average 35%.
Even though around 30% of patients need a face to face, only 15% are asking for one. GPs are having to persuade some patients to come in.
It seems obvious after all: patients don’t want an appointment, they want help with their medical problem from someone they trust.
But if you make it a thing to book appointments online, then that’s what they will do, and take 10 minutes of GP time, even though neither party wanted it.
The BBC listened, thank you, and we have been saying this to NHS England for a long time, but they aren’t listening. Can you help?
PS #GarethSouthgateWould not mention that 6 out of 9 England goals have been scored by a Harry, so neither would I.
PPS All the above practices started with Pathfinder – Could you be ready to change? It’s normally quiet in summer but we are surprisingly busy and it is actually the best, quietest time so do get in touch today.
Links are provided below to published material evaluating the eCONsult/webGP software supplied by eConsult Health Ltd (formerly Hurley Innovations Ltd). To our knowledge no other independent studies have been released – please respond below if any are missing.
BJGP, from CAPC, Jon Banks et al.
“Conclusion The experiences of the practices in this study demonstrate that the technology, in its current form, fell short of providing an effective platform for clinicians to consult with patients and did not justify their financial investment in the system.”
Number of eCONsults received per practice per day: 0.9
BMJ, Uni of Exeter, Mary Carter et al
“Results: WebGP uptake during the evaluation was small, showing no discernible impact on practice workload.”
Number of eCONsults received per practice per day: 0.9
BJGP, Michael Casey et al. The product name has been changed to “Tele-Doc” but the context leaves no doubt that this is a study of eCONsult.
“Uptake of Tele-Doc by patients was low. Much of the work of the consultation was redistributed to patients and administrators, sometimes causing misunderstandings. The ‘messiness’ of consultations was hard to eliminate. In-house training focused on the technical application rather than associated transformations to practice work that were not anticipated. GPs welcomed varied modes of consulting, but the aspiration of improved efficiency was not realised in practice.”
MDPI, J Cowie et al, University of Stirling, 11 practices in Scotland over six months to August 2017.
“However, there is less certainty that it has fulfilled expectations of promoting self-help. In addition, low uptake meant that evaluation of current effectiveness was difficult for practices to quantify.”
3.1.1 “The distribution types of eConsult submitted were 32% specific conditions, 27% administrative help, 41% general advice (24% for a new problem, 17% for an existing problem).”
3. 4 “Consensus was that a straightforward phone call simply requesting an appointment could be handled quickly and in less time than processing an eConsult.”
3. 5 “However, at the current levels of submissions, there was a general consensus that eConsult did not offer cost savings”
Number of eCONsults received per practice per day: 1.3
NIHR Journals, Atherton et al, 8 practices including 2 using eConsult.
“E-consultations were also very rarely used, accounting for 0.22% and 0.23% of consultations in those practices that offer them.” p89
“The current very low level of uptake of alternatives and the lack of clear evidence of benefit may influence their uptake on a wider scale, something which is favoured by policy-makers.” Conclusions p98.
One of the policy-makers was Dr Arvind Madan, former NHS England National Director of Primary Care (resigned 5/8/18), also a partner in Hurley Group, owner of eConsult. Other Hurley Group senior partners and major shareholders in the company are CEO Dr Murray Ellender and former RCGP chair Dr Clare Gerada.
This NHS England engagement document contains on page 6 a case study, mentioning 145,000 eConsults in 2017, from 4.4 million patients in 465 practices. This allows us to calculate the proportion of total demand sent through the platform. The average practice sees 6.5% of patients seek help from a GP each week (figures collected over 7 years by ourselves, and used in all capacity planning models). In a year, 4.4 million x 6.5% x 52 weeks = 14.87 million consults.
145,000/14.87 million = 0.97%
From their own data, fewer than 1% of consults in their customer practices are through eConsult.
Compare the above with claims made on their website econsult.net. At the time of writing the above links could not be found on the site.
Increasingly practices ask us how others use askmyGP, so we have collected here examples with agreement to be in the public domain.
Please be aware that they are all busy GP practices so have not committed to answering in person an unlimited number of queries. They are all different in some respects from your practice, yet they all share common features of a registered list of patients whom the GPs are committed to serve.
They are all on a journey of change, which started with Pathfinder – could you be ready?
Concord Medical Practice – 14,500 suburban family practice, north of Bristol. SAPC poster.
Central Surgery Oadby – 8,700 suburban Leicester. Presentation given to the CCG. Webinar with Dr Chris Thompson Online Consults – Our (very short) Journey of Change
Balaam St Surgery – 5,600 East London practice, blog post of interview.
Witley & Milford Surgeries – 11,200 rural Surrey, two sites. Dr Dave Triska @dave_dlt tweets as launch unfolds. This 45 minute recording could change your life: Witley and Milford launch, as it happens – Dave Triska interview.
Every practice will work out their own mode of operation, and with our help can seek to optimise effectiveness and efficiency. Each of the above sees between 30% and 80% of demand arriving online and their numbers are part of over 70,000 patient episodes managed through askmyGP in the first year of version 2.