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.”

Harry Longman

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.

With the publication in this week’s BMJ of the Tele-First study into the telephone first model of general practice, you would expect me to read carefully and respond.  So here are the headlines:

• 65% of patients report being phoned by a GP in less than one hour.
• 56% of patients find it more convenient vs 22% less convenient
• Large improvement in length of time to be seen, 20% move in GPPES survey.

At a time when we are told repeatedly that patients are having to wait ever longer to see a GP, often measured in weeks, these are quite astonishing figures, all quoted direct from the report.  But, dear reader, these are not the headlines you have seen in Pulse or the BMJ Editorial are they?  Studies, and the interpretation of studies, are political.  We have an interest, and so does everyone else.

Therefore the first thing I want you to do is read the full text so you can make your own mind up independent of headline writers.  It is much more detailed than the print version, framed by an angry looking GP model and a scared looking patient model, giving more space to a commentary piece than the actual study.

There is much to absorb but for brevity I’ll comment on the summary section.

What is already known on this topic

• GPs are struggling with the current demands on general practice and looking for effective ways to manage patient demand
• Claims have been made, reproduced in NHS England literature, that a telephone first approach, in which all patients wanting to see a GP are asked to speak to a GP on the phone first, results in major cost savings for primary care and reductions in secondary care costs

We do not make those claims, but you can still read them here on the home page of PPC Doctor First, a 20% drop in A&E and £30,000 saving per GP per annum. I’m grateful to the authors for proving these false. *

What this study adds

• In general practice, many problems can be dealt with by a GP on the phone
• The new telephone first approach resulted in more phone calls, fewer face to face consultations, and, on average, more time spent consulting
• There was wide variation between individual practices, including large increases and large decreases in workload after adoption of the telephone first approach
• There was no evidence that the telephone first approach would reduce costs of secondary care

In a way it is disappointing to see no secondary care effect, but not unexpected and unless the evidence changes, that is what we accept.

But what has really got GPs aerated is this finding of “more time spent consulting”.  This was derived from data sent by us to the study, which we have not used to make a calculation on workload for several reasons:  much of it is missing (and as the authors state, had to be imputed), it shows wide variation, and it cannot account for total workload.  Let’s consider:

Workload = demand/efficiency + non-clinical work + waste

We do not have a reliable way to measure the total, and given that the study used only one of our three datasets, I don’t see how they can make this assessment.  Just one example:  many practices have told us of the drop in home visits, each one saving the time for many surgery consultations.  This is not measured.  It may be a good thing to have more recorded time consulting, if less time is wasted.  Not only does this finding seem to me unsafe, it also brings us back to the question of purpose, for the study and indeed for the NHS.

If the purpose is to minimise GP workload, we can do so very simply:  design the working day so you see 4 or 5 patients in the morning, take a good lunch and a nap, then spend a little time in personal reflection and development before heading home., purpose achieved.

I’ve worked with a lot of very hard working GPs and they would not be satisfied with that purpose.  No, the purpose of general practice and therefore the purpose of change must be to improve patient care.

There’s a missing term in the workload formula, and that is “unmet need”.  Behind those words lies untold suffering and frustration of patients, heard perhaps by a receptionist (one wrote last week, “I dread having to tell the patients there’s nothing left”) while others do not even get through on the phone.  This is the dirty secret of general practice, and over many years we’ve measured it in practices we’ve helped, variable around an  average of 14%.

One in seven patiients is told to go away.  Although we offered this data to the study team, they didn’t want it and took no account of it.

Their figures cannot distinguish between the workload of one GP helping 30 patients in a day, who had all waited two weeks, and another helping 40 patients in a day, on the same day they called.  It could be life changing for those 10 patients, indeed all 40 of them for not having to suffer two weeks of disease, pain, or anxiety.

Both GPs may have equal skill and compassion, but the difference comes from efficiency.

By framing the question on workload rather than efficiency, the study misses a huge opportunity.  It offers no help on how to become more efficient, and while it found wide variation in performance, the data were munged into averages rather than investigating in detail why the best ones worked better.

I’ll tell you a secret:  we’re in this for the patients.  To help the patients we have to help the GPs be more efficient.  There is never a final answer to the method, there is only “the best we know for now, while we look for the still better way”.

We’ve helped around a million patients so far, with another 50,000 to be added in the next month. and as telephone triage (done well) is more efficient than pre-booked face to face, digital triage is already proving to be the next step.  Sometimes we fail, but we press on.

Every day over 100,000 patients are told by practice receptionists “Nothing left, call another day”.  Not on any basis of clinical need, just because the GPs have no slots.

It’s my personal mission to eliminate that phrase.  What’s yours?

Regards,

Harry Longman

* The 20% A&E effect came from my 2011 study, based on pioneer practices with up to 10 years running the model, and promising at the time.  The figure was copied by Dr First but never attributed.  We could not show that the effect was reproducible, and therefore stopped making any specific claim about A&E 3 years ago.  £30,000 saving?  We make no such claims, although if GPs tell us about savings we are happy to report them.  Why did NHS England swallow this?

@harrylongman