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.
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?
* 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?
Hypothesis: efficient operation of primary care depends on clinical triage of all demand, to optimise the use of scarce consulting resource – GP time.
The faster and simpler the system, the more patients will co-operate.
Who does what, when and how?
Patient “I need help…” Make it easy to provide enough detail for triage. Online, anytime.
Reception ”I’ll assign you to a clinician, unless I can help you myself” (within minutes, verify patient, choose clinician)
GP “I’ll work out how to help, usually phone, may see you, send a message, or refer” (take seconds, within minutes, from online entry)
Consult & complete – precisely appropriate for the patient and episode.
Presented at EFPC European Forum for Primary Care, Annual Conference Porto 24-26 September 2017
Download the poster here:
A quick note with exciting news, we’ve just had our poster published at the Society of Academic Primary Care SAPC Annual Scientific Meeting in Warwick.
askmyGP has now passed over 50,000 patient episodes, 4,000 of them on the all new platform launched just two months ago.
The case study with Concord Medical Centre, Bristol, is here:
What took demand to 30% online? In a nutshell, it’s:
– Personal (“Hello, I’m Dr Bradley…)
– Universal (all patients, all problems)
– Responsive (we’ll get back within the hour)
– Simple (“Easy to use” main theme of feedback)
We took the decision in version 2 to take OUT the clever technology we’d put in v1.
It’s much simpler, with the aim of putting patients in faster, easier, touch with their GP, and vice versa. It builds trust by allowing patients to express exactly what they mean.
The result? Positive feedback has shot up, both from patients and GPs.
Dr Simon Bradley comments:
“The thought that goes into putting something into writing often helps the patient to have reflected on their problem prior to initiating a request.
Then for the clinician to have reflected on the request and reviewed relevant elements of the record means we can be more aligned with the patient’s agenda.
Online communication is asynchronous which allows both patient and practice to use their time more effectively.”
Aha. Time. The only absolutely finite resource.
Time for recreation too – enjoy the weekend.
Download pdf: What makes patients use online consultations?
Summer may be a-coming in, we will see beaches and I promised to take a look at that pattern of patient tidal flow.
GP demand is like a rolling wave. Or quite like a skijump, or one side of a volcano, but let’s stay with the wave for the purposes of surfing.
We’ve analysed hundreds of practices and when you allow patients call any time in working hours the pattern is strikingly similar across the board. The calls start high when you open at 8, stay there for a short time and from 9 fall rapidly through the morning. They flatten out through the middle of the day and early afternoon, then tail off from around four down to very little by 6.
Aha. So how to respond?
- Tidal deniers: “We hold our partnership meetings at 8.30 on a Monday morning. Works well for us as everyone is in, perfect start to the week”. If only they spent five minutes in reception.
- Tidal self harmers: “Sorry, what do you expect, it’s already 8.17 and there’s nothing left. Call back tomorrow but make it early I should to be sure of an appointment” Funny how every day is the same.
- Dudes: we’re ready, on it as the demand comes in, phone or online first response, deal with it now, decide to see some later when incoming is quieter. Stay on the wave, take a break, mentally prepare for face to faces, back for next session. It’s a full on day, but we feel in control.
Someone accused me on Twitter this week of common sense and I strenuously deny all charges, but really, is it that hard? So why do patients wait an average of 5 days to get help from their GP? And why do GPs end the day shredded?
One practice we’re working with has hit a median response time by a GP to any patient demand of 17 minutes. Within five weeks of launch. 17 minutes. Surfin’
askmyGP & GP Access Ltd
PS Delighted to see that Matthew Swindells, new Director of Operations at NHS England, is starting to call out NHS111 for the monstrous waste that it is. I wrote this on the launch of 111 in 2013. Sad to say that it’s taken a change of personnel to admit the truth, while those four years have seen hundreds of £m wasted, never mind the frustrations for patients, GPs and staff. So will he actually do the necessary?
This week’s blog was written by a patient to his local paper, and I loved it so much I’ve copied it here in full:
My local doctor’s surgery, Audley Mills in Rayleigh, has changed its appointment system.
When you call for an appointment you will be called back by a doctor. The doctor will then either deal with your query over the phone or ask you to come in to the surgery.
I used the system today, and I must say that it worked for me. I was asked to come in, and got to see a doctor within minutes. The waiting room was almost empty, and the consultation did not feel rushed at all.
I expect the majority of queries can be dealt with quite adequately over the phone, and doing so allows for quicker and less rushed appointments for patients who really need a face-to-face meeting with a doctor.
I was very impressed.
Simon Bishop, Rayleigh
What I most love about his letter, sent the day after Audley Mills launch on June 12th, was this phrase “the consultation did not feel rushed at all” It recalled the fourth principle of consultations from John Launer’s article last week – unhurried.
Like you, I’m suspicious of anecdotes unless they illustrate a body of evidence. But here’s the survey data from Audley Mills week one: they called 46 patients at random, of whom 39 said the new system was better, 5 same and 2 worse. A staggering 85% say better, and only 21 of the 46 had seen the doctor.
I spoke yesterday to lead GP Dr Luke Whiting who said Monday had been very busy but demand had tailed off over the week and now they had free slots, unused. It’s so predictable. We allow 15% for random variation in our plans, so it’s not uncommon to have free time.
Luke: “We’ve been tearing our hair out for years. Now suddenly the place feels relaxed, the building is so quiet, we’re on top of the work.”
So what made the difference at Audley Mills? Why could they do this when others all around are still tearing their hair out? Are they larger, smaller, younger, older, more urban, more rural, whatever, than the rest?
No, just one thing: they made a decision.
PS The data shows no change in average face to face consultation time before and after launch. But the range increases as GPs have more flexibility to give the appropriate time to each patient.
PPS I’ve been speaking at NHS England and CCG events in the last month. There is no doubt about the appetite for change. What’s needed is evidence, method and frankly, a sense of urgency.
“It’s lovely not being shouted at 24/7”
Receptionist Karen’s first comment to me was both startling and predictable. Her Somerset practice launched their demand led system two weeks ago, and since then she has been able to help every patient. Three weeks ago she and her colleagues were turning away one in five patients (we measured it) but they have moved straight into the super league, with a median response time from the GPs of 26 minutes.
The GPs love it too, but I find they are more buttoned up and try to find at least one thing to grumble about. “I’ll be home early so will have to put the kids to bed,” said one.
That didn’t take too long did it, or seem so hard? It was four weeks of preparation, to abolish the old system and start the new.
So why aren’t we hearing about this from the commentariat? I get a stream of dismal blogs from Nuffield/King’s Fund/Health Foundation (why don’t they just merge, it would save all those personnel transfer costs?) wringing their hands about how hard it is to change anything.
Another one today on General Practice at Scale, is it working? Yawn. Fiddling with structures, the obsession of policy makers who should get out more and ask “WHAT WORKS?”. Instead we’re told,
“Motivations… centred on a desire to offer better access…
Most strikingly, what the survey revealed was just how long enacting change can take – at least two years to even begin to achieve what they’d set out to do.”
Useless. And no measure of performance is even offered. This is why Deming said that motivation is fine but worthless on its own. The question is “By what method?”
Method is central to our work and it’s so repeatable now that the outcome is binary: either the practice decides to change, and it all happens within a month, or it doesn’t, and nothing much happens at all, ever.
But method is not static, we are continually learning and having to adapt. Another Midlands practice told me yesterday they are learning lots from having a GP in reception, sometimes even taking calls from patients, and their performance is rocketing while demand is falling.
I’m not going to call it a trend yet, but if you are a demand led practice you’re probably enjoying the sunshine dividend today. Have a great weekend.
PS Learning a lot from askmyGP users too, with over 1200 episodes and 130 patient feedbacks on the new system, 55 suggestions from staff, a terrific response. We’ve already put dozens into service and next week’s plans include one for low using practices (they will get an email notification of an online demand) and one very much anticipated by high users.
GPs have been emailing patients because it’s convenient – but it’s not secure and poorly controlled for IG and patient safety. From next week those on the Transform programme will be able to securely message patients in a two way conversation. It’s going to be another huge time saver. Will let you know how it goes.