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!
01509 816293 / 07939 148618
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.
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!
We’re delighted to have reached a milestone today, just over four months after launching version 3. Steve Black our chief analyst told us:
“At 08:31 this morning Aisha at Balaam Street closed the 100,000th patient episode.”
Wonderful to know that in the absence of a functioning government, some things keep rolling along.
History is informative but I’m even more excited about the present, as we announce today the launch of video consulting through our askmyGP platform.
- No app to download
- No need to change surgeries
- Works on any device with a camera
- Your own NHS GP initiates the call
The first ones have happened already, one GP telling me of a child he could see happily running around- saving a visit, and a mole he could tell was benign – giving reassurance. Another tells me of checking on a wound and saving a whole morning off work for a patient.
The experience was easy for both parties, with high quality pictures over wi-fi, and no cumbersome pre-booking arrangements.
Video consults are driven by what is clinically appropriate in the GP’s view, and it’s going to be so interesting to see how this mode affects practice. My guess is it will be around 5 – 10% of consults, but this is the thing: we don’t know.
Have a lovely evening.
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?
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.
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”
It’s remarkable for a quote that seems almost modern in politics, often attributed to Abraham Lincoln, but it seems he was quoting John Lydgate of Suffolk, writing in the fifteenth century, “You can’t please all of the patients, all of the time.”
OK he said people, not patients, but the point is made. You’d be mad to try and please all of the patients, all of the time, because whatever you do, some won’t like it, and that’s the thing about people. Perhaps that’s what makes us interesting.
Having said that, “Happier Patients” is one half of our motto and it is of utmost importance for us to do what is best for patients in the quality of service both we and the doctors provide. We ask patients directly for their feedback to help us achieve that.
In our version 2 askmyGP we’ve had over 4,500 patient comments from 105,000 episodes in the last 18 months. They have been overwhelmingly positive, with some negatives and some suggestions, and they have been a big part of our design process for version 3.
One difference is that where we used to collect feedback when the patient submitted the request, in the new version it’s done after the request has been completed. Ah, we thought, all those complaints based on the patient not believing it possible would vanish, and positivity would go up.
So far (first 4,000 episodes) it hasn’t quite worked out like that. We’ve structured the feedback very simply as you can see from this form. The killer question is whether the new system is Better, Same or Worse, and the figures as I write are 98, 4, 27. We have a real time online chart which you can check any time – you might be lucky enough to see the hundred come up.
Yes, it’s overwhelmingly positive, and I’d love to share all the comments with you but even though we ask patients not to enter personal details, sometimes they do so we can’t do a real time feed. Some examples are below.
But I know what you’re thinking. I’ve been working with GPs for over nine years now and if I may be allowed a little over-generalisation, you’re really interested in the negatives. (btw academics are worse. They couldn’t find the silver lining in a solid silver tea service, present company excepted of course).
What’s interesting is that with the 21% who say it’s worse we are picking up reactions not only to askmyGP (though some are, and there were a couple of technical issues), but mainly to patients’ views of the GP. The main driver for negatives at 16/27 is very poor on “solving your problem”. It might be that something went wrong with the process, there was a delay, or the patient just didn’t like what the doctor said. Well, it happens, and you can’t please all of the patients all of the time.
Anyway, it’s good to see that 76% of those responding say the new system is better, while for those of you who think they are trumped by the 21%, you are amply justified in doing nothing.
Everyone can enjoy our star comment of the week, from a fellow Yorkshireman. This is only the opener and the rest has had to be moderated for family viewing, but you get the gist: “Whoever thought of this stupid idea wants a good kicking up the arse.”
PS Some of the feedback this week:
“Very good service it’s been amazing when I’ve needed advice for my children never waited longer than an hour for reply”
“far easier using this system than actually going through the surgery reception” male 28
“The new system is so much better, especially if you only want to ask a question rather than seeing a doctor. Massive thumbs up 👍” female 45
Thoughtful for others: “Ok for those who are familiar with the use of computer systems but I have concerns for elderly who would have no idea how to use a computer” female 70