Read this NHS Digital press release and shudder: “NHS 111 online hits one million triages mark”
You will be very familiar with the quality output from NHS111 sent to GPs from the standard version, where a human reads a list of questions from a computer to a patient, and based on their answers tells the patient what the computer tells them to do. Data shows the disposition is 8% to ambulance with a further 7% advised to attend A&E.
That process has now been fully automated into NHS 111 Online, and the number advised to attend A&E has reached 24.7%. Yes, almost one in four patients seeking help “when it’s not an emergency” is told that after all it is an emergency.
Over many years we’ve run audits, n>200k, where GPs labelled just 0.4% or 1 in 250 consultations as emergency. So we can estimate the proportion of false positives in the NHS 111 online dispositions at around 98.4%.
As you would expect, I have tested the system myself, in the interests of science. During a break in the weather we managed a cycle club run this morning and after 53 miles I am shot to pieces, so I tried “aching legs”. Answering just 6 questions, all truthfully and all negatively, except that the aching was all over, sure enough I got the result in big red letters: “Phone 999 now for an ambulance”
Folks, if you read the press release they are actually proud of this. I put the figures to Simon Stevens at a Reform meeting last week. Earlier he had spoken of the benefits of machine learning in assessing images, an application which makes sense as computers are good at comparing similar things and looking for differences. When it came to 111 he assured the room that results would improve when the algorithms had more cases from which to learn. They’ve had a million, how many do they want?
247,000 innocent patients have been advised by this abominable software to call an ambulance or attend A&E. Tariffs vary but if we take an average of £200 (ambulances much more) that’s around £50m, almost all of it overtreatment. We are told that ambulances and hospitals are under pressure and want to reduce demand… is anyone in Skipton House paying attention?
Suppose these million patients had been diverted to a qualified human to assess their needs and respond appropriately, that £50m could have been invested in front-line services so beloved of politicians.
My only hope is that most patients had the good sense to ignore the advice. But what have we come to when the NHS is spending money to make people afraid?
We get asked to bid for contracts with CCGs to provide online consultations through the intriguingly named “Dynamic Purchasing System”. Most of the specifications require an algorithm to triage patients automatically to an appropriate disposition. We explain why we won’t do that because it would be both wasteful and dangerous. We don’t win any DPS contracts.
It doesn’t have to be like this. Public money could be spent on evidence based interventions. Ploughing our own evidence based furrow can be lonely but we’re going to keep on doing what works. As far as we know at 20,000 per week we’re already the largest provider of online consultations, mostly from practices self-funding because they make such a difference to their workload and profitability. They absolutely love it.
Cheer up, believe that better is possible, right now, and smile with the staff at Witley and Milford practice.
PS Barry Sullman showed me the numbers from his CCG this week, Balaam St winter A&E attendances fell by 24% in his first year with askmyGP. That’s the power of human intelligence.
It seems pretty clear that the main plank of government policy towards patients is: let them book their GP appointments online.
The new contract says that 25% must be available online, and they are investing £6.3m in the NHS App with appointment booking the headline feature.
Yet we all know that anything which requires compulsion or bribery is probably a BAD IDEA. The badder it is, the bigger the bung. Good ideas have a life of their own and no government can stop them.
Online appointment booking has been a contractual item for years, and yet while everything travel, banking or retail is online, only about 4% of GP appointments have gone that way. The technology is there already – it’s the GPs who don’t want to release appointments for self booking.
They know that without reception as the intermediary, many will be taken by patients who don’t need them, reducing equity of access for those in greater need. They are even paying receptionists from their own profits to suffer all the stress of turning patients away, rather than put everything online and leave the phone off the hook.
Yet we know that when they trust the practice to give them the help they need, patients don’t even want appointments. We ask them how they would like to be contacted and were astonished to find the average at only 25% by face to face, some down at 11%, GPs begging them to come in.
“Super service thank you for implementing it. Much easier than an appointment” wrote a lady in Somerset today.
So we turn to the Pilot Evaluation of the NHS App. Credit for publishing this for comment within 3 months, but let’s look at the detail:
- 34 practices, given lots of on site support and training over 3 months to 21/12/18
- 3,192 patients used it
- 337 appointments booked, and 106 cancelled.
Now I’m “just saying”, as they say, but in the same period and with only 28 practices we had 100,000 patient submissions on askmyGP. No appointments were booked directly, but they all got help and about 30,000 had a face to face.
We’re coming up to eight years old as a company and I’ve found it necessary many times to do the opposite of the zeitgeist. There’s never any guidance on being counterintuitive and it’s very costly, but what keeps me going is that it works.
I was at a Leicester practice this week for their training and the enthusiasm they have is infectious. Next week a couple more launch in Sheffield and Glasgow. They are all paying for themselves, taking control of their own workload. It’s becoming unstoppable.
Two quick things to do now so as to see the difference:
1. Do the patient demo and get how easy it is, without being able to book an appointment at Bramley Demo Surgery.
2. See how easy it is to respond by signing up to the GP Demo, triage 50 real patient requests.
Summer is coming, don’t spend evenings in the practice.
NHS commentators specialise in gloom as I don’t need to remind you, and this week they have had plenty to moan about with the publication of the latest Nuffield/Kings Fund British Social Attitudes Survey.
Overall satisfaction with the NHS is down 3%, and for the fourth year running the principal reason cited, at 53%, is “It takes too long to get a GP or hospital appointment.”
As sad as it is predictable, the only response from all parties has been “Give us more, more money, time, resources, GPs”. It’s not happening, GP numbers have shrunk this year.
Our latest practice launch this week was a middle of the road performer, with about 60% of demand “on the day” and a long spread thereafter leading to an average wait of 5 days.
In week one they dealt with almost all demand on the same day, achieving a median completion time (that’s completed, not just first response) of 49 minutes. Patients have loved it, with 8 to 1 saying it’s better. All done with no more resources – it’s only possible by saving time, managing 2/3 remotely.
I’ve had two contrasting conversations with practices this week. One is in a prosperous market town, in a brand new multi £million health centre. The GPs know they are making patients wait four weeks for a “routine” appointment, and they are quite happy with that, protected by their contract and local monopoly.
We can’t help them.
Imagine any normal company like us treating our customers like that – we’d be out of business in a minute. And that is why Babylon GP at Hand has a point, even if we don’t share their business model.
The other practice is in a decades old building, serving one of the poorest populations in their city, a minority having English as a first language, and dealing with huge problems of deprivation. Yet they have an absolute passion to help their patients, already providing a superb same day personal service. They just want to make their own working lives sustainable too.
We can help them.
Looking forward to more launches next week. Glad to say that every one gets easier with new features, this week it’s the NHS Spine lookup for patients, improving accuracy and saving time on reception.
PS GPs with that service ethos, don’t miss out any longer. Start with our free online demo.
Today’s guest blog is by Dr Hugh Reeve, senior partner at Nutwood Medical Practice in Grange-over-Sands, Cumbria. Not exactly a population pyramid, with 40% of patients over 65 Nutwood boasts more of a population parasol.
Below is his series of almost daily tweets over the two weeks since launch, and I think as the story unfolds you will be moved as I was.
Over to Hugh…
6/2/19 Day 1 AskmyGP. Wow – all today’s work done today. Online take up impressive for day1. Staff coped – 2 said it was best Weds ever! positive pt feedback. Drs slightly frazzled getting head round new system and strange only seeing f2f 30% of usual numbers 😀
7/2 Day 2 @askmygp 89 yr old sent me online message about her shoulder! Our salaried GP cleared all her admin & finished at 5.30-first time she’s left before 6.30 in 3 years. We had 62 new requests for help -phone and online-of these saw 15 people f2f. We’re cautiously optimistic!
8/2 Day 3 @askmygp GPs managed am and pm coffee breaks. 76 problems sorted – 32 f2f and one home visit. 89yr old who emailed yesterday sorted – one phone call and joint injection arranged next Tues. Old system would have taken at least 2 weeks! Next Monday’s rush the real test!
9/2 One of my partners told us of the incredulity and gratitude of a patient who was seen in surgery one hour after sending an email for a non-urgent problem.
Anyone that needs a physical examination we arrange to come in and see us – the same day they contact us , or visit at home. We now also get tests/xrays etc done first and then see people. Previously we phoned about 25% of pts and saw 75%, early results we see about 30% now.
Our access not bad at all but as you know continuity a real issue. Early signs are it could really help this.
11/2 Day 4 @askmygp – best Monday in 13 years at Practice. Gobsmacked! Pt with ?intracranial bleed after HI 10d ago-sorted CT-pt wanted routine appt, 10d wait on old system. Colleague spent 40 mins with pt who burst into tears at reception, she still left at 4.45pm with clear desk!
13/2 Week 1 @askmygp A revelation! 373 contacts of which 71% by phone and 29% online- this for a practice where 40% patients 65 or over. Of these we saw 30% f2f. Staff love it – no more telling pts no appt. Feedback from pts so far almost totally positive No downsides yet! I’m 😄
Pt feedback from pts at our Practice using online service @askmygp in week 1. Amazing Wonderful Excellent Brilliant Worked perfectly Professional Quick Instant Superb Astonishing First class modern service Time saver Reassuring Good technology. This is surely what it’s all about😀
14/2 Real test for new @askmygp system today. One GP sick leaving 1.5 GPs to do today’s work. Real benefit of no full surgery to rearrange-just one person booked in. At end of day all work sorted. One GP had 48 contacts 40% f2f, said still better than when crisis hit under old system!
15/2 No signif downsides as yet Peter. However have to make sure enough capacity available each day and understand the predictable demand for each day of the week otherwise the system will grind to a halt.
20/2 2 wks @askmygp. Getting used to system and love it. Pts seem to as well 34/37 online users think it’s better. 33% of all contacts coming in online and increasing by the day. More time to follow things up, phone people with results etc. Waiting time for a routine f2f appt <1 day!!
We still have work to do adjusting to a radically new way of working. Also fair bit of preparation beforehand. But so far gone better than we expected!
We book very little in advance now, starting the day with near empty schedule and as far as possible deal with today’s work today. At present we see f2f about a third of people who contact us and deal with rest either on phone or online.
Thanks Sam. Have never fallen out of love with general practice but was definitely very jaded. Now in my early 60’s and feel like the embers are starting to glow and real energy returning. Sounds a bit corny I know but true. This will keep me working – because I want to 😀
The Department of Health and Social Care published on 19/2/2019 its Code of Conduct for data-driven health and care technology.
Our response to the ten principles follows:
- Understand users, their needs and the context. askmyGP users are broadly two groups, patients and providers which includes all GP practice staff. Our design principles are for simplicity and ease of use, a difficult task when appealing to patients of all ages and abilities, both in general education and familiarity with online tools. We cater equally for proxies (parents and carers), all gender expressions, and keep language simple to help those with limited English. To assess our effectiveness we monitor age specific adoption by patients in each practice, and feedback from patients informs our development process.
- Define the outcome and how the technology will contribute to it. Our mission is to make it easier for patients to get help from their own GP, and easier for GPs to provide that help. We measure attainment against this outcome by volumes, response and completion times, and measures of efficiency through resolution mode by providers. We also collect and monitor patient feedback and present all measures to the provider organisations.
- Use data that is in line with appropriate guidelines for the purpose for which it is being used. We comply with all relevant legislation including GDPR, Data Protection Act 2018 and collect data only for necessary purposes. Personal data is processed on behalf of providers (the data controllers), stored and transmitted encrypted and over the secure N3/HSCN network. Anonymous data may be used for research and marketing purposes as allowed under the same principles.
- Be fair, transparent and accountable about what data is being used. All data is used in accordance with Caldicott principles, and the conditions are agreed by patients and providers.
- Make use of open standards. We support the use of open standards and wherever technically possible provide open links to others for legitimate interoperability reasons. We use standard NHS number coding for any authorised data transfers.
- Be transparent about the limitations of the data used and algorithms deployed. We collect and transmit plain text and other file formats between patients and providers, but we do not use algorithms to produce triage decisions or advice to patients.
- Show what type of algorithm is being developed or deployed, the ethical examination of how the data is used, how its performance will be validated and how it will be integrated into health and care provision. We do not develop algorithms. We do offer a third party service with Isabel Healthcare, which uses a machine learning approach. Our users may enter any number of symptoms, and be shown a range of possible conditions.
- Generate evidence of effectiveness for the intended use and value for money. Integral to our offer to all customers is standard reporting on usage, patient service, timeliness and efficiency through the use of askmyGP. We provide an economic model (Loadmaster), configurable by each customer, which demonstrates their value for money. We also conduct our own analysis of performance and value and may publish on this site and in other media from time to time.
- Make security integral to the design. From the outset of design, security has been built into askmyGP. Key features include:
- N3/HSCN access required for all live patient data by providers.
- Encryption of all patient data in transit and at rest
- Strength checked passwords required for all users.
- Separate code and database for live and demo systems
- Independent penetration testing and fulfillment of all comments raised.
- Define the commercial strategy. Our strategy is that self-funding customers should see a high rate of return from their investment, and do so from the date of launch (typically four weeks from engagement). Growth is therefore not dependent on taxpayer funding, but on efficiency and financial savings generated through the use of our services.
Harry Longman, 21 February 2019
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.