Looking out on the rain, memories quickly fade of, for once, that glorious bank holiday weekend.
In GP land you may have noticed a lighter week too, because demand is predictably sensitive to weather – whether warm sunshine or heavy snow.
We need to qualify the effect however, because if your system is book ahead and wait, lower demand only shows up as a smaller backlog and maybe less pressure on reception. You will still see the same number of patients who have patiently waited whatever the urgency of their need, and it will feel like a treadmill.
The point of a demand-flow system is that there’s always plenty of capacity for the predicted demand, and if it comes in below prediction, you can enjoy the sunshine. A colleague of mine visited one practice we work with on Thursday lunchtime and there were just no patients, time for chat.
Now with summer on the way it is of course the perfect time to put that demand-flow system in place but let me tell you about a real problem we are struggling with.
I can name three practices right now where they are very clear on the challenges they face, they can’t cope with the workload, they know the service is terrible, and their receptionists are getting abuse every single day.
They’ve done a thorough analysis, all the surveys, know exactly what to do, and four GP partners can hardly wait to get going. But one, or perhaps two, partners have dug their heels in.
I’m a great fan of the partner model for a host of reasons, and I haven’t seen a better one, but it has its drawbacks. One partner can veto any change. They are condemning the others to live with the same or worsening situation. Why isn’t there a veto on doing nothing?
Fundamentally I think this imbalance in favour of inaction is holding GPs back, perhaps the whole profession, even if a majority can see what needs to be done.
Are you in this situation or do you have any suggestions?
Meanwhile two north east practices launch on Monday and let’s hope they enjoy the summer.
PS: One who did act was Dr Sue Arnott and she joins us for this Thursday’s webinar at 1pm.
Some background on how she came to be running a 4,700 practice as a single hander here.
Many have asked for the first in the series recorded, so it’s here, 45 minutes, “Exploding the myths of online consultations”
GPs are talking an awful lot about online consultations these days, with another BMJ article (paywalled) out last month from Martin Marshall.
From many conversations I find most divide into three groups:
- the wishful who expect online access magically to divert patients away
- the fearful, convinced they will be buried in trivia when patients have a new way to get at them
- the conflicted who believe both the above at the same time
if you’re familiar with the published evidence (BJGP on eCONsult 2017) you’d be very skeptical of any claims.
But having managed well over 100,000 online consults in two versions of askmyGP over three years, we’ve gained quite a bit of experience of what doesn’t work. We still have a number of practices where it doesn’t work.
So which group is closest to the truth?
I’ll be examining the emerging evidence in the first of our webinar series next Thursday 3rd May 2018 1pm, 45 minutes
It’s already booking up fast and though free we have limited participants on our new Zoom platform (which we love by the way).
There’s a fourth group of course, and we’ll come on to them in the next webinar but first it’s important to understand what doesn’t work. We’ll look at technology, implementation, even beliefs and I can tell you, innovation is over 90% failure so much of the hard won evidence will be painful to relate.
Do join us next Thursday at 1pm.
askmyGP & GP Access Ltd
PS: I’ve had to update the blog from last week from Dr Barry Sullman at Balaam St Surgery. I would never dare to promise the new life he leads. And he can’t stop talking about it.
NHS England has trialled four digital versions of NHS111 in an attempt to shift channel from telephone to online.
An internal report dated December 2017 and obtained through HSJ reveals the astonishingly low take up of these heavily marketed pilots. Download the full report here:
Data contained within the report shows the four trials covered a population of 7.5m for the period February to June 2017. The total completed digital triages came to 8671.
A separate chart shows NHS111 telephone volume at around 1 million per month, for a population of 50m.
The digital trials covered around 15% of the population, and over the 5 months of the trial would see pro rata around (15% x 1,000,000 x 5 months) = 750,000 calls.
Digital triages therefore accounted for 8671/750,000 = 1.2%
We know that the digital option was heavily marketed in the four pilot areas, in the public domain, GP surgeries and through IVR messages. We have no idea of the costs incurred.
We can see by comparing the charts that conversions from “I registered or downloaded the digital solution” to “I completed a triage” range from about 60% for Babylon and Sensely to 30% for Pathways and 10% for Expert 24.
Figures given on dispositions are compared to 111 phone triage dispositions and what is striking is the similarity. Much is made of the 18% advised to self-care. However, it is very disturbing to see 20% advised to call 999 or go to emergency. Compared with GP audits of their demand, which they rate at around 0.5% as emergency, these are astonishing numbers. Work we have analysed with a GP led OOH service showed GP disposition to ambulance at 1.4%.
Following the advice of the algorithms would multiply use of emergency services by a factor of 10 to 20.
Worse than this, we suspect that the low take up means the diseases entered are highly unrepresentative of the overal disease burden, and are likely skewed to conditions which are “easy to triage” and therefore less acute.
Given the above analyses, and if you knew the eye-watering costs incurred, what would you do?
PS The conclusion of the report’s author may surprise you, page 4:
The learning from these pilots supplemented with data from other health systems and from
other online services would continue to support the case for an online interface for urgent
care. This evaluation does not recommend one product over another but demonstrates that all
products have some similarities and differences but all products tend to support channel shift
and management of demand whilst providing patients with a good experience.
To gain further understanding of NHS111 Online and the impact on the health system, larger
data sets and linked data will need to be considered. Therefore, the expansion of pilots and
further analysis will enable a more robust evaluation.
When there’s a chink of light in the dead of winter (and wall to wall NHS crisis on the BBC) we have something to celebrate.
I spoke with Dr Sue Arnott, who runs a practice of 4,600 patients in a traditional ex-mining community in central Scotland. She had tried for months and failed to recruit a GP, so is now running single handed, supported by an ANP and further part time nurses.
She explained how they are now up to about 60% of demand online, of which she responds by secure message to about 60%, largely without even a phone call. It means she has time for all the patients’ needs, in the appropriate mode, today, and is on top of demand, feeling in control.
How? There’s no coercion involved, just that the receptionists point the patients to the website, show them where to start and help as needed. If not possible, they’ll take the request by phone. And patients are very very happy.
When we were first in touch in the autumn I was more than a little concerned about the few GP sessions for the list size, and said they’d need to go all out for change. They have, they love it and they are providing a fabulous service. That’s my cause for celebration, because anyone can do it.
Philip Hammond is not going to bung any more money into the NHS. Even if he did, Jeremy Hunt is not going to magic 5,000 GPs out of thin air. (and I submit that it’s immoral to recruit them from nations where doctors are even scarcer).
Patient demand is not going to go away because we tell them to self-care more (we’ve been telling them for decades. They know).
So we have the demand that we have, and the GPs that we have. But by changing the system in every practice in the UK, which is up to every GP in the UK, we can manage.
Indeed we can thrive, like one practice in Lanarkshire.
PRESS RELEASE 3 January 2018:
askmyGP overcomes NHS Choices search gremlins with new free webapp
Patients are being urged more than ever to self-care, in order to cut demand on NHS GPs in the winter season. While NHS Choices provides high quality advice, until now searching the site has been hit and miss.
askmyGP, the leading online consultation platform, announces today a free version which lets patients search NHS Choices with a unique smart search algorithm.
Founder Harry Longman explains the reasoning:
“We’ve always directed patients to seek self-care advice from NHS Choices. It covers virtually every medical condition, the information is clearly presented, evidence based, and free. It carries no advertising and never tries to sell to patients, whether medications or consultations, as other sites do.”
But the weak area has been search. Put “Back of knee hurting” into NHS Choices and you’ll see “La Bomba dance workout video” – not exactly what you were hoping for.
The same phrase entered into askmyGP takes you straight to knee pain and its potential causes.
Many similar examples are exactly as entered by real patients. “3yr old holds his breath”, NHS Choices: Your guide to an echocardiogram. Or Dentures. Perhaps not.
“Had coff for over 5 weeks”, gets you Norman’s Hip Op video.
Try all these in the askmyGP demo site and compare with NHS Choices itself, even though all our content is provided by NHS Choices. What patients want is a smart but sympathetic search which won’t quibble over how they spell diarrhoea (we’ve found the right page with hundreds of spellings in askmyGP, from diria to dhearrorrea).
We don’t believe NHS Choices content should be reformatted and sold back to the NHS for private profit, as some suppliers have done. What we sell is the askmyGP online consultation system, helping more GPs and patients every week (over 25,000 episodes managed so far).
We’re giving away the very best we can offer to help patients self-care. The askmyGP search webapp is available from January 2018 to all NHS practices and organisations, no strings attached, it’s free, for everyone and for anything.
Note to editors: askmyGP is provided by GP Access Ltd, founded in 2011 with the vision “To transform access to medical care.” We are serving NHS GP practices, CCGs and Health Boards in all four countries of the UK.
Chief Executive Harry Longman, 01509 816293, mobile 07939 148618
I guess that like me a lot of your time is spent grinding through one (damn) thing after another. In the short days and long nights it can seem like more grind than ever.
So when plans struggled over for years suddenly work it’s a very special day. It feels like the sun coming out on the brilliant white of fresh snow.
Dr AV, a single hander GP in Scotland with 2,900 patients emails me: “Best Friday I have had in 2 years!?”
The reason? He’s in control, he’s reached 50% of demand online, the rest by phone, and he and the team are dealing with everything as it comes in. In the middle of December he writes “We have free slots – many in fact – on any given day !?”
Sorry I don’t even know how to write emojis but I think that means a cheesy grin.
Actually, he’s not the only one, Dr SA has done the same, and she has even more patients. I’m using initials because they don’t necessarily want you all to ring them up at once.
What was it that suddenly made the difference? Last week I promised to tell you if it continued. Well it’s so ridiculously simple that I’m almost embarrassed to say.
We’ve had this idea on one of our powerpoint slides for months, but never really pushed it because no one had tried it so we didn’t know it would work.
The receptionists guide the patient to the practice website and get them to try askmyGP. They are even more effective than the GP giving a telephone message. They love it – they feel empowered too, and when the requests come in they are better equipped to deal with them – many are answered by secure email.
The GPs love it because every single one is saving minutes, and when you’ve 3,000 patients to manage, and preparing for Christmas too, that counts for a lot.
One terribly important point I must make: there is no forcing patients online. You may hear of other case studies where the telephone option has effectiively been removed.. We refuse to condone such an approach – in fact, telephone service improves.
Look, the vast majority of things that we try, fail. You don’t hear about them, and we try a lot, and some of the failures are painfully costly. So when something works, we might as well ? about it.
Anyway, you can see what the receptionists and GPs are directing patients to do on Bramley Demo Surgery.
askmyGP & GP Access Ltd
Comment on the blog
PS You might even say the struggle goes back to 1981 when the electronics lecturer is trying to explain to thicko engineering undergraduate why asynchronous communication is so much more efficient. He wins.
Do you find yourself getting asked for feedback the whole damn time? Ever wonder what happens to it? I admit to being the bloke who stood in the customs area at Luton Airport for 10 minutes, hitting the Friends and Family sad face just for devilment, but please don’t do as I do…
I want to give you some insight as to how we use patient feedback because it’s a big part of our development process and we have some rather good news to report.
The first thing is to get lots of feedback, make it very easy and quick to collect, without being intrusive. So we give every patient the chance after they’ve sent their askmyGP request online. They get two tick box questions and one free text.
The response has been huge, over 2,200 from nearly 20,000 patient episodes, a rate over 11% of users and it shows how much they care about their experience.
We read every one and mark it positive, negative, suggestion or other. Other is mostly don’t know yet, or issues with the practice rather than the software. We get lots of suggestions which is useful. Overwhelmingly the sentiment is positive, the strong themes being speed and ease of use.
The positives are uplifting but in a way they don’t help as they don’t tell you what to do. We’ve been running at about 10% negatives, they can hurt, and sometimes they don’t pull punches
“I absolutely hate this system. Too impersonal, takes too much time.”
So we’ve taken a hard look at the themes and made a number of changes, some quite subtle, over the last few weeks. Two weeks ago negatives fell to 7%, and last week to 4%. It’s wonderful to see. Positives don’t go up, but suggestions do as patients feel they have something to contribute.
Yeah, OK, I’ll end on a positive note, this from a lady last week:
“Amazing service! It has improved my experience considerably. No more calling for 30 mins at 8am and a fast response from the doctors.”
It’s a team effort. Biggest part of the experience overall is the speed of response from the practice and the care from GPs.
Last weekend I was in London and faced all over the Tube with Babylon’s “GP at hand” adverts. If you’re worried about them bagging 150.000 patients, don’t be.
You can do better. Easy.
How is your Monday going? If you’re a GP, I already know the answer, it’s busy, because 28% of the week’s demand arrives on Monday, and 3/4 of that in the morning. It’s not news.
News last week was that GP numbers have fallen by 1,300 over the last two years. A bit of a problem when at the half way point to Jeremy Hunt’s election pledge of 5,000 more GPs, we’d have expected growth of 2,500.
We need happier GPs.
The Dutch have happier GPs. Listen to Jako Burgers tell the RCGP conference why (20 minutes or so). Students compete for their GP training places, they recognise it as a top choice.
There are differences in funding and so on, but a lot about the system is similar to ours and they are paid about the same. Practices are smaller, there’s no obsession with scale, and they love the independence.
Let me float this idea for the UK: GP opening hours are too long. For many years now more women have been joining GP, but 8am is too early to be family friendly, and a 6.30 finish is too late. While we’re there, why shouldn’t fathers be at breakfast with their school age kids? Of course they should.
6.30 finish? “You’d be lucky” I hear partners say. Yes, many GPs are working very long days, I’ve heard 12 – 14 hours. Then taking days off. Working with hundreds of practices we almost never come across a full time GP.
I’m not proposing to cut GP working hours, though we should cut pointless overwork. But to spread them out evenly. Operationally it’s much better to work a regular five days, reasonable, family friendly hours, offering better continuity to patients.
I’m not proposing to cut access to GPs, but improve it (clue’s in the name). The difference in pushing back opening from 8 to 9 is an hour – compare with the three week wait forced on many patients. (by the way, the Austrian health department is trying to get GPs to open in the afternoon). Extending hours to 8pm and opening weekends for routines is catastrophic – sucking GP capacity into low demand periods, destroying continuity and burning money.
Understanding demand and flow means help for patients within the hour is not just normal, it’s easy. Minor problems we have with the Transform programme are firstly, we know that GPs starting work at the same time as reception is crucial for daily flow, and 8 is too early for many. Secondly, part time working causes uneven capacity through the week.
While our policy makers focus on inputs, number of GPs, number of hours, we need to look the other way. How do we make GP more professionally rewarding and practically possible?
Jako Burgers: “Happy GPs will do a better job than unhappy GPs.”
It’s not rocket science is it?
At long last the CAPC study on eConsult has been published in BJGP.
“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.”
From his online response to the study, you might think that chief executive Dr Murray Elliender were running a charity. This is far more than simply capitalism red in tooth and claw. eConsult clearly would not be sustainable were the truth known about its performance, well known at the time to Dr Ellender and his partners as he makes clear.
But one of his Hurley Group partners is Dr Arvind Madan, NHS England National Director, Primary Care and author of the 2016 GP Forward View, which helpfully includes a £45m fund, ring fenced to be spent only on e-consultations, in which the company is already a 90%+ market leader.
Another of his partners is Dr Clare Gerada (BMA council, RCGP council etc) who emailed “50 most influential GPs” on 16 December 2016
“…As a leading member of the GP community, I hope you don’t mind in me blatantly promoting Web-GP (now known as e-Consult) an on-line GP consultation platform that myself and my partners developed three years ago.
eConsult is designed to make general practice more efficient… NHSE has announced funding… please have a look…contact firstname.lastname@example.org”
I’ll leave aside the misuse of nhs.net email for commercial gain, strictly against NHS rules, as much more is at stake here.
That study on eConsult again “…the overall feeling from practices was that e-consultations did not save time; the system generated work by adding another stage in the workflow for GPs and administration staff.”
So who put the CON into eCONsult?
Sometimes the NHS does spend money on stuff known to be worthless. £92,412 went on homeopathy in 2016, but they’ve stopped that.
The funny thing is that so many GPs, some of them quite prominent, have told me over the last two years the same story of their experience with eCONsult (The study quotes a range of daily use from 0.2 to 2.9. Almost homeopathically tiny concentrations).
The sad thing is that unlike homeopathy, digital triage from online requests for help is fundamentally a sound idea.
This is my note of hope for the day: we set out for askmyGP to have 10 or 100 times the use, and it’s working. Only then can it increase efficiency, and only with rapid parallel service by telephone can it guarantee equity for patients who can’t access online.
We are determined that CCGs should not be forced to waste their ring-fenced funding, but have a choice. That choice should be based on evidence of what works, not who’s behind it.
You cannot have failed to notice Babylon’s GP at hand service all over the media this week. As a PR exercise, on the Today programme, You and Yours, TV, front page of the Times and an almost unheard of positive story in the Daily Wail, it was SIMPLY BRILLIANT.
What you may not have appreciated is the existential threat this makes to regular NHS GPs. While presenting it as “the NHS has suggested that the service may however be less appropriate for…” the list of exclusions is in fact the engine of profit for Babylon. Read the list. It’s 90% of a normal GP workload. It begins with women (twice the consult rate of men in middle years), who are or may be pregnant (more work. And babies – lots of work). All the usual suspects, the elderly, sick, frail, confused and multi-morbid are there. They are work. Babylon doesn’t want them.
Babylon has got something spot on: patients are fed up with the often abysmal service from their current GP.
They want the young, fit and healthy, especially men, who rarely need a GP but when they do, want help fast, and don’t want to bother with going to a surgery unless they have to.
All these patients carry the same capitation. Think: what if you lost half your income and the easy half of your population? But kept 90% of the work? If it isn’t obvious yet, GPs will go under. That may not be you, but your neighbouring practice, whose list will be dispersed… to you… and you know those dispersed will be high demand. Nice.
They are in London so far, but Babylon’s ambition is limitless and I fear a multiplier effect from the mechanism above. They have the law (practice boundaries abolished), the funding model, the technology, the demographics and clearly the PR on their side. No doubt BMA is dreaming up legal challenges as I write, but they are no match for weasel words backed by £60m of VC money, while changing the law takes years, at best.
If it were simply about better GP services, I would be cheering. But the inevitable consequence is to stoke the Inverse Care Law. Those who most need help will find it most difficult to obtain. General practice will be dramatically less profitable in the hardest areas, and will suffer even in the most privileged. This undermines nothing less than the core principles of the NHS, universal, accessible and free at the point of use.
I will end on a note of hope, because this is not hopeless if we act fast. I founded GP Access & askmyGP with the vision “to transform access to medical care” and some might say Babylon have achieved that.
But our vision is universal. We have no exclusions. We understand the quality and safety from relationship continuity, to say nothing of the professional joy in work.
Although Babylon’s offer is getting the PR, it’s actually not that great. 2 hours for a video? So slow. 48 hours to be seen? So long. Travel within zones 1 – 3? So far to go.
You can beat it. Faster, easier, closer, with the GP you know.
As @stevekellGP tweeted yesterday, “All patients contacting the surgery today for GP help have spoken to GP & been seen if needed. No DNAs, clean start tomorrow. No videos needed” – most of them spoken to within half an hour.
If you haven’t seen his 2 minute interview you really must.
Our vision is of a transformed general practice that you own and you run for the care of all your patients. It is not a transformation done over you by the power of money.
I’ve been saying this for six years. Now wake up GPs, before it’s too late.