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.

Harry Longman

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.

Do you glaze over when they report the latest A&E statistics?  It’s all about what % of patients were seen within four hours.  The latest figure for July is 89.3% and while it produces a lot of headlines, gnashing of teeth and calls for more resources, the saddest little note in the NHS England Statistical Commentary is where it says, “The 95% standard was last met in July 2015.”

Readers of this column know that I’ve been campaigning against the target culture that grips the NHS for many years.  For me the personal journey was working in manufacturing in 1990 when I came across the work of W Edwards Deming, who said we must abolish all numerical targets.  I fought against that thought internally as I tried to come up with ever cleverer targets for the factory, to cover all bases of timeliness, efficiency and quality.  Until I crumbled – they could never work.

Nearly thirty years later we have this regime in the NHS which daily makes hard working professional people feel like failures.  It has seen off a string of hospital chief executives who were either unlucky enough or failed to cook the books enough to keep their impossible jobs when the inspector called.

Measurement and accountability matter, but they are completely different from targets.  Just briefly, let us suppose that the time to be treated in A&E matters – well I think it does – we can measure the median time, and chart it day by day, week by week, ever so simply.  Everyone can be engaged in improving the system which will show in this and other appropriate measures.  Fear of failure is replaced by pride in work.

I’m building up to some quite astonishing news but while we are on the theme, similar thinking is applied to ambulance response times.  Red C1 and C2 calls have to get a response in 8 minutes 75% of the time, and there’s a vast bureaucracy, dreaming up and calculating the numbers and beating up the failures.  Sigh.

Back in the GP world thankfully there are not so many high profile arbitrary targets (arbitrary ratings on arbitrary measures by CQC are another matter) but there is related anxiety about some of what we do.  We get asked “How does your online askmyGP system handle red flags?”  I assume on the basis that the patient may have something urgent wrong with them.

My answer is always the same:  “Red flags are dangerous because algorithms cannot completely and safely cover all eventualities, yet they can give a false sense of security.”

Because we are very concerned about patient safety, we have a different approach, which is to understand that safety is a function of the system as a whole.  Rapid response by a GP, appropriate to the patient and their condition, is a very safe system.  Oh, and we make it very clear to the patients, “Do not use in emergency.”

We are also very clear on what they can expect, which is a next day response out of hours, or in working hours “usually within the hour.”

When GPs doing our Pathfinder diagnostic hear about this they often blanch and explain how they would water this down as it’s clearly impossible.  And then we look at the data.

So here is the astonishing news from the first two practice launches with our new software (no, you didn’t miss anything, we haven’t announced it yet).  In the first week of operation they achieved a first response average time respectively of 6.0 and 5.2 minutes.

That’s a personal response from a GP who has seen their request and triaged how to help (a face to face may come later).  But it’s average, all demand, not just what someone considers urgent.  No blue lights, no inspectors, no targets, no pressure, no overwork, no rework, just ordinary GPs, predictable demand and good flow.

Have an ordinary weekend.

Regards,

Harry Longman

PS Dr Simon Wade of Webinars for GPs has invited me to present this Wednesday 22nd August 8 – 9pm.  Do join us on “Workload stress and burnout: can online access make a difference?”  CPD points too!

What a week!  I don’t refer to the lack of grown-ups in politics, but in our world the self-styled “Devil’s Advocate” was forced to resign from NHS England last Sunday.  At GP Access Towers we sobered up by about Wednesday and can now reflect on the long shadow he has left.

Master of obfuscation, Arvind Madan made his centrepiece the GP Forward View, on the face of it £2.4 billion extra per year for general practice, in reality a myriad of little funding parcels in Kafkaesque wrappers.  It produced immediate returns for the Hurley Group with the award of a 3 year £19.5m contract for what they love to call the “NHS GP Health Service”.  The patients are NHS GPs, the provider is private, led by their own Clare Gerada, who endlessly regales us with her doctor as victim narrative.

The £45m online consultation fund is ring-fenced so CCGs have every incentive to spend it, whatever the evidence, and little incentive to examine products in terms of value for money.  Procurement is being done by CCGs on behalf of users, rather than GP users themselves, and the 3 year term gives no chance for review.  NHS England’s specification matched Hurley’s eCONsult closely enough and it has scooped up the lion’s share of contracts, despite 5 independent published papers exposing its tiny usage and unmet claims.

But these are niggles compared with the undermining of traditional general practice we have witnessed under Madan’s regime.  £2.4bn shared equally would be £45 per patient, an uplift of over a third on the revenue per registered patient for GPs.  While that is not the only way to spend the money, and it may not all be there yet, it is clear from normal practices that they have seen precious little return from a lot of complexity.  Both BMA and RCGP have made this point:  where is it all going?

The devilish policies Madan advocated anonymously online were backed by huge sums directed at services outside traditional GP.  Euphemisms litter the GPFV marketing machine – who could argue with “collaborative working”?  But who can say what it actually means?  Extended access sounds so desirable, but what that means is directing patients who wanted to see their own GP at their own surgery to see someone else in a different location at time they don’t want.

The NAO showed that these services even as planned are 49% more expensive than core GP.  We understand the reality is much worse, with many empty slots and rework back to own GP.  The numbers take no account of the loss of continuity, never mind inconvenience to patients, and the fact that as patients are already registered to a GP, the whole exercise is double commissioning.

Trying to tot up the amounts being thrown into this known sinkhole via such opaque documents is beyond me at present.  I’ve read £6/patient being offered, which makes £321m, probably too low but can anyone help?

It won’t surprise you that Hurley run 5 urgent/extended hours centres.  Far from promoting better access and accountability in core GP, which is most effective and efficient, these centres profit from and legitimise poor access to local practices.  Watch this space for more evidence.

Madan was not the originator of NHS England’s intoxication with larger “GP at scale” but as a partner in a very large practice he was an enthusiastic and supremely powerful promoter.  All without a shred of evidence of better outcomes or efficiency, indeed poorer continuity and lower patient satisfaction with increasing size.

In his own words, most businesses would be “pleased to see a rationalisation of their markets”.  Sure the survivors would.  Having a view is one thing, having the power to tilt the scales is quite another and it would not surprise me to see legal challenges to NHS England from smaller practices.  Has the commissioner acted in bad faith through its policies by treating contractors differently based on size?

So where is the light?  Firstly, for the jewel in the crown of the NHS to be less in thrall to a tiny, commercially conflicted clique can only be a good thing.  Secondly, there will be new leadership, who may be open to evidence. The failed policies of recent years need to be turned over and fast before more damage is done.  It’s no secret that GP morale is at rock bottom, reflected in the difficulty of recruitment in pretty much all areas.

Talking down GP partnerships as Madan’s Hurley partner Gerada has done for many years, while tilting the economics against them, has had the desired effect.  Funding has been diverted from relational GP to sessional ie transactional contexts, impoverishing patient experience of the NHS.  This is not inevitable, it is the direct result of the policies above sucking the life out of one of the best careers in the UK.

We have a new SoS and Hancock’s Holy Trinity of “improving outcomes, helping clinicians and saving money” is a perfectly good start on the purpose.  The next step needed is clarity on how to measure the outcomes.  I wonder whether Hancock has the courage to sweep away the arbitrary targets which have stifled the NHS since the Blair years?

Then there’s the question of how. What works?  How can we make it work better?  It’s not a question of money, it’s a question of method.  Those in the know know that if you get this right, the money comes out right too.  There are plenty of excellent people in NHS England and general practice, and if Hancock can set us free to innovate, with clarity of purpose, patient-centred outcome measures and insistence on evidence, the sky’s the limit.

Regards,

Harry Longman

PS For balance, praise for the GPFV from this Pulse contributor:

Alan Almond | Locum GP 21 May 2018 5:47pm

“It’s great to see NHS England valiantly fighting to make sure patients up and down the country can’t get to see their preferred GP. Heart warming that continuity of care continues to be dismantled in this way, and reassuring to hear the program rolls on. Always these guys are fighting for what patients, time and again, survey after survey, say they want, appointments on a Sunday with a Dr they don’t know. Great work guys, truly your doing great work.”

PPS It has been an exciting week for us internally too.  I can’t say too much yet, but we are only weeks away from a public announcement.  The first few customers have pushed us further and faster than we dared to hope.  We’ll be talking about superpractices – of all sizes.