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:

1.  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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.
10. 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

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.

Kind regards

Harry Longman

PS: One who did act was Dr Sue Arnott and she joins us for this Thursday’s webinar at 1pm.

Online consultations – what is working and why?

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”

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:

111 Online Evaluation DRAFT_

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?

Harry Longman

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.

With the publication in this week’s BMJ of the Tele-First study into the telephone first model of general practice, you would expect me to read carefully and respond.  So here are the headlines:

• 65% of patients report being phoned by a GP in less than one hour.
• 56% of patients find it more convenient vs 22% less convenient
• Large improvement in length of time to be seen, 20% move in GPPES survey.

At a time when we are told repeatedly that patients are having to wait ever longer to see a GP, often measured in weeks, these are quite astonishing figures, all quoted direct from the report.  But, dear reader, these are not the headlines you have seen in Pulse or the BMJ Editorial are they?  Studies, and the interpretation of studies, are political.  We have an interest, and so does everyone else.

Therefore the first thing I want you to do is read the full text so you can make your own mind up independent of headline writers.  It is much more detailed than the print version, framed by an angry looking GP model and a scared looking patient model, giving more space to a commentary piece than the actual study.

There is much to absorb but for brevity I’ll comment on the summary section.

What is already known on this topic

• GPs are struggling with the current demands on general practice and looking for effective ways to manage patient demand
• Claims have been made, reproduced in NHS England literature, that a telephone first approach, in which all patients wanting to see a GP are asked to speak to a GP on the phone first, results in major cost savings for primary care and reductions in secondary care costs

We do not make those claims, they were made on the home page of PPC Doctor First, a 20% drop in A&E and £30,000 saving per GP per annum. I’m grateful to the authors for proving these false. *

What this study adds

• In general practice, many problems can be dealt with by a GP on the phone
• The new telephone first approach resulted in more phone calls, fewer face to face consultations, and, on average, more time spent consulting
• There was wide variation between individual practices, including large increases and large decreases in workload after adoption of the telephone first approach
• There was no evidence that the telephone first approach would reduce costs of secondary care

In a way it is disappointing to see no secondary care effect, but not unexpected and unless the evidence changes, that is what we accept.

But what has really got GPs aerated is this finding of “more time spent consulting”.  This was derived from data sent by us to the study, which we have not used to make a calculation on workload for several reasons:  much of it is missing (and as the authors state, had to be imputed), it shows wide variation, and it cannot account for total workload.  Let’s consider:

Workload = demand/efficiency + non-clinical work + waste

We do not have a reliable way to measure the total, and given that the study used only one of our three datasets, I don’t see how they can make this assessment.  Just one example:  many practices have told us of the drop in home visits, each one saving the time for many surgery consultations.  This is not measured.  It may be a good thing to have more recorded time consulting, if less time is wasted.  Not only does this finding seem to me unsafe, it also brings us back to the question of purpose, for the study and indeed for the NHS.

If the purpose is to minimise GP workload, we can do so very simply:  design the working day so you see 4 or 5 patients in the morning, take a good lunch and a nap, then spend a little time in personal reflection and development before heading home., purpose achieved.

I’ve worked with a lot of very hard working GPs and they would not be satisfied with that purpose.  No, the purpose of general practice and therefore the purpose of change must be to improve patient care.

There’s a missing term in the workload formula, and that is “unmet need”.  Behind those words lies untold suffering and frustration of patients, heard perhaps by a receptionist (one wrote last week, “I dread having to tell the patients there’s nothing left”) while others do not even get through on the phone.  This is the dirty secret of general practice, and over many years we’ve measured it in practices we’ve helped, variable around an  average of 14%.

One in seven patients is told to go away.  Although we offered this data to the study team, they didn’t want it and took no account of it.

Their figures cannot distinguish between the workload of one GP helping 30 patients in a day, who had all waited two weeks, and another helping 40 patients in a day, on the same day they called.  It could be life changing for those 10 patients, indeed all 40 of them for not having to suffer two weeks of disease, pain, or anxiety.

Both GPs may have equal skill and compassion, but the difference comes from efficiency.

By framing the question on workload rather than efficiency, the study misses a huge opportunity.  It offers no help on how to become more efficient, and while it found wide variation in performance, the data were munged into averages rather than investigating in detail why the best ones worked better.

I’ll tell you a secret:  we’re in this for the patients.  To help the patients we have to help the GPs be more efficient.  There is never a final answer to the method, there is only “the best we know for now, while we look for the still better way”.

We’ve helped around a million patients so far, with another 50,000 to be added in the next month. and as telephone triage (done well) is more efficient than pre-booked face to face, digital triage is already proving to be the next step.  Sometimes we fail, but we press on.

Every day over 100,000 patients are told by practice receptionists “Nothing left, call another day”.  Not on any basis of clinical need, just because the GPs have no slots.

It’s my personal mission to eliminate that phrase.  What’s yours?

Regards,

Harry Longman

* The 20% A&E effect came from my 2011 study, based on pioneer practices with up to 10 years running the model, and promising at the time.  The figure was copied by Dr First but never attributed.  We could not show that the effect was reproducible, and therefore stopped making any specific claim about A&E 3 years ago.  £30,000 saving?  We make no such claims, although if GPs tell us about savings we are happy to report them.  Why did NHS England swallow this?

@harrylongman

Quite a week but let’s put all that to one side and reflect on a fabulous article I came across, which put into perspective what we are trying to do.

Dr John Launer of HEE asks Is there a crisis in clinical consultations?  Although he sets the paper in a hospital context, most of his working life has been in primary care and the same principles and questions apply.  It’s all about

“the idea that making it easier for clinicians simply to talk with patients may solve many problems that managers might assume need far more complex technological solutions”

Aha. Let’s add to that the assumptions of politicians, along with structural, financial and all kinds of other complicated solutions.

Launer quotes Dr Gordon Caldwell who has outlined ten fundamental conditions to optimise consultations, including:

• The patient should be as prepared as possible
• The clinician should be as prepared as possible
• Ready supply of information into the consultation

Telephone consulting pioneer Dr Steve Laitner contrasts traditional general practice in a tweet, “like having a day of back to back meetings every ten minutes with no idea who you’re meeting and no agendas”

Stressful and far less productive than it might be.

Yet patients are willing to spend their own time writing and preparing when they seek help – we need the system to make it available to GPs.

A recurring theme of patient feedback on askmyGP is “I was able to gather my thoughts before seeing the doctor.  I so often forget things when I’m in there.”

Clinicians value enormously what patients write, whether preparing for a phone or face to face consultation.  Our task is to develop the handful of questions which provide the most useful information, and I’m delighted to say that researchers are interested in this too.

Our other focus is to make online access so easy and attractive that it becomes the norm.  We are over 30% in one practice and it will take a lot of experiment and refinement but I’m looking forward to reaching 50%, which I hope will make a big contribution to clinical quality.

I’ll leave you to look up all ten principles in Launer’s article, but here’s one you will like:  “The clinician should be regularly refreshed”.  He doesn’t say what with.

Harry Longman

askmyGP & GP Access Ltd