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.

Harry Longman

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.

Harry Longman

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.

Regards

Harry Longman

PS GPs with that service ethos, don’t miss out any longer.  Start with our free online demo.

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.

Harry Longman

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!

Harry Longman

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.

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!

Harry Longman