The long shadow and the light
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.
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GP pay, rations and recruitment
No doubt your inboxes have been weighed down with the debate on the “2% pay rise for GPs”. Is it 2%, 1%, 3.4% or 4.2%? Of course it’s nothing of the sort.
It’s a contract uplift to independent contractors. If you buy a pencil, it comes out of your drawings. If you save a pencil, it goes into your drawings. I’m afraid the general public don’t understand this, but never mind.
There is no perfect model and of course it has its drawbacks, but I think the ability to run your own business is one of the great strengths of UK general practice. GPs have huge freedom to determine their own business performance, and therefore their profits and drawings.
Alongside improving patient service, one of our explicit goals is to make GP practice owners more profitable. Some of you seem rather coy about this, strangely, but I see it in very simple terms: why else would you pay us?
Because business owners take home the difference between income and expenses, they know that they can increase their incomes vastly more than 2% by investing in a machine to make pencils – I’ve over-extended the analogy.
Pencils are cheap but the expensive bit of the GP business is the GP. So the game is to make the GPs 30% or 40% more productive.
We are drawing near to Hancock’s Holy Trinity of “improving outcomes, helping clinicians and saving money”
Meanwhile there’s a monstrous failure: NHS England can’t persuade enough foreign trained GPs to come here. They wanted 2,000 no doubt at vast expense, and they are under half the target. They are looking in the wrong place. We already have the GPs. And by enabling them to be more efficient, and more profitable, we’ll have plenty.
It is a national scandal that a developed nation should steal the trained workforce from other countries who may have far fewer GPs per head than the UK.
We can do better.
Regards,
Harry Longman
PS I loved this tweet earlier today from @dave_dlt “Heck of a day, 4 sessions down then one partner needing to get away unexpectedly yet 1650 building calm and quiet”.
We are seeing partners shed locums and salaried sessions then still get away on time and enjoy the sunshine dividend.
Matt, meet Aneurin
Who’d have thought it before the Chequers meeting, but there it is, we have a new health secretary. I’ve put together some words from the very latest, and the first, of those at whose desk the NHS buck stops.
At the start of Matt Hancock’s term those interested hang on to every word, but to save time I’ve cut and pasted what I find most relevant here:
“as you may have heard I use an app for my GP. The discussion around my use of a Babylon NHS GP, which works brilliantly for me, has been instructive.
Some people have complained that the rules don’t work for care provided in this revolutionary new way. Others have said the algorithms sometimes throw up errors.
Emphatically the way forward is not to curb the technology – it’s to keep improving it and – only if we need to – change the rules so we can harness new technology in a way that works for everyone: patient and practitioner.
I want to see more technology like this available to all, not just a select few in a few areas of the country.”
A lot of positives. Sees the potential of technology (the NHS is so far behind, he could hardly not), brings in personal experience. Wants universal coverage, hear hear.
Steps into controversial territory with a commercial namecheck perhaps, but there’s a precedent. What I suspect he doesn’t understand is that GP at Hand while limited to the London area at present is not and cannot be a universal model. They exclude a long list of those most in need of a GP, as I don’t need to remind you, and they can’t offer continuity of care.
Our approach is rather to enable existing GP providers with local access and coverage for all patients, to give a much better service, much more profitably. We already serve about 8 times the number of patients covered by GP at Hand, but you might not think so by the volume of noise.
In recent week’s we’ve seen a growing body of GPs tweeting to let the world know that it’s really working. If you haven’t seen it do join the conversation, click to follow @askmyGP
Now to Aneurin Bevan, who wrote to the profession on 3rd July 1948:
“There is nothing of the social group or class in this: and I know you will be with me in seeing that there does not unintentionally grow up any kind of differentiation between those who use the new arrangements and those who, for any reason of their own, do not….”
We can say without fear of contradiction that all parties are agreed on that. The question is how, and what policies could threaten it. Bevan continues
“My job is to give you all the facilities, resources, apparatus, and help I can, and then to leave you alone as professional men and women to use your skill and judgment without hindrance.”
I’ve no doubt that 70 years later Bevan would be banging the table to say we had better get up to date with the means of doing so.
“Skill and judgment” – that’s human intelligence and in relating to, diagnosing and caring for patients, AI algorithm chatbots can’t hold a candle. Someone telll matt.hancock.mp@parliament.uk.
Harry Longman
PS Babylon’s recruitment page says its GPs “will see up to 5 patients an hour”. Jaw hits table. Our GPs tell us they would collapse with such a poor rate of producton. Looks even more like the Babylon business model can’t cope with anything but a fit and healthy demographic.
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Improve continuity, die less often
Did you hear the wonderful piece on Inside Health yesterday as Mark Porter interviewed Sir Denis Pereira-Gray? Listen on iPlayer from 4:40 minutes.
Sir Denis has been a tireless campaigner for relational continuity and his new paper published in BMJ Open. is the first systematic study linking better continuity with reduced mortality. Boom – the doctor knows the patient, they are likely to live longer.
But as he points out, continuity is actually falling, by an astonishing 27.5% between 2012 and 2017 as measured in this Leicester paper.
This is not inevitable.
It is the consequence of policies, system design and operational practice.
Therefore reversing the decline is a choice. The question is how?
Working with a huge range of GP practice structures and sizes, we have a very simple method.
- GPs set up their availability
- Patient chooses named GP
- Reception assigns patient to GP.
The data is interesting – only 25% of patients name a GP and quite often reception will look up the usual GP and assign to them. But most patients don’t mind and where it doesn’t matter, this gives enough flexibility to share the workload evenly.
It all happens within the normal flow of the demand led day, and crucially patients who feel their need is urgent are not faced with the dilemma of “You can see the duty doc today or that one you want in 3 weeks”
Now all of a sudden there’s a way to convert this into money. There always was, since continuity improves efficiency as GPs sort things out once properly, and patients don’t create rework.
The new time limited way is thanks to the Health Foundation launching a programme to increase continuity in general practice.
All excellent stuff and I wish you well.
Harry Longman
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Appy Birthday NHS 70!
I’ve no doubt Jeremy Hunt meant well by what he called his birthday present to the NHS, a new NHS app. But as W Edwards Deming said, “Best efforts are not enough, you have to know what to do.”
“I want this innovation to mark the death-knell of the 8am scramble for GP appointments that infuriates so many patients.” says Hunt.
He’s right that innovation is needed, right that there’s an 8am scramble and right that patients are infuriated. One phoned me this morning, absolutely fizzing about her practice, but not one of ours and there was nothing I could do. She told me she could book online, but there were never any GP appointments soon enough so she physically went this morning and still no joy.
The gap is in understanding the problem: it’s the system. It’s not lack of online access, standard for some years. Bad news, it’s the system, meaning the operating system of the practice. Good news, it’s the system, meaning it can be changed. By whom? The GPs who run the practice.
Even better news, it isn’t a matter of resources. The BMA is right that Hunt’s NHS app won’t create any more appointments, but their knee-jerk reach for the begging bowl so lacks imagination.
I won’t bore you with how we are helping practices to achieve 30 – 40% efficiency gains, and help patients within minutes, because you’ll tell me it’s too good to be true.
But I’ll share with you a brand new chart which astonished me this week, and it goes to the heart of Hunt’s problem definition. A month ago we started asking every patient when they send in from askmyGP how they would like the GP to respond, whether email, phone or face to face. This is from 12 practices who have done Transform, online varies from 15% to 80% of demand, average 35%.
Even though around 30% of patients need a face to face, only 15% are asking for one. GPs are having to persuade some patients to come in.
It seems obvious after all: patients don’t want an appointment, they want help with their medical problem from someone they trust.
But if you make it a thing to book appointments online, then that’s what they will do, and take 10 minutes of GP time, even though neither party wanted it.
The BBC listened, thank you, and we have been saying this to NHS England for a long time, but they aren’t listening. Can you help?
Harry Longman
PS #GarethSouthgateWould not mention that 6 out of 9 England goals have been scored by a Harry, so neither would I.
PPS All the above practices started with Pathfinder – Could you be ready to change? It’s normally quiet in summer but we are surprisingly busy and it is actually the best, quietest time so do get in touch today.
Babylon/GP at Hand: GPs need to change their game
In this third instalment on Babylon/GP at Hand the cards are on the table, and you’ll see why.
I’ve looked at what they are getting right, patients’ desire for speed and convenience (don’t blame the patient, think of the last time you were one). I’ve looked at their AI claims, partial, unproven but fundamentally a disease based rather than demand led model.
Now the nub of it: GP at Hand is disrupting traditional practice with a city wide (London only for now) service attracting young, fit, male and mobile adult patients – your most profitable demographic. The exclusions effectively mean
- it’s not whole person
- it’s not whole life
- it’s not whole family
- it’s not whole community
Even a normal healthy female would go through four changes of GP to use this service during her lifetime.
Infant – no. Young adult – yes. Mother – no. Older adult – yes. Elderly – no. “All the world’s a stage…” but only bits of it are covered by NHS Babylon. (Kudos to them for getting Malcolm Grant onto their stage on Wednesday night btw. What was he thinking?)
Let me be absolutely clear where we stand: for high quality general practice covering the whole person, life, family and community. Sounds rather like the RCGP, indeed the NHS. It has to be local to do that (and unit size is irrelevant, except to patient satisfaction which goes up as size goes down).
But to compete against the likes of GP at Hand, and to be profitable in ever more squeezed circumstances, you have to work much more efficiently. Not lilttle 3% tweaks, but 30% leaps. That is exactly what we do.
That kind of efficiency gain (Dr Sue Arnott, single hander, has 4,600 patients) is changing the economics.
The normal experience of askmyGP patients is to send a request online, get a response within minutes and for the 30% or so who need to be seen, it’s today. The record posted last week was a feverish child seen within 12 minutes of sending. GP at Hand can’t touch that.
Safety must be paramount, and two features of the system design are crucial. Firstly it enables you to be responsive, easier to contact by phone as well as online, and we know the average practice should expect a couple of emergency presentations each week. I would never have made this claim, but Dave Triska tweeted on Wednesday, “so far I can count 3 lives saved in 4 weeks by this method.”
Secondly, it enables and encourages continuity by allowing patient choice of GP, and giving GPs total flexibility within the day to provide. Here is today’s BMJ paper, better continuity reduces mortality.
Increasing numbers of practices are asking us where to start, without leaping into the unknown (really not unknown, the once familiar delight of being a doctor) and that’s what we do wtih Pathfinder – Could you be ready to change?
It’s the kind of change which is necessary to stay the same. Don’t give in. Don’t see decline as inevitable. Don’t expect bungs or contract changes to bail you out – not this five year plan.
Use the power you already have over your own destiny.
Harry Longman
PS Please don’t believe me. Believe the GPs doing it, and if you haven’t yet, hear the amazing interview with Dr Dave Triska.
PPS This tweet from Dr Lis Flett moved me: “One of the two patients who wanted a face to face appointment this morning (that’s right, 2) sat with me for half an hour. Many problems solved, patient felt listened to: Medicine the way it should be.”
PPPS Just had an email from Babylon “Babylon’s AI is on par with doctors”. You. Could. Not. Make. This. Up.
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Babylon/GP at Hand – AI vs HI
With all the debate going on it seemed right to tackle the question of AI and in particular Babylon’s grand reveal yesterday.
The stage show was to accompany the latest marketing, not peer-reviewed and published, but designed to look like a scientific paper. You can read it here. The point is that they have trained a computer to pass an exam, for MRCGP.
Exams are necessary but not sufficient to be a GP, as I’m sure they would agree with RCGP, but what have they really achieved with 100 made up vignettes and patients played by GPs? Others will answer much better than me on the safety of the process (follow this brilliant thread by @DrMurphy).
I’ve done my own trial of the AI chatbot based on two diseases I’ve personally had in recent months.
“Toenails brown and broken” I start. “Please rephrase…”
“Brown and broken toenails”, and so on. Absolutely no idea from Babylon, who end up asking, “Do you have any other symptoms?”
So I move on to my next trial:
“Wrist pain”. At least they recognise this, and there follows over four minutes a series of 39 questions, of which only 3 seem to me to be relevant, and the diagnosis comes out as:
“8/10 broken bone in the lower arm. Go to A&E”. I answered everything honestly. What I really had was tenusynovitis, tendonitis of the wrist, and I guess rather more common than a broken arm.
The way we do this with askmyGP is to let the patient type in on the very first screen whatever they want, then search for self-care advice. Try it yourself on
Try anything, medical, colloquial, badly spelled, phrases, anything. It’s not perfect but for example my trials above got me in two clicks to fungal nail infection, and the other to wrist pain where tendonitis was one possibility.
I could dress this up as AI and call it the answer to everything, but really it’s just our own algorithm to search NHS Choices better than its own search. It works, and crucially it’s very fast, much faster than having to register wtih all the details and answer 39 questions one after the other. Remember that most patients’ first concern is speed and convenience and this search costs nothing.
We had a clever history taking algorithm in our version 1 software, and very good it was too, but not good enough. Patients got bored and GPs got fed up with too much irrelevant information.
The much simpler interface, respectful of patients’ ability to express themselves, has proven hugely more popular and that has enabled us to move over half the demand online with practices that really understand the benefits.
You have no doubt heard of Elon Musk, technology billionaire and founder of SpaceX and Tesla motors. On that company’s calamitous production problems, flowing from their overambitious automation, he said last month, “My mistake. Humans are underrated.”
You probably haven’t heard of Dr Ellen Stofan, former NASA chief scientist, who said last year they are sending a human to Mars because they’ll get more information, sooner and cheaper than by sending a robot.
I’m an engineer, as keen as anyone on the benefits of technology for humankind, but to get benefits we have to understand how computers can help, not pretend with smoke and mirrors. They are good at searches, communications and analytics, simple and repetitive tasks. For the tricky stuff, we need HI, human intelligence.
Who knows what they might do in some unknown future, but we have a problem right now in general practice, and it’s not a lack of intelligence.
There’s a fundamental difference between Babylon’s start point and ours. They work from DISEASE and have put together an algorithm to try to convert Q&A into diagnoses.
We work from DEMAND and very simply get it to the right clinician to triage in seconds and decide how to care.
That is only the start and tomorrow I’ll discuss our Systems Thinking approach to intervention, in which we’ll see that technology is but a small part.
Time will tell which gives the greatest benefit. but for a taster of how much can change in only a couple of weeks just listen to this interview with Dr Dave Triska .
Harry Longman
PS If you’re on Twitter, click to follow Dave @dave_dlt for some moving reports of the change they have undergone.
PPS Did you hear about the latest AC – Artificial Caring?
- Published in News
Babylon are getting speed and convenience right
You might be surprised to see the title, and unless you’ve been on a different planet recently you can’t have failed to notice the PR. Babylon/GP at Hand (their NHS service) are brilliant at finding the limelight.
The chief reason is: they offer something that people want, speed and convenience in getting medical help. Who knew?
The sites are very nicely designed, and if you think that’s easy, you haven’t tried. At present they are nicer than ours (watch this space) and looking attractive is important – people buy on emotion even if we kid ourselves that we’re logical.
People of all ages expect to do everything online, and with younger people a huge majority expect it to be on mobile. The experience must be seamless and beautiful.
A colleague of mine told how a complete stranger struck up a conversation while shopping last week. He told in amazement how he got help within an hour from GP at Hand.
But how? The business model is fantastic too. Low cost of service, with low estates overheads as so much is done remotely, and low usage from a largely fit, young, male demographic. As you all know they’ve been able to exclude children, the frail, elderly, chronically ill and women in danger of pregnancy – most of the people who need a GP.
NHS England pretty much told them to, incredible as it seems, undermining the shared risk model of local general practice. Malcolm Grant speaking today doesn’t seem to understand what this is doing to existing practices who are left with the rest. Anyway, the theme has been so well rehearsed elsewhere I won’t say more, but the reaction from GPs led by the BMA has been as pathetic as it has been predictable.
“Foul!” “Placards!” “Marches!”. Anyone would think the whole lot of them were a cartel bent on nobbling the competition with their newfangled ideas. But we know better. GPs are a fine upstanding profession who embrace innovation to improve their service to patients.
And that vote at the ARM to put a cap on daily contacts? The perfect gift for Babylon/GP at Hand, who will pick up more of those patients they have turned away. Only the profitable ones mind.
Next time I’ll look at what you can do to reverse the slide, and it won’t involve marching on Richmond House.
Harry Longman
PS Babylon do some crazy stuff too. My favourite was the email to subscribers last November which advised eating more garlic and listening to jazz to ward off the flu. That didn’t go well!
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Enjoy the summer?
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”
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Why online consulting isn’t working
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
Exploding the myths of online consulting – link here
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.
Kind regards
Harry Longman
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.