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.
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.
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 .
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?
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.
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!
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
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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.