Have to say it makes one a little queasy to see the Secretary of State take the platform at a competitor HQ and tell they world he wants their product to be offered to everyone. Taking a few shortcuts on procurement, open competition, evidence and so on, but then he’s new.
Two things I share with Matt Hancock are his enthusiasm for how technology can help, and his frustration with the glacial rate of innovation adoption in the NHS (plenty of innovation does not equal high rate of adoption).
But we absolutely must see technology within the whole system context, which is why we call what we do “Systems thinking applied to general practice.”
Mr Hancock might like to consider a few matters before handing over the jewel in the NHS crown to Babylon’s GP at Hand:
– their patient profile is skewed to younger adults
– they’ve traded access for discontinuity of care
– their exclusions, agreed by NHS England, cover children, pregnancy, many chronic conditions, those who can’t travel, pretty much most of the demand on GPs.
– taking out the above patients leaves remaining GPs with most of the work but much less of the income.
He’s right that a quick query on an acute illness from the back of the ministerial Jag could and should be dealt with online (if appropriate) by the patient’s own NHS GP. But from the GP side, that’s a very small segment of demand.
I fear a sinister side to the Babylon gig on Thursday: BMJ reports that Ali Parsa is lobbying NHS England not to cut funding for “digital first” GP providers out of area. Well he would say that, but having the SoS publicly tout your product is quite a nice negotiating gambit.
We aren’t just going to rail at the darkness. It would be lovely to have the endorsement of the SoS but until then, we’ll let the evidence talk.
- Practices running askmyGP serve about 8 times as many NHS patients as GP at Hand.
- Last week they did 6,600 online requests, probably 3 times as many as GP at Hand (and twice as many as eConsult, who claim 500 practices now to our couple of dozen)
- All patients had a choice of their own GP.
- They are digital first but never digitally exclusive – patients are able to use the channel that works for them.
- They get a faster service than Babylon can do, response in minutes and face to face same day.
- No patients are excluded from the GP list or turned away.
Call it disruptive innovation if you wish, but we’re disrupting the operating model, not the business or contracting model. That’s why GPs love it.
Parsa announced on Thursday another $100million investment into his company to be spent on AI, on top of the $60m already sunk. I don’t know whether this has been systematically reviewed, but it couldn’t recognise my fungal toenail infection. More seriously, @DrMurphy11 has shown how it misses a “barn door PE”.
I’m announcing today a secret weapon in askmyGP. We call it HI. It’s used for every single clinical diagnosis and decision, and even better, it does care. It can care for any patient, even one deaf, blind, lame, foreign, depressed and pregnant all at once. It understands context, nuance, subtlety, ambiguity, the importance of relationships. It even takes responsibility.
We work with over 100 GPs and I can tell you, each one is worth well over $1million. So much we can’t measure it.
Something else you need to know about GP at Hand, which is why they worry so much about funding per patient. Their Achilles heel is operating costs, sky high, compared with regular partnerships offering digital first. Drop me an email to find out how we know.
Our mission is to enable regular local GPs to outcompete Babylon, online, on quality, service and profitability. We’re showing how any practice can do it. We’re growing multiple times faster than GP at Hand, adding another 20,000 patients this week.
Someone will notice before long. A GP copied me yesterday her invite to Mr Hancock to come and see askmyGP in action.
Game on, Babylon.
PS A North East practice launched two weeks ago and has already blown my socks off as well as its own. They’ve gone from a median 5 day wait to see a GP to median completed request in 70 minutes, and demand went down in week 2.
One of their 91 year old patients commented, “Excellent, this service should have come earlier”
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.
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.
Another week, another specification thumps onto the floor in front of my inbox. NHS Blithering CCG* has copied down the questions from the last lot, added the requirement to integrate with local place-based cloud-enabled remote home visits by Longstay (Vietnam) NHS Telecare plc, and there, ta-da, is the blueprint for online consultations.
As I read through the same tired wishlist, my heart sinks. Must have:
- red flags (unsafe and cut patient use by around 60%)
- symptom checkers to divert patients away (unsafe and patients hate them)
- ability to book GP appointment (wastes GP time as 70% of patients don’t need a face to face)
It goes on, and of course we aren’t going to rewrite our software to meet this specification and thereby ensure it doesn’t work. What’s missing from the list are many of the features which really do matter to patients and GPs, let alone any serious understanding of the journey of change which is much more expensive to deliver than software.
If the CCG has decided on a tick box procurement process, we’ve put ourselves at a serious disadvantage. We run a permanent policy of not lying about evidence, rather presenting the raw data and letting the customers talk about the outcomes. Worse still, we don’t promise the moon unless we have clear technical and economic means of reaching the moon. Overall disastrous.
So I’m going to ask you a genuine question, if you’re in an English CCG, or a GP affected by the DPS procurement process through the ringfenced £45m online consultations fund, set up by Arvind Madan, former eCONsult chief executive: should we pull out of the DPS?
CCGs can still procure askmyGP or any competing product via G-Cloud 10, and draw on the same £45m fund. We are fully compliant on patient safety, information governance, security and so on. But our product development is driven by the simple question “what works?” rather than “what is specified?”.
It’s a philosophy that has enabled orders of magnitude greater usage and value for patients and GPs.
What those tick boxes and essay writing competitions can never ask is whether it will do this. Copied to me yesterday by Dr Barry Sullman, writing to another GP and he’s delighted to share:
“AskmyGP is a revolutionary system, that has transformed my work/life balance. It is now normal for me to have breakfast, and tea with my family. It has also transformed care at the surgery, empowering patients, and creating efficient SAME DAY care.
But I don’t want to talk hyperbole. I want you to come and see this on a live system, where you can see this really happening. I have recovered the cost of the system in 3 months, and I will continue to recover the cost many times over indefinitely until I retire. Let me show you the math when you visit.
This is the future – and doctors need this sorely as do patients.”
So what do we do? Advice welcome or if you like put it in public and comment online.
PS Wales and Scotland do not suffer the same procurement blight as England and they are pulling ahead, as are English GPs investing in their own businesses for the return Barry mentions above.
*Blithering and its staff are an unregistered trademark of the great @jtweeterson, used without permission. The genuine article is here.
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.
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.
“We’ll get the information a lot sooner and for a lot less money by just sending a person.” I was dumbfounded. Dr Ellen Stofan, outgoing Chief Scientist of NASA, was talking to Jim Al-Khalili on the Life Scientific about no less a task than finding life on Mars.
It’s a fascinating interview from the start, or jump to the quote at 19 minutes in. So that’s why they want to send a person, not for the ultimate ego trip, but the simple purpose of finding life. Jim pushes her on the reason, doubtless at a cost which is telephone numbers cubed, and it’s simple: humans are creative, flexible and mobile.
All they have to do is break open rocks and look for fossilised microbes. With NASA’s vast resources and access to the world’s best brains, their secret weapon isn’t AI and robotics, but human intelligence.
I’m an engineer and a technophile. I read Wired online and I have three bicycles, one of them all carbon. But I’m ever so wary of the claims made for AI chatbots revolutionising healthcare any minute now.
At Best Practice show last week half a dozen companies were offering some clever algorithm to make your patients go away. They are so seductive, even plausible. But when I ask, “How many patients have actually used them?” I get stonewalled.
Substantial wedges of venture capital say “It must work”. Rather different from asking, “What works?”
What humans are good at:
- searching huge databases in milliseconds
- communicating instantly and securely
- organising and analysing information
What computers are good at:
- solving tricky problems through experience
- building relationships of trust
- caring for people in need
Our philosophy with askmyGP is very clear: we get the computers to do the boring easy bits they do so well, so the humans can get on with the real hard work of looking after patients.
We’re proud to call it HI and we’re on the same track as NASA.
PS Did I get that the wrong way round? Doh! Must get a new proof reader.
The humour of David Walliams’ character Carol Beer is all human, of course. “Computer says no” would never work if an actual computer said it. At least the hapless customer can try to reason, to get that look from Carol.
So when an actual computer says no to your patient in their time of need, it’s a punch in the face.
Let’s say you have pain in your hand (arm,, shoulder, hip, knee, ankle, foot, it matters not). It’s been there over six months, came on gradually, still mild but you decide you are going to do something about it and see the GP.
You put all this into webGP/eConsult, as you can’t seem to get through by phone. Then it asks:
Did the pain come on after an injury?
Yes No Not sure.
Honestly after six months it’s not at all clear, so “Not sure”
Computer says no.
Up comes the big red box listing six things you should do, from “seek urgent medical advice” right up to “go to A&E”. The one thing you can’t do is carry on with the eConsult. It stops right there.
Now I’m not suggesting that A&Es are filling up with cases of mild hand pain of uncertain origin over six months old. Most patients have far more sense. But who do we have to thank for this sage advice? Drs Clare Gerada, Arvind Madan, Murray Ellender and co at Hurley.
At the last count some 212 of what they call “red flags” were embedded in eConsult, sometimes as subtle as the difference between scoring pain at 5 or 6 out of 10. It can be a superhuman challenge to navigate your way through a questionnaire to reach the submit button.
“Red flags” are touted as a safety feature, but of course there is logically no way to cover all red flags for all patients in all circumstances. Any reassurance we may feel is false. Yet thinking you are wearing a safety belt, when it’s made of paper, is itself dangerous.
The one thing patients don’t have is patience, and this is the killer with red flag thinking. When the computer keeps saying no, patients won’t bother again, they go back to pleading with a human, however stressful. This is at the root of the study finding, “Online consultations don’t save time or money” where 36 Bristol practice running eConsult moved just 0.16% or 1 in 600 demands online, and this most commonly for admin issues.
As you know we have an interest in this through askmyGP, but our thinking is driven by the evidence of “what works?” We have to enable GPs to be much more efficient, and while online consultations can be a part of this (GPs tell me they save 3 minutes with each one), they only work if lots and lots of patients use them.
We’re up to 30% so far (see Concord case study), and we’re working on 50%. That will only happen if we welcome all patients, all problems, we give them a great service, and we find that patients want to help.
Computer NEVER says no.
PS You can try askmyGP as a patient on Bramley Demo Surgery. It’s simple because we tried clever and complex and it sort of worked, just not well enough. If only we’d realsed sooner! Anyway patients and practices love the new simpler version, and it’s focussed all our efforts on GP productivity.
PPS If you can’t get enough of Carol’s “Computer says no” you can see her with German subtitles for extra giggles.
OK, you’re forgiven for thinking I wrote DNA rate, and you were expecting to read about how to reduce Did-Not-Attends, perhaps a mix of clever texting apps and a patient blame-fest of warnings, charges and excommunication. No matter, although we have shown that DNAs are a system problem, not a patient problem, and if you change the system, DNAs disappear.
I wrote DNH meaning Did-Not-Help, the patients who are told by reception, “Sorry, nothing left, call back tomorrow. And make it on the dot of 8, I should, we’re very busy.”
No clinical systems measure this, NHS England would rather ignore it, no political party understands it or has the method or means to deal with it. The various prescriptions of “waiting time targets” or “8-8 x 7 day opening hours” aren’t based on examination of the evidence, so the diagnosis is wrong and the treatment will fail.
We collect the evidence through our Datalog audit, real time, patient by patient, we have n > 300,000 from over 200 practices, and the average rate is… 12%. Yes, it’s roughly twice as high as the average patient DNA rate, and it’s not caused by patients but by GP practices and systems. The highest we’ve measured in any practice is a staggering 31% of demand turned away.
I’ve worked with enough GPs to know that the vast majority joined the profession to help patients, so the data may come as something of a shock, but something which should move us to action. True, there’s a small but powerful minority who seem to take a different view, maximising profit by minimising service to the point where they just escape being caught. Sometimes they do get caught.
But we are concerned with the vast majority, those working hard to provide excellent patient service. Getting GPs to work harder is a sure fire vote loser, I think you know that. So the answer is giving them the method and means so that they can work much more efficiently, dealing appropriately with all demand and feeling in control.
Our task in fulfilling the vision “to transform access to medical care” is working out ever better ways to make this happen. We know that dreaded phrase, “Call back tomorrow… ” is uttered around 100,000 times per working day in the UK and our manifesto is to eliminate it.
You will vote many times in your life. Make your vote count.
You will live only once. Make your life count.
Founder, Chief Executive, GP Access Ltd
PS Exciting to report that the next little piece of that road is now in place, two way secure messaging between GPs, their staff and patients. It enables more efficient use of GP time by not always having to find phone numbers and hope for an answer. Spoke to one user yesterday who already loves it after sending 3 messages! It’s built into askmyGP Transform and Improve.
PPS as election guide I defer to the inestimable @jtweeterson
You told parliament yesterday that it was time for “an honest conversation with the public about their use of A&E“. Are you up for one too, as Secretary of State?
Unfortunately there is no evidence of honest conversations, cajoling, beating or any other persuasive endeavour having the slightest effect on patient behaviour in seeking healthcare. You may even be stoking demand simply by talking about it (as the Behavioural Insights Team has shown.) Dr Taj Hassan is spot on when he says it’s about the system. As Deming said, 95% of the problem is the system, and that’s where leaders spend their efforts.
You’re fiddling with four hour targets, and the language of targets, but Deming said 35 years ago, “numerical targets must be eliminated”, tellingly calling his book “Out of the Crisis.” It wasn’t until 1992 and after mental torment over what this meant that I personally got it. Well, the next principle is to eliminate exhortations…
It’s crucial to understand the difference between targets and measures, and to Deming (a statistician) measures were absolutely critical. It matters to patients how soon they are seen Mr Hunt, and therefore it must matter to you and all NHS staff: measure the times, the demands and the flow in A&E and strive continually to improve them.
You’ll be asking me how in a minute, but look, read Simon Dodds on how they did it in Luton and Dunstablehospital. There’s a very simple parallel to what they did and our work in primary care: put the senior clinician at the front of the house where the demand comes in. It saves time for the senior clinicians and saves time for everyone else.
I spent yesterday in Riverside Practice, Portadown, NI, on the day they launched their new system. Patients reported an average 39 minutes to be in touch with their GP. 81% said the new system was better. The GPs said it had gone much better than expected, and when they’d cleared the decks, most of them went home early. Someone please pass this on to Helen Stokes-Lampard who is threatening us with 4 week waits.
Wonderful stories came throughout the day. The man who got the GP call in the library. The woman who broke the new rules, turning up in the surgery without calling, but with agonising back pain. She saw the doctor within minutes. Any healthcare system which doesn’t have compassion at its heart is worthless.
Riverside GP has gone from having one of the worst access records in NI to one of the best, overnight. OK, so the preparation took four weeks. OK, so it took a year for the GPs to overcome their fear of change. But they changed overnight.
Leave aside political shocks for a minute, there’s a medical earthquake happening in NI right now, standing primary care the right way up.
It’s such a dreadful shame that NHS England is missing out, but I’m sitting by the phone Mr Hunt.
Founder, Chief Executive, GP Access Ltd
PS You can change patient behaviour, not by exhorting them but by changing their perception of where to get help. Rapid response from their own GP does it, and don’t worry, it’s less work for GPs. But please get off their backs, stop the 7 day nonsense and as Deming also said, cease dependence on inspection to achieve quality.
It’s been a fun week after our official endorsement in the Daily Mail which meant two radio interviews before coffee on Monday. Huge support came from many GPs and patients who know the truth that a demand led GP telephone consulting system has transformed their lives and their access – thank you all so much.
The DM is right on the button (in its inverted fashion) as a big report has just been quietly snuck out out by NHS England. It’s the final evaluation of the GP Access Fund wave 1. (yes, it’s right at the bottom of this page, just published though it relates to September 2015).
I’ve read the ever-so-small print and have concerns about some of their arithmetic but the headline is: from a £60m investment they identify £1.9m savings. Nevertheless, one bright spot in the conclusions is “Telephone-based GP consultation models have proved most popular and successful.”
We were involved in several of these, the financials showing a positive investment return (p31) and increasing GP appointments by 7 – 16% within core hours. This is no surprise as we’ve been saying the same for years.
The contrast with the next conclusion is stark, “Other non-traditional modes of contact (for example video or e-consultations) have had fewer tangible benefits and have generally had low patient take-up to date”
Seven schemes offered e-consultations and sadly askmyGP wasn’t among them at that stage but the leading platform was webGP/eConsult.
Moving swiftly on, it’s time for NHS England Shared Planning Guidance. Don’t worry yourself about the evidence for telephone access, the word isn’t mentioned, but on page 50 there’s £45 million ring fenced for e-consultations. That means you can’t spend it on anything else, so your CCG might as well apply. Do hurry! Applications must be in by December 23rd.
Some say it’s no coincidence that the author of the GP Forward View and NHS England National Director for Primary Care, Dr Arvind Madan, is also a major shareholder in Hurley Group/webGP/eConsult, provider of such online e-consultation software. Of course, “I couldn’t possibly comment”.
But I will be reviewing and comparing the evidence on competing platforms over the next few weeks.
As we know, only the Daily Mail can get away with ignoring the evidence.
PS A number of readers have been commenting on this Analysis of access in large GP groups. It’s all from public domain data, so I’d be delighted if any researcher would reproduce or extend it. A close look at the names reveals some surprises.
The BMA guidance includes the key message:
- Doctors must use resources efficiently for the benefits of patients and the public. Difficult decisions about resource allocation are inevitable, but should be evidence based and made in consultation with other colleagues and patients.