Today’s guest blog is by Dr Hugh Reeve, senior partner at Nutwood Medical Practice in Grange-over-Sands, Cumbria.  Not exactly a population pyramid, with 40% of patients over 65 Nutwood boasts more of a population parasol. 

Below is his series of almost daily tweets over the two weeks since launch, and I think as the story unfolds you will be moved as I was.

Over to Hugh…

6/2/19 Day 1 AskmyGP. Wow – all today’s work done today. Online take up impressive for day1. Staff coped – 2 said it was best Weds ever!  positive pt feedback. Drs slightly frazzled getting head round new system and strange only seeing f2f 30% of usual numbers 😀

7/2 Day 2 @askmygp 89 yr old sent me online message about her shoulder! Our salaried GP cleared all her admin & finished at 5.30-first time she’s left before 6.30 in 3 years. We had 62 new requests for help -phone and online-of these saw 15 people f2f. We’re cautiously optimistic!

8/2 Day 3 @askmygp GPs managed am and pm coffee breaks. 76 problems sorted – 32 f2f and one home visit. 89yr old who emailed yesterday sorted – one phone call and joint injection arranged next Tues. Old system would have taken at least 2 weeks! Next Monday’s rush the real test!

9/2 One of my partners told us of the incredulity and gratitude of a patient who was seen in surgery one hour after sending an email for a non-urgent problem.

Anyone that needs a physical examination we arrange to come in and see us – the same day they contact us , or visit at home. We now also get tests/xrays etc done first and then see people. Previously we phoned about 25% of pts and saw 75%, early results we see about 30% now.

Our access not bad at all but as you know continuity a real issue. Early signs are it could really help this.

11/2 Day 4 @askmygp – best Monday in 13 years at Practice. Gobsmacked! Pt with ?intracranial bleed after HI 10d ago-sorted CT-pt wanted routine appt, 10d wait on old system. Colleague spent 40 mins with pt who burst into tears at reception, she still left at 4.45pm with clear desk!

13/2 Week 1  @askmygp A revelation! 373 contacts of which 71% by phone and 29% online- this for a practice where 40% patients 65 or over. Of these we saw 30% f2f. Staff love it – no more telling pts no appt. Feedback from pts so far almost totally positive No downsides yet! I’m 😄

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Pt feedback from pts at our Practice using online service @askmygp in week 1. Amazing Wonderful Excellent Brilliant Worked perfectly Professional Quick Instant Superb Astonishing First class modern service Time saver Reassuring Good technology. This is surely what it’s all about😀

14/2  Real test for new @askmygp system today. One GP sick leaving 1.5 GPs to do today’s work. Real benefit of no full surgery to rearrange-just one person booked in. At end of day all work sorted. One GP had 48 contacts 40% f2f, said still better than when crisis hit under old system!

15/2 No signif downsides as yet Peter. However have to make sure enough capacity available each day and understand the predictable demand for each day of the week otherwise the system will grind to a halt.

20/2 2 wks @askmygp. Getting used to system and love it. Pts seem to as well 34/37 online users think it’s better. 33% of all contacts coming in online and increasing by the day. More time to follow things up, phone people with results etc. Waiting time for a routine f2f appt <1 day!!

We still have work to do adjusting to a radically new way of working. Also fair bit of preparation beforehand. But so far gone better than we expected!

We book very little in advance now, starting the day with near empty schedule and as far as possible deal with today’s work today. At present we see f2f about a third of people who contact us and deal with rest either on phone or online.

Thanks Sam. Have never fallen out of love with general practice but was definitely very jaded. Now in my early 60’s and feel like the embers are starting to glow and real energy returning. Sounds a bit corny I know but true. This will keep me working – because I want to 😀

@hugh_reeve

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6,000 patients, Plaistow, East London.  A multitude of languages are spoken in this diverse, deprived and mobile population.   Dr Barry Sullman launched with askmyGP in April 2018 and with his staff explains what a difference it has brought.

5,000 patients
Shotts, North Lanarkshire.  Small town and surrounding areas, ex-mining community.  Traditional, somewhat deprived area.
Dr Sue Arnott, full time single hander GP.  Team consisting of 8 session ANP, practice nurse.
“We were looking to do things completely differently”
As well as hearing the story, you may like to see the data.

Burnbrae charts to 12 August 2019

This page is not for patients, who must find their own practice website to use askmyGP.

This time yesterday I was in Plaistow, East London and while Cockney rhyming slang is spoken in these parts, you are as likely to hear any of a dozen East European or South Asian languages on the street.  It’s quite deprived and extraodinarily diverse.

I was visiting Balaam St Surgery.   As anyone knows in general practice, it is pandemonium first thing in the morning when the phones go over.  So here’s what Nihul on reception told me:

“We only had three phone calls between 8 and 9 this morning”

That dog and bone just lay there.

Practice manager Divya came out to ask what was not going on.  This is week 7 and the numbers have subsided as they keep giving out the same message:

“Do you have an email address?” – yes

“Do you have a smartphone or internet?” – yes

“Can I tell you about a shortcut to get help from the GP?” – yes

Then they show them the practice website, click askmyGP and take it from there.  80% of demand is now online.

Barry Sullman the GP was working from home that day for family reasons, had all 25 askmyGPs directed to him via VPN and messaged or called them from the home office, bringing some in to see the GP on site.

He tells me Monday – Tuesday are hard work, Weds was fine, he looks forward to Thursday – Friday.  This has never happened before.  He’s saving money, doesn’t need locums any more, takes the kids to school.

While Pulse moans on about GPs turning patients away, Barry is recruiting patients.  He keeps telling me “It’s digital triage.  There isn’t the strain of telephone triage.  This is the future of the NHS.”

The thing I find difficult is that when I report what they are telling me in their own words, people say it’s too good to be true therefore it isn’t true.

That’s really sad, because while GPs are sitting there moaning and disbelieving, their most profitable patients are turning to GP at Hand to get a service far worse than what Barry and his team are providing from their own local surgery.

Spend 5 minutes in reception when it opens tomorrow morning and see what you could say goodbye to.

Increasingly practices ask us how others use askmyGP, so we have collected here examples with agreement to be in the public domain.

Please be aware that they are all busy GP practices so have not committed to answering in person an unlimited number of queries.  They are all different in some respects from your practice, yet they all share common features of a registered list of patients whom the GPs are committed to serve.

They are all on a journey of change, which started with Pathfinder – could you be ready?

Concord Medical Practice – 14,500 suburban family practice, north of Bristol.  SAPC poster.

Larwood Health Partnership – 32,500 large multisite town practice, Worksop.  Video interview with Dr Steve Kell, on  NHS England site.

Central Surgery Oadby – 8,700 suburban Leicester.  Presentation given to the CCG.  Webinar with Dr Chris Thompson Online Consults – Our (very short) Journey of Change

Balaam St Surgery – 5,600 East London practice, blog post of interview.

Burnbrae Medical Practice – 4,800 Shotts ex-mining community N Lanarks.  Listen to Dr Sue Arnott on the webinar, skip to 29 mins:  Online consults – what’s working and why?

Newarthill Medical Practice – 3,000 N Lanarks.  Listen to Dr Ashish Vijayan on the webinar Exploding the myths of online consultations

Witley & Milford Surgeries – 11,200 rural Surrey, two sites.  Dr Dave Triska @dave_dlt tweets as launch unfolds.  This 45 minute recording could change your life:  Witley and Milford launch, as it happens – Dave Triska interview.

Every practice will work out their own mode of operation, and with our help can seek to optimise effectiveness and efficiency.  Each of the above sees between 30% and 80% of demand arriving online and their numbers are part of over 70,000 patient episodes managed through askmyGP in the first year of version 2.

This page is not for patients, who must find their own practice website to use askmyGP.

“My costs have shot through the roof” says Barry with a chuckle.  “It’s the school holidays and I’m taking the family out to restaurants every night” (a list follows, burgers, pizzas, curries). Barry Sullman first made contact with us on 28th Feb and I met some of the family on a video conference because Sunday was the only time he had a minute to spare.  He was working until 8pm and secretly wanted to finish at 6pm so he could rejoin the human race.  To be on the safe side he told me 5 but I didn’t promise. Two weeks since launch he tells me he’s going home at 4.  Except for Thursday when he phoned me at 1, from home, complaining that his salaried GP had nothing to do most of the afternoon, one patient booked at 3.45. So he’s changed his plans to recruit a GP and instead will take on an ANP to run the shift until 6.30, CPR trained, as he’ll refer appropriate patients and his work is done by 4. That should pay for a few nights out. He impresses upon me the difference between telephone triage (which he’s tried) and digital triage:  now he doesn’t spend ages on calls which are really non-medical.  Reception have done them, or he’s emailed a message.  So he’s not drowning or suffocating. He’s prepped for the consultation, may have looked up previous notes.  He’s impressed by what the patients write, quite detailed, even helps with the non-English speakers.  He’s choosing who to see face to face, no more, and it’s all done today. He doesn’t have to up type all the symptoms, just copies into the clinical system. He has gone straight to 70% of demand arriving online, which is 250 per week, and it’s ever so simple how they’ve done it – while not forcing anyone or shutting the door for those who can’t.  Patients are happy, reception is peaceful. Barry epitomises the GP who is self reliant, independent, committed long term to his patients, business oriented and decisive.  But his Balaam St practice is different from yours – deprived East London, young, multi-ethnic and many non-English speakers. Maybe your practice is more like Joanna’s:  prosperous, elderly, all speaking the purest Somerset.  They launched this week too, having just lost a GP partner and another on holiday.  With a quarter of their capacity removed, and costs saved, they’ve transformed the service in a single week, all patients sorted.  Had to scrabble around to find things for the locum to do on some days. She tells me “We couldn’t have done it any other way.  This is infinitely better.” Barry, Joanna, dozens of others:  big smiles.  You?  Feeling overwhelmed, helpless perhaps?  What is the difference between them, their practices and you?  Nothing at all, just that they made a decision and got on with it. Kind regards Harry Longman

A week later on 27/4/18 a GP in a Welsh practice emailed these questions:

Could I ask you first how long since you launched the system ?

As with any change to our appointment system, there is always a honeymoon period, then the rot sets in again, I wondered if you felt any loss of efficiency the longer you run AskmyGP?

And some more specifics:

1)How did you/ do you manage ‘walk-ins’?

2)Was there any backlash against loss of the GP early morning slots for working folk?

3)Do you work with Nurse Practitioners? We have three who see a lot of our minor illness.

4) Can you give me examples of which appointments you do allow to be booked at reception ( CDM? Nurses?)

PS: One other thing in common, both practices invested in Pathfinder and then Transform themselves.  They didn’t wait around for months or years hoping the taxpayer would pay for them. PPS: My colleagues and I absolutely love the work we do with practices like the above.  But do spare a thought for us at this difficult time.  My least favourite activity is the essay writing contest which is NHS England’s Dynamic Purchasing System for Online Consultations,  a Sisyphean task as meaningless as it is mindkilling. If I may use an analogy, our Digital Transformation Strategy Engagement Delivery Leads go to a gallery and see an inspirational painting.  A painting can’t be painted without paint, so they think it’s about paint.  They specify the paint in finite detail, colours, hues, formulation, viscosity, non-toxicity and so on, with which specification all suppliers must comply.  By Monday at 12:00:00. They are surprised however when the outcomes are revealed – instead of a series of Leonardos, Picassos and Monets, the precisely implemented procurement process has produced brown walls.

With those lines from the terraces of Murrayfield ringing in our English ears, it’s a night to celebrate north of the border.  And there’s more to celebrate for a handful of Scotland’s GPs.

Why are patients flocking to register at Newarthill Medical Practice in North Lanarkshire?

Very simple, the access is brilliant.  Where neighbouring practices are making patients wait three weeks, Dr Ashish Vijayan can sort them out the same day.

You know what I’m going to say next, but there’s a surprise to come.  Yes, he launched askmyGP as a whole system just three months ago and loves it, along with his patients evidently.

The secret is to have time for the patients who need it, just the right time for the right patients.

If you’ve followed this blog for long you’ll know that’s only about one in three, while the others still need help, but it can by remotely and much faster by phone, and now faster yet by secure message.

When Ashish first got in touch in the autumn he was swamped, not knowing what to do with his high demand population, many quite deprived in the ex-mining and steel area.  (you might have seen that North Lanarks is the only place in Britain to offer free school meals at weekends).

But they’ve really gone for it, with a fantastic reception team helping patients to go online, and if they can’t putting them on the system too for the doctor.

They are doing 170 online requests every week, the vast majority of all their demand.  It’s the most unlikely place to be leading the digital revulution in general practice.

While this week’s BMA News is a cover to cover Moanathon, Ashish is positively bursting with optimism.

The surprise:  he’s a single hander, and from 2,900 patients in December, he’s gained nearly 200 since then.

So that’s 50% more than the average fte GP list.  Think about the national shortage of GPs, then think again.

Harry Longman

So you arrive at your practice on Monday morning, looking forward to what the day may bring.  The screen is nearly blank as only one patient prebooked last week, who wanted to wait.

Demand comes in quickly now and about half the patients have kindly written down their problems in some detail.  You can quickly triage them, about a third you’ll choose to see, another third you’ll phone, a third you’ll send a message – they wanted that, not to waste their time and yours coming in.

Other patients have left a message with reception and you phone them, or delegate to another clinician.  The sense of control comes from you deciding as a GP how to help each patient – you’re good at this.

Now after coffee break the first patients are coming down, and you can give each one the time they need.  It feels more personal, you can build relationships because some of them have chosen to see you – which they can, because you’re here today, der.

The afternoon session has less than a third the new demand, so it’s more relaxed with much of the time seeing patients contacted this morning and then catching up on paperwork.  After 5 very little comes in so you take it in turns staying until 6.30 to switch off the lights.

It’s such a difference from before you changed. Back then, you were constantly frustrated about endless extras, 14 hour days, and the diabolical duty doctor rota.  But this is no longer a problem. Every day is pretty much alike, bar the infinitely intriguing variety of patients.

I’ll stop here because at this stage, I’m quite sure that you are laughing your head off.

The idea of a world where you’re feeling in control from the start of the day, able to offer the best professional help to all your patients, and go home with nothing left undone is the holy grail for most GPs.

It’s something which practices we’ve helped take for granted and achieve easily. It seems to come naturally to them.

And yet it seems to fantastical… So preposterous…. So unachievable…. to you, that I might as well have been describing a world where man has landed on Saturn.

Why is this the case?

Many doctors believe it simply can’t be done.  That balance of work and fulfillment cannot happen, because demand is infinite.

I don’t believe that at all, and that’s based on the evidence.

I believe GPs are almost universally making two very significant mistakes when it comes to their operating system – mistakes that are sabotaging their chances of success.

If you overcame them, you would discover that a balanced workload was not out of reach at all.

I’ll tell you about the first one on Monday. Watch out for that email…

Kind regards

Harry Longman

PS by the way, if you are concerned about claims being made for NHS 111 digital, you may be interested in a report which has come to light.

@harrylongman