Witley & Milford Surgery serves 11,200 patients in the rural Surrey commuter belt. Yet the partners felt under pressure, not in control.
They weren’t providing the service their patients deserved. Dr Dave Triska and colleagues explain what happened from June 2018. Below the video, see the numbers.
Charts on demand volumes, patterns, response times, channel of demand and response, continuity and patient satisfaction:
Witley and Milford charts to 14 May 2019
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.
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.
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.
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.
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…
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.
If GP workload is your prime concern I’ve got great news: you can cut it by 10% without fail in just four weeks. Simply take 3 appointment slots off your daily template. Boom.
You can even claim some high-minded motive, reducing GP burnout, decision fatigue, keeping away the worried well, timewasters and so on. Your receptionists will have to turn away a few more patients, but they are used to that.
Don’t worry, you’ll be no worse than some other local practice and the CQC won’t notice – they have no way of measuring what you’ve done.
The only folk who will suffer are some of your patients, the unlucky ones, but they don’t have a voice anyway.
If so please unsubscribe, we can’t help you.
There are plenty of others who promise to reduce your demand, divert your patients, make them wait longer, travel further, see someone they don’t want to see at a time they don’t want to go. Much of this is taxpayer funded. Links on request – they just don’t have any evidence that it works.
Want something better for your patients?
Before we begin any change programme we ask the partners a few questions, one of the most revealing of which concerns their ambition for patient service.
Very few admit to “Never mind, it’s all about the money”. A few say “No worse than others locally”, “A bit better than we are” or even “Top quartile performers”. The vast majority go for “The best we possibly can be.”
We can work with them, because they have the inner fire to carry them through what could be tough in the early weeks, as you get used to dealing with true demand.
You will be much more efficient from day one. Typically you will deal with 60% of demand remotely and we measure this (though below 50% the efficiency change is marginal, many are soon even higher. The latest hit 65% in month one.)
Don Berwick, mindful of the need to provide excellent care with finite resources, says “Efficiency is a moral imperative.” It’s far more important to study efficiency than workload, because you can do something about it, now, without waitiing for handouts from someone else, or worse taking it out on patients.
But what about the workload? It’s related but a different question. A big factor is the amount of unmet need pre-launch. We measure this too, with the average at 14%.
The highest we’ve ever seen is 32%, and before that practice launched last week I warned that it was going to be tough. Talk about inner fire – Sue the GP principal told me on Thursday at 5pm that something wasn’t right, she had free appointments right now and time to do other things.
We can’t make absolute promises on workload because of the variables, though GPs continually tell us that they feel more in control.
Our laser focus is on efficiency, never a final answer, always improving, sometimes in leaps like the one from telephone triage to digitial triage, sometimes in tweaks like the half day session plan (ask me how it works, very neat).
Our promise is to help you become as efficient as possible, so you can give the best possible patient service.
Dr Chris Peterson of The Elms, Liverpool, 5 years on:
“It’s more efficient, but it exposes unmet demand.
It’s completely liberating!
We are delivering demand lead care, not capacity constrained. We have no one waiting to see us.”
Can you say that every night when you go home?
“It’s lovely not being shouted at 24/7”
Receptionist Karen’s first comment to me was both startling and predictable. Her Somerset practice launched their demand led system two weeks ago, and since then she has been able to help every patient. Three weeks ago she and her colleagues were turning away one in five patients (we measured it) but they have moved straight into the super league, with a median response time from the GPs of 26 minutes.
The GPs love it too, but I find they are more buttoned up and try to find at least one thing to grumble about. “I’ll be home early so will have to put the kids to bed,” said one.
That didn’t take too long did it, or seem so hard? It was four weeks of preparation, to abolish the old system and start the new.
So why aren’t we hearing about this from the commentariat? I get a stream of dismal blogs from Nuffield/King’s Fund/Health Foundation (why don’t they just merge, it would save all those personnel transfer costs?) wringing their hands about how hard it is to change anything.
Another one today on General Practice at Scale, is it working? Yawn. Fiddling with structures, the obsession of policy makers who should get out more and ask “WHAT WORKS?”. Instead we’re told,
“Motivations… centred on a desire to offer better access…
Most strikingly, what the survey revealed was just how long enacting change can take – at least two years to even begin to achieve what they’d set out to do.”
Useless. And no measure of performance is even offered. This is why Deming said that motivation is fine but worthless on its own. The question is “By what method?”
Method is central to our work and it’s so repeatable now that the outcome is binary: either the practice decides to change, and it all happens within a month, or it doesn’t, and nothing much happens at all, ever.
But method is not static, we are continually learning and having to adapt. Another Midlands practice told me yesterday they are learning lots from having a GP in reception, sometimes even taking calls from patients, and their performance is rocketing while demand is falling.
I’m not going to call it a trend yet, but if you are a demand led practice you’re probably enjoying the sunshine dividend today. Have a great weekend.
PS Learning a lot from askmyGP users too, with over 1200 episodes and 130 patient feedbacks on the new system, 55 suggestions from staff, a terrific response. We’ve already put dozens into service and next week’s plans include one for low using practices (they will get an email notification of an online demand) and one very much anticipated by high users.
GPs have been emailing patients because it’s convenient – but it’s not secure and poorly controlled for IG and patient safety. From next week those on the Transform programme will be able to securely message patients in a two way conversation. It’s going to be another huge time saver. Will let you know how it goes.
Poster presented at FMLM Belfast conference, 9 March 2017. Download pdf here
“A year ago in February 2016 we took the plunge and embarked on GP Access. The time between making that decision and going live was barely 4 weeks, but in that time Harry and his team analysed our data, gave us information about staffing levels, leaflets and publicity for our patients and training for staff.
Since then we haven’t really looked back. It is fair to say that some of our patients have taken longer than others to get used to the system, but now mostly they all understand how it works and comply. We do still get the occasional walk-ins, but manage these effectively. Our DNA rate has also dropped dramatically.
We have developed our own way of using the system, which is unique to us – but that is the beauty of the concept.
From the point of view of our patients, in particular those who ring in the first couple of hours of the working day, by mid-morning most will have spoken to the Doctor of their choice and be coming to the Surgery either to have a face to face consultation with a doctor, nurse or to have investigations carried out prior to a GP appt… Or at the other end of the day, those phoning after 4pm have been called back and seen by 6pm if that is what is needed!
We often get remarks about the lack of patients lingering in our Waiting Room and it was interesting that when the CQC came to inspect us only a couple of months after we had embarked on the new way of working, they were most disappointed not to find anyone who had waited ‘hours’ in the Waiting Room to interview opportunistically. I think it came as quite a shock to them!”
Michèle Hole, Senior Receptionist, Millbrook Surgery, Castle Cary, Somerset.
See what a Millbrook patient wrote in the local paper in June 2016.
Ballywalter, population 2,027, lies on the Ards peninsula in Co Down. Just smell the sea!
In the first full week (from 16th January) 72 patients used askmyGP to get help from the 5,200 patient surgery. That’s 20% shifting channel from telephone to online. Since then it has risen closer to 30% and the effects are growing.
Practice manager Leah Larmour writes:
“I have to say over the last several weeks things have been really difficult in the Practice, both with the launch of the system and a few other issues going on. They didn’t really settle until the end of last week when we had launched the online system and had a Practice meeting to discuss what further ‘tweaks’ the GPs wanted to make to the system. This week has gone much more smoothly so I will be submitting figures and patient surveys from the past week…
The online element getting up and running has definitely been a turning point and we are now feeling the difference we hoped for. All our telephone demand is dealt with the same day and the online requests the same day or following day depending on demand and what time the form was submitted. The patients are finding it easier to get through to reception as there no longer needs to be a rush to get through at 8.30 before all the appointment and telephone slots are filled (often this was by 8.50am)…
The system has massively improved access for our patients and made the workload more manageable for the GPs. I think it is important to note for other surgeries thinking of taking up the system that they may not feel the immediate positive impact that some have. If it does initially get more challenging it is most definitely worth persevering as the end results will be worth it with patients being happier with easier access and GPs feeling in control of their workload.”
Patient feedback has been flowing too:
“Brilliant to get advice without taking up GP hours. Good that you can still see a GP when needed.” male 34
“Easy and efficient! Highly recommend!!” mother of child, 10
“I am very pleased with the practice’s continuing efforts to make improvements to meet the increased demands placed upon it. A system such as this suits me much better than a frenzied rush to redial/redial/redial… at 8.30am to get medical attention. Thank you.” female 37