“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.
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?)
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.
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
Dr Philip Lusty writes:
“I’ve just witnessed a miracle and it happened in Portadown…
Portadown, a large town in Northern Ireland has had significant negative publicity lately with the threatened closure of a neighbour general practice leaving this month 5000 patients without a GP and potential list dispersal. The stress and strain this has put in all those involved in trying to provide solutions and the neighbouring GPs who fear a list dispersal and worry about domino effect is very palpable within the area. The patient population are in fighting spirit as they demand a solution from local government that protected their much loved GP practice and maintained service where they were familiar.
A few metres away at a neighbouring practice where I work, Riverside Portadown, with just under 14,000 patients, the Health and Social Care Board kindly supported our involvement to participate with askmyGP pilot. They had already kindly granted us a list closure following a shock resignation of a partner last June that left us struggling to survive with list size 2,500 per FTE. With further resignations entering into 2017 we faced the real possibility of adding to the problems of Portadown by handing our contract back if unable to rescue our practice, as we had failed to recruit sufficient GP cover to make us feel safe and secure. All the negative vibes have been successful at encouraging young GPs to avoid the area making it even more difficult to recruit.
Preparing to launch askmyGP and overnight change our system felt like our last stand at trying to survive as a practice, bit like the 11th round in a Rocky Movie. Entering into the 11th round we have had some serious knocks this year and been on the floor several times. We have entered into the last round exhausted and beaten and like some of the best Rocky movies, it looks like askmyGP has paid off giving us the tools to get back on our feet again and are punching back with force!!
Everything Harry said would happen has taken place. We had never any need to worry about the change. But what Harry doesn’t fully understand is that in Northern Ireland we never truly believe what we hear and often we expect the worst as part of our personality and when things go right we often wait for everything to go wrong. I know I’d have colleagues reading this now skeptical saying “too good to be true..what’s the catch…” We can be a pessimistic bunch! Plus we seem to have our fair share of skeptics in Northern Ireland “Oh it would never work here our patients are too old..too young…too rural…too many foreigners… etc etc.” I have heard every reason from the skeptics!
Now 5 days into askmyGP I definitely have witnessed a miracle and that is from day 1. There is joy back in my working life again, I have a spring in my step and everyone around me share in the same happiness and success of this new change. A miracle has surely occurred on Monday 11th January and all we did was launch askmyGP overnight!! It did take almost one year of discussion, convincing and then over one month planning the change but it was worth it as all the skeptics (which there are many) have been silenced, and everyone and I mean everyone is very happy…yet some are still waiting for that tsunami.
I am so glad that I and my partners had faith in Harry Longman’s experience and knowledge as he coached us over our fears of change helping us to take the initial steps this week. All the planning and discussion has paid off in spades and to see everyone more relaxed, and doctors saying they have got their joy back of practicing medicine is highly rewarding for me. The reception staff no longer have to face the daily “sorry there are no appointments left for 3 weeks” and all the emergency appointment are gone at 8.40 am and yes sometimes our patients have been known to get verbally aggressive upsetting my staff. No one seems to have been that annoyed by anyone else this week!! The pressure had come off and stress levels are at their lowest.
The “On-call” doctor no longer has to face the 50 plus contacts per day to triage on their own and decide where and when to see them as there is nowhere left and all your colleagues are too busy to help buried in their own same 15 patient surgery that runs same time every day. Now the demand is faced together as a team who collectively take responsibility of the entire days’s work load and everyone feels equally valued. There is time for lunch and on Tuesday I noticed at our pre lunch team meeting with doctors that this went on for about 45 minutes as we just enjoyed the new experience of calm and started to converse sharing other ideas of how to drive the practice forward. No one was in a rush. I now have time to empty my bladder as much as I want, time for coffee break and also time for lunch, plus I am getting home earlier and far less stressed. The change is immense.
The patients are amazed at how easy they get access and are equally delighted that they do not need to attend the practice unnecessarily when something can often get managed easily on the phone. Harry did say we would manage 60% of our contacts on the phone on our first day and when we made our calculation we managed exactly 60%, not 1% more or less on day one. In three days this improved further and last look we had managed 70% of our phone contacts. Our patients are so happy they have offered to write in to congratulate us on our achievements. The praise from our patients this week has been such an encouragement to us as they too value the service they receive from their GP and are only too aware of the stress many of us have been under.
I am 100% wholly converted to no pre booked appointments, manage all your demand in one day. In the current climate of dissatisfaction within the profession, GPs threatening to hand contracts back to HSCB, it is nice for once to have a good news story where other than the money to fund the expertise of Harry Longman and his team there has been no cost to the practice thanks to the funding from HSCB. The first person who introduced me to the concept of askmyGP was Bride Harkin, one of the assistant directors of commissioning in Northern Ireland, when she sent me an e-mail during my time as GP on her local commissioning group. Bride wanted to take all the credit if this week had been a success!! There is a revolution taking place and I urge all politicians and policy makers to take note and wake up and see some of the positive contributions to health care that can happen and I urge you all to listen and follow Harry Longman in his quest to change how we can operate.
I have witnessed a miracle and a rebirth in our passion for delivering a high quality service again for our patients. Time is our most precious resource for caring and now I feel more in control to give that time appropriately to those who most need it and show Care with big C that one of my old partners used to talk about in a previous role.
Like Rocky Balboa I think we’re now well off the ropes, bit battered by experiences, but you know what I think we’ve lost some of that pessimism and we might just attract that new doctor we need now to the practice. If that happens not sure where can stop us.
Harry thank you so much for your patience with us as we took our time to consider our options. Bride I know you’ll read this and what can I say but you are one of the many excellent examples of good leaders I have witnessed within my time at Health and Social care Board and I think you deserve some of the credit!! Can’t forget Margaret, Sloan or Keith either!!
Things can only get better!!
Updated 20th January from the local Portadown Times:
Way in to Riverside practice in Portadown Health Centre: