Poster presented at FMLM Belfast conference, 9 March 2017. Download pdf here
Couple of mornings ago I was just enjoying my porridge when the Today programme told me that four out of five hospitals need to improve! Spluttering, I had to leave the porridge to cool while I took to Twitter.
No, it’s not the four I’m worried about, but the other one which presumably thinks it doesn’t need to improve. All of us need to improve – companies large and small, hospitals, GPs, parish councils and governments. A minute later Radio 4 was telling us that 2/3 police forces were performing well while 1/3 weren’t. Utter nonsense.
The real scandal is not the hospitals, or the police forces, but the thinking which labels performance as binary good/bad, pass/fail, and it’s this system of rating which infects government from top to bottom. People moan about CQC for its charges, its bureaucracy and bother, but the heart of the evil it spreads is the way that it rates its victims.
Measurement is crucial to improvement, but it matters what you measure and how. The best place to start is with what matters most to patients, and if you don’t know, think about the last time you wanted help from your GP. Yes, it’s how fast you can get help. Not the only thing that matters by any means, but you’d have thought that at least the multi £million CQC would have realised.
Recently we’ve produced datasets for two practices, one labelled by CQC as “good” and the other “inadequate”. It’s clear from the former that patients are being turned away almost all day from 8.45, and are struggling to make appointments. The latter, while ticked off for records on staff checks and vaccines, has a policy of never turning patients away, and it’s clear from their data that they don’t, accepting calls right up to closing time.
Do you want a tick box culture in general practice, or one with a passion for patient service at its heart? I know what I want, and if the government wants it then nothing short of a total rethink of CQC will get there.
“When the Facts Change, I Change My Mind. What Do You Do, Sir?” There’s a lengthy discussion on who said it first, perhaps not Keynes or Churchill, but never mind.
I’ve been saying that there is no evidence of patients being diverted from seeing their GP through online help, and now that’s changed.
Our evidence is from two hard tests to see whether askmyGP can reduce demand. The first is to measure overall demand (by analysing all consultation records for practices in time series over months) and we’ve seen no measurable change up or down, a valuable finding in itself. Demand doesn’t increase even when 20% of it now arrives online. Nor have we seen overall reductions.
The second test is at the patient level, where we offer symptom specific NHS Choices information to patients. Many view this and find it helpful, but very few are deflected from consulting: we measure this continually, so far only 30 out of 38,000 episodes.
Then this Dutch study arrives, high quality evidence of 12% overall demand reduction. Enormously interesting, because the Dutch registered list and capitated system is similar to ours in the NHS (though insurance funded). The reduction was over 2 years and the result not only of the technology but also a complex intervention of GPs advising and encouraging their patients to use it.
But the technology matters too. It’s notable that while NHS Choices is also very popular, there is no evidence of demand reduction as achieved by thuisarts.nl. It was created by NHG, the Dutch equivalent of RCGP. The differences between the two websites may appear subtle, but the fact is, one of them works.
But reducing demand has been an aspiration, subject to finding something that works – perhaps we are now a little closer.
Some of you reading this may be in a position of power and influence. With these new facts, I know what I’d do.
Dealing as I do with GPs week after week I admit to a twinge of envy that I will never personally be able to help a patient as a doctor, while they get the privilege every day.
But we get a little something from the feedback patients leave on askmyGP, and I wanted to share with you everything that’s come in the last 24 hours. Each one carries a story, and they are typical of recurring themes over the last two years.
They range from the simple, for which I’m grateful:
“Excellent facility.” male 54
to the more specific:
“Well structured questions to analyse symptoms etc.” male 62, sciatica
solving a real problem for many stressed parents:
“Much better as can use at any time and also don’t have 2 keep trying 2 get through on the phone in the morning” Parent of 3 year old, earache
and towards the other end of a lifespan, relief about the:
“Option for relatives of elderly patients.” on behalf of a 96 year old
Improving access without increasing surgery hours, and the importance of rapid response:
“This system worked well for us the first time we used it. We emailed out of hours but got a fast response as soon as the surgery opened.” male 81
Lastly something rather special, helping the clinical encounter itself by changing the channel:
“I get nervous talking about personal matters – this way the Dr can see what they are dealing with prior to speaking with me” female 44.
Perhaps we have shared in the privilege of helping this unknown lady. Being able to reflect and write down the problem is quite a common theme. There is lots of patient engagement online with 15% leaving feedback, over 5,600 items so far and we keep a running summary here.
The desire to help one another runs deep in the human psyche, and I think that is why, above all the cacophony of crisis, the long term studies of job satisfaction always feature GPs near the top.
Don’t talk yourselves down, and don’t dwell on the latest “GP-as-victim” blog in the columns of Pulse. Margaret McCartney writes powerfully in this week’s BMJ on the intrinsic value of long term relationships which GPs enjoy with their patients, unique not only among the professions but specific to general practitioners.
Treasure it, enjoy it, guard it.
PS Many more have enquired since last week about how to get Resilience funding for their practice to improve service and workload. We are doing our best but it seems time is tight, so please get in touch soonest.
PPS I’m a big fan of Julian Patterson’s NHS Networks blog and this week’s consultation on STPs is a must. Light up a grey day!
“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.
Dear Mr Trump,
I get your sense of terror towards all those out groups like women, liberals, Mexicans, Muslims, Chinese (not Russians, oddly?), hordes from abroad… but they aren’t your biggest worry.
You’ve made a great start on dismantling the hateful Obamacare. OK, 20 miliion more Americans got health insurance, but it didn’t make much of a dent in the 17% of GDP you spend on healthcare. I agree, however well intentioned it didn’t go nearly far enough. You want something like our beautiful NHS, halve the cost and cover everyone, dontcha?
You can do even better, ‘cos ours ain’t even free! Hard working adults have to pay £8.40 just for a prescription. And hospital car parking can add up to the cost of essentials such as a pint of beer or a couple of newspapers. Then there’s the appalling inefficiency – most of the population have to wait more than a day to see their GP.
Butt – if you saved half the cost of healthcare, think of all the walls you could build, and the missile shields. They’re damned expensive, even against friendly missiles, ‘cos those things are soooo unpredictable.
No, the real terror is on a whole different page. They come in boats and planes as well as over land borders. They never get work permits, never pay taxes, they can run AND they can hide. They can move at the speed of light. They have intent, and meaning, they act alone or in deadly organised cells known as “sentences”. They threaten your policies and even your person. One traced to a middle eastern source said “Many who are first will be last.”
They are words, Mr Trump. Beware words.
PS And now for some good honest real news. This tiny seaside village is so achingly beautiful I can’t wait to go. They’ve just dived in to askmyGP online access and their website is absolutely the coolest I’ve ever seen (I’ve seen hundreds). Take a deep breath – you’ll feel better instantly.
I wrote last week to Mr Hunt and sat by the phone all weekend, but it appears ministers are not offering a proper out of hours response so I have little choice but to go direct to Emergency PMQs.
Your headlines: “a large number of surgeries are not providing proper out of hours care – and patients are suffering as a result because they are then forced to go to A&E.”
GPs have a contract since 2004, mostly GMS or PMS, which defines their core hours. Simply saying you don’t like it really won’t do. The Telegraph has “Under Mrs May’s plans, GPs will have to be open from 8am to 8pm every day of the week unless they can prove there is not demand in their catchment area.”
We’ve been measuring demand for over five years and I can assure you there is always demand, but we do need a higher level of understanding from our PM, well intentioned and intelligent as you are. Demand out of hours is predictable and perhaps surprisingly low, but covered by out of hours services (as provided for in the 2004 contract).
But you are confusing demand with capacity. We know precisely the profile of demand, by day, by hour, even by minute, we know what is in and out of hours. We also know that spreading the same capacity over longer hours will cut that capacity and increase costs. When Sir Amyas Morse states “They are seeking to improve access despite not having evaluated the cost- effectiveness of their proposals and without having consistently provided value for money from the existing services.” it is well worth listening. His NAO report says extended hours GP costs are 50% higher than core hours. I’ve seen evidence that the true ratio is closer to three times.
Ignoring the evidence you have deeply upset GPs and confirmed the view of many that they are being bashed. I could call this counterproductive but the language you’ll hear over the next few days is going to put such bland terminology in the shade.
I do more data nerdy stuff than emotions, but I want to finish on a note of hope and if you’re prepared to listen, read one thing. Dr Philip Lusty was exhausted and beaten, along with all his colleagues and staff, as I personally witnessed. Now read what happened.
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.
So the Red Cross tells us there’s a humanitarian crisis in our NHS hospitals and ambulance services. What reactions does that trigger in your mind?
This is the same Red Cross which is helping those left alive flee the ruins of Aleppo, and in context I don’t know about you but I have a problem with that language. I don’t mean to shrug “Crisis, what crisis?” but the point is that it is so easy to make headlines by building on public perceptions and so hard to challenge them.
Many players within the NHS ecosystem and media thrive on continual crisis but strangely it doesn’t help us to measure, analyse, reflect and redesign. We are addicted to firefighting.
Now I want to raise the subject of cognitive dissonance. If you haven’t yet read Matthew Syed’s “Black Box Thinking” then I urge you to do so: well written, engaging and with a powerful message. (the subtitle about marginal gains doesn’t do it justice. It’s much more about learning from failure).
I’ll declare an emotional “COI” here in that aviation comes out much more favourably than healthcare, and some decades ago I was a tiny cog in the industry at Rolls-Royce aero engines. The difference centres around attitudes to failure: forensic analysis, learning and rapid dissemination in aviation, versus cover up in health. Doctors have admitted to me that that’s a huge fear of failure in medicine, but the problem as Syed so eloquently puts it is that failure happens continually and repeatedly. Aviation by contrast is very open, and very safe.
I’ve talked for some time about the primal fears which keep GPs from change, impenetrable to evidence. But perhaps I’m wrong, it’s more the gap between beliefs about current practice and what we imagine we might have to do – cognitive dissonance.
Does reframing the problem make it any easier to solve? Your thoughts gratefully received.
PS Counter that crisis thinking with this US doctor’s experience of the NHS as a patient. We must count our blessings vs USA never mind Syria.
Yesterday in deep frost the view from Great Mell Fell in Cumbria was blissful. I hope your holiday had similar moments, and they will continue to inspire as we get to work in 2017.
I’m optimistic about the year ahead as more and more GPs and their patients are seeing the benefits of a demand led system, whether phone or online. But I’m concerned about polarising views and we saw this only last week when, perhaps to her own surprise, RCGP chair Helen Stokes-Lampard made the front page of the Sun with “A MONTH TO SEE GP” winter misery shocker.
The testimony of hundreds of GPs says there’s no need for a trade off between workload and waiting time, and no need to divide the infinitely variable needs of patients into “urgent, trivial” and “routine, life threatening.” They know they can deal with demand as it comes in, appropriately and compassionately. We shall keep on putting that message across because it happens to be based on evidence.
Already today this year a new practice has launched, in the west of Fermanagh about as rural as it’s possible to be in these islands. There isn’t even a house next to it, just fields.
And this morning these three patients left the latest feedback on askmyGP:
Better since streamlined process. Thanks! (f 41)
Feel I can explain my problem easier writing it than talking about it. Quick service is great (m 38)
I use this service as it saves me from making a phone call, it is easy to use and i have received a follow-up call from the GP quickly (f 17)
This is what should be on the front pages.
Chief Executive, GP Access Ltd
PS we’ve been very busy today with enquiries on askmyGP, as new year prompts new ideas and minds turn to making the most of the GPFV funding. Do get in touch.