How is your Monday going? If you’re a GP, I already know the answer, it’s busy, because 28% of the week’s demand arrives on Monday, and 3/4 of that in the morning. It’s not news.
News last week was that GP numbers have fallen by 1,300 over the last two years. A bit of a problem when at the half way point to Jeremy Hunt’s election pledge of 5,000 more GPs, we’d have expected growth of 2,500.
We need happier GPs.
The Dutch have happier GPs. Listen to Jako Burgers tell the RCGP conference why (20 minutes or so). Students compete for their GP training places, they recognise it as a top choice.
There are differences in funding and so on, but a lot about the system is similar to ours and they are paid about the same. Practices are smaller, there’s no obsession with scale, and they love the independence.
Let me float this idea for the UK: GP opening hours are too long. For many years now more women have been joining GP, but 8am is too early to be family friendly, and a 6.30 finish is too late. While we’re there, why shouldn’t fathers be at breakfast with their school age kids? Of course they should.
6.30 finish? “You’d be lucky” I hear partners say. Yes, many GPs are working very long days, I’ve heard 12 – 14 hours. Then taking days off. Working with hundreds of practices we almost never come across a full time GP.
I’m not proposing to cut GP working hours, though we should cut pointless overwork. But to spread them out evenly. Operationally it’s much better to work a regular five days, reasonable, family friendly hours, offering better continuity to patients.
I’m not proposing to cut access to GPs, but improve it (clue’s in the name). The difference in pushing back opening from 8 to 9 is an hour – compare with the three week wait forced on many patients. (by the way, the Austrian health department is trying to get GPs to open in the afternoon). Extending hours to 8pm and opening weekends for routines is catastrophic – sucking GP capacity into low demand periods, destroying continuity and burning money.
Understanding demand and flow means help for patients within the hour is not just normal, it’s easy. Minor problems we have with the Transform programme are firstly, we know that GPs starting work at the same time as reception is crucial for daily flow, and 8 is too early for many. Secondly, part time working causes uneven capacity through the week.
While our policy makers focus on inputs, number of GPs, number of hours, we need to look the other way. How do we make GP more professionally rewarding and practically possible?
Jako Burgers: “Happy GPs will do a better job than unhappy GPs.”
It’s not rocket science is it?
At long last the CAPC study on eConsult has been published in BJGP.
“Conclusion The experiences of the practices in this study demonstrate that the technology, in its current form, fell short of providing an effective platform for clinicians to consult with patients and did not justify their financial investment in the system.”
From his online response to the study, you might think that chief executive Dr Murray Elliender were running a charity. This is far more than simply capitalism red in tooth and claw. eConsult clearly would not be sustainable were the truth known about its performance, well known at the time to Dr Ellender and his partners as he makes clear.
But one of his Hurley Group partners is Dr Arvind Madan, NHS England National Director, Primary Care and author of the 2016 GP Forward View, which helpfully includes a £45m fund, ring fenced to be spent only on e-consultations, in which the company is already a 90%+ market leader.
Another of his partners is Dr Clare Gerada (BMA council, RCGP council etc) who emailed “50 most influential GPs” on 16 December 2016
“…As a leading member of the GP community, I hope you don’t mind in me blatantly promoting Web-GP (now known as e-Consult) an on-line GP consultation platform that myself and my partners developed three years ago.
eConsult is designed to make general practice more efficient… NHSE has announced funding… please have a look…contact firstname.lastname@example.org”
I’ll leave aside the misuse of nhs.net email for commercial gain, strictly against NHS rules, as much more is at stake here.
That study on eConsult again “…the overall feeling from practices was that e-consultations did not save time; the system generated work by adding another stage in the workflow for GPs and administration staff.”
So who put the CON into eCONsult?
Sometimes the NHS does spend money on stuff known to be worthless. £92,412 went on homeopathy in 2016, but they’ve stopped that.
The funny thing is that so many GPs, some of them quite prominent, have told me over the last two years the same story of their experience with eCONsult (The study quotes a range of daily use from 0.2 to 2.9. Almost homeopathically tiny concentrations).
The sad thing is that unlike homeopathy, digital triage from online requests for help is fundamentally a sound idea.
This is my note of hope for the day: we set out for askmyGP to have 10 or 100 times the use, and it’s working. Only then can it increase efficiency, and only with rapid parallel service by telephone can it guarantee equity for patients who can’t access online.
We are determined that CCGs should not be forced to waste their ring-fenced funding, but have a choice. That choice should be based on evidence of what works, not who’s behind it.
You cannot have failed to notice Babylon’s GP at hand service all over the media this week. As a PR exercise, on the Today programme, You and Yours, TV, front page of the Times and an almost unheard of positive story in the Daily Wail, it was SIMPLY BRILLIANT.
What you may not have appreciated is the existential threat this makes to regular NHS GPs. While presenting it as “the NHS has suggested that the service may however be less appropriate for…” the list of exclusions is in fact the engine of profit for Babylon. Read the list. It’s 90% of a normal GP workload. It begins with women (twice the consult rate of men in middle years), who are or may be pregnant (more work. And babies – lots of work). All the usual suspects, the elderly, sick, frail, confused and multi-morbid are there. They are work. Babylon doesn’t want them.
Babylon has got something spot on: patients are fed up with the often abysmal service from their current GP.
They want the young, fit and healthy, especially men, who rarely need a GP but when they do, want help fast, and don’t want to bother with going to a surgery unless they have to.
All these patients carry the same capitation. Think: what if you lost half your income and the easy half of your population? But kept 90% of the work? If it isn’t obvious yet, GPs will go under. That may not be you, but your neighbouring practice, whose list will be dispersed… to you… and you know those dispersed will be high demand. Nice.
They are in London so far, but Babylon’s ambition is limitless and I fear a multiplier effect from the mechanism above. They have the law (practice boundaries abolished), the funding model, the technology, the demographics and clearly the PR on their side. No doubt BMA is dreaming up legal challenges as I write, but they are no match for weasel words backed by £60m of VC money, while changing the law takes years, at best.
If it were simply about better GP services, I would be cheering. But the inevitable consequence is to stoke the Inverse Care Law. Those who most need help will find it most difficult to obtain. General practice will be dramatically less profitable in the hardest areas, and will suffer even in the most privileged. This undermines nothing less than the core principles of the NHS, universal, accessible and free at the point of use.
I will end on a note of hope, because this is not hopeless if we act fast. I founded GP Access & askmyGP with the vision “to transform access to medical care” and some might say Babylon have achieved that.
But our vision is universal. We have no exclusions. We understand the quality and safety from relationship continuity, to say nothing of the professional joy in work.
Although Babylon’s offer is getting the PR, it’s actually not that great. 2 hours for a video? So slow. 48 hours to be seen? So long. Travel within zones 1 – 3? So far to go.
You can beat it. Faster, easier, closer, with the GP you know.
As @stevekellGP tweeted yesterday, “All patients contacting the surgery today for GP help have spoken to GP & been seen if needed. No DNAs, clean start tomorrow. No videos needed” – most of them spoken to within half an hour.
If you haven’t seen his 2 minute interview you really must.
Our vision is of a transformed general practice that you own and you run for the care of all your patients. It is not a transformation done over you by the power of money.
I’ve been saying this for six years. Now wake up GPs, before it’s too late.
“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.
I’ve enjoyed being at a couple of conferences in the last two weeks, the RCGP and then Best Practice. Dozens of conversations each day left me happy but dazed, even monosyllabic by the end.
One of the funniest ones goes along the lines of “We have a huge problem and we need to get around much faster. I understand you do planes, but we are rather scared of flying, so I wonder whether you could provide us with half a plane?”
There are variations: “We want a plane like yours but with a steel frame, because steel is really strong and low cost.” Fine I say, but it won’t fly.
“We are used to driving piston engined cars and they are very reliable, so we want to put them in one of your planes.” Fine, but it won’t fly.
“We have a lot of wood available, so we need a wood powered plane”. It won’t fly.
A plane of any size flies because it is a system where all the components, power and controls work together to produce the outcome of flight.
Crucial to understanding flight are height and velocity, and of course if you don’t measure these, you could be blissfully happy watching films on the tarmac.
They are like demand and flow in general practice. How many patients and how fast are you dealing with them? Failure to understand these basics are why other organisations are offering so many alternatives:
“4 deployment templates” from eConsult
“6 alternative access systems” from Doctor First
“10 High Impact actions” from NHS England.
They can have no confidence in their models as they have no consistent measures or knowledge of how they perform.
Asking for directions, Alice in Wonderland said, “I don’t much care where I’m going”
“Then it doesn’t matter which way you go,” said the Cat.
Alice would like our Start package which lets you deploy askmyGP any way you like. We’ll measure it for you too.
But if you want to fly, then Transform is our one simple, reliable, current best way.
askmyGP & GP Access Ltd
PS System matters but size doesn’t. Just now we’re helping one of 2,900 patients, another with 32,500. Latest news from Larwood, which Dr Steve Kell kindly spoke of at Best Practice: “The wait to see me has dropped from 5 weeks to 15 minutes.” This astonishing statement produced barely a murmur in the room.
He tells me of Dr B who in fairness had been skeptical. He used to go home and watch Channel 4 news on the +1 channel at 8 o’clock. Delighted now to be back at 6.30 and watch it live at 7, a whole new experience!
PPS If you don’t know what you want yet, then Pathfinder will help you decide and I sincerely hope will calm your fear of flying.
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?
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.
Known since before Tudor times, named Gresham’s law in 1860, thoughtful observers have realised that “Bad money drives out good”. When two forms of currency are in circulation, the debased version quickly replaces that of true value. It’s happening now, paid for by the NHS, in general practice.
Oxford CCG proudly trumpets the big numbers, “15,000 extra GP appointments in £4m scheme.” Divide £4m by 15,000 x 12 months and we find the cost per appointment is £67. That’s over twice the fully absorbed average cost of a regular GP appointment.
It gets worse: regular GPs are funded by capitation, not by activity (per appointment) and their contract means they are already responsible for their registered patients who are or believe themselves to be ill. The CCG is paying £6 per patient for a service already fully funded – it’s paying twice. But not the CCG – it comes from an NHS England pot, descended from a GP Access fund which covered less than 10% of England – a lottery as to whether your area is included.
It gets worse: a GP federation officer says it’s for those patients having to wait 2 to 3 weeks to see their own GP. These GPs are failing their patients with an appalling service. They are being rewarded for failure, incentivised to fail more as worse access will move more of their patients into the “extended service hubs”. Patients at GPs offering an excellent service, such as Oak Tree Didcot which we helped over 5 years ago, have no need and no desire to travel further to see a doctor they don’t know.
It gets worse: my Didcot GP friend tells me “it is virtually impossible to find GP locums or recruit GPs because many are now working in these hubs seeing relatively straight forward problems, with 15 minute appointments, whether the patient needs 15 minutes or not.” [and we know that utilisation of slots is low, many will be left empty]
All right thinking people can see this. So why is it happening? Control of the money lies with those who don’t want to see: NHS England, who knows why, Oxford CCG who think they have a “nice” headline, and the GP federation owners so happy to take up the offer of highly profitable light duties. £4m will get soaked up in a year with no difficulty at all, and when the money stops, so will the service. This is the very antithesis of sustainable continuous improvement.
What can you do? Fight this debasing of general practice with every bone in your body. The RCGP, BMA and all in leadership positions should be calling this out. Local GP Dr Helen Salisbury says, “It might be better if we could just fund GPs properly,’ Too right. NHS funding must go to where it is of highest quality, most effective and productive, core general practice.
I don’t like to end without hope, because we need hope, and Gregory Bateson’s analogue is worth noting: “the oversimplified ideas will always displace the sophisticated, and the vulgar and hateful will always displace the beautiful. And yet the beautiful persists.”
Fight for the beautiful.
PS last week’s launch in Surrey has gone well, GPs dealing with all demand on the day, patients amazed. A couple of examples stood out for me on day one: the lady who walked straight to the desk at 8:35 expecting a queue of 10 and a rammed waiting room: nobody. Look of total bewilderment – “are you open?” And the patient late in the afternoon who, on the way out, stopped at reception to thank the whole team for the wonderful service she’d had. Gets me out of bed every morning.
I do hope you are thoroughly refreshed and have enjoyed the break from my blog. I mean your work. Oh, whatever, I’ll stop digging.
But I wonder how you view the thought of a 10 hour working day? Horror or relief? It’s relative isn’t it, because to some that would be 2.5 hours over the regulation 7.5, to others it might bring sanity at last to a regime which has been 12 or even 14 hours. People aren’t made for that and whatever you earn, it can make life not worth living.
So I was struck when a GP partner recently said she had this burning ambition for a 10 hour day, when completing our Leading Change Questionnaire (we do this with everyone thinking about system change. Nothing matters more than having a burning ambition).
Reducing GP workload has been number one topic in Pulse, BMA, RCGP and goodness knows where else, and the bad news is that we can’t wave a magic wand to reduce it. There are lots of factors. One is patient demand, which is remarkably constant, whatever we do. It isn’t going up, though revisiting a Liverpool practice we first helped five years ago is encouraging – demand is down 10%.
But what we can do, and to some this does seem like a miracle, is dramatically improve efficiency. It’s intense, and getting it right means careful analysis of consultation times, modes, referral and resolve rates, but it does work. Unmet demand is a factor, and simply meeting this can soak up a proportion of time freed up by a 20% efficiency gain, but almost always there’s plenty left over for getting the hours down.
Efficiency is our absolute laser focus – how you convert that to your benefit is up to you.
Overwhelmingly GPs tell us “I feel more in control”, as another partner did last month having launched in June, and it’s the control that makes work satisfying, even though it can be intense.
We love what we do and those kind of comments get me out of bed every morning. It will be an early start Monday to be at our first autumn launch in Surrey – I can hardly wait.
Are you enjoying the Proms? I’ve only been a couple of times but I love the wealth of music on offer, some familiar, some challenging.
David Sawer’s “The Greatest Happiness Principle” and the Proms Extra talk got me thinking last Saturday. We put “Happier GPs” on our askmyGP home page, because it’s a direct quote from GPs. But what might that mean? A non-stop cheesy grin, I think not.
The evidence is that we don’t consciously think of ourselves in a state of happiness (the strong conscious emotions are the negatives), but we are living in the moment. Contributors include:
- doing something good for others
- flow, being totally absorbed at the limit of our capability
- control of our own time and efforts
It isn’t the same as an “easy life”, pleasures with which we may relax but too much of which don’t give us meaning. So we aren’t saying to GPs, put your feet up, but reflecting the kind of things they say. Last week I was in a practice where one partner reflected “I feel so much safer now” (they are dealing with all demand same day, where it had been only 40%).
In another, the manager said last Thursday they had all finished by 4pm so they went home except for the one on duty, who dealt with five calls before 6.30. That’s not every day, but most GPs would have a clinic full of patients booked three weeks ago who may or may not turn up. In contrast, knowing you are providing a fabulous service and can have that flexibility is enormously liberating.
You don’t need me to tell you that the narrative in the medical press is so different, and BMJ front page last week has BURNOUT in big capitals. But the editorial is right on the mark: “Solutions have traditionally focused on individuals and their resilience.” whereas, they continue, “A systems level approach is imperative…”
We couldn’t agree more. It’s the system.
PS this makes me a little bit happy, the first askmyGP feedback at 8 this morning, “I really like this new service and I cannot say enough how much easier this is to access medical treatment. The surgery is fantastic.” This theme is so often repeated that it’s getting boring. The meaning for me comes in asking, “How can we multiply it by ten thousand?”