Looking up Eric Berne’s classic “Games People Play” I was surprised to find it was published in 1964. He calls it “a way of predicting people’s behaviour.”
It would be pleasing to say we have learned more as time has passed. I doubt it would be true.
Without going into the great psychiatrist’s theories too far he was clear that destructive games caused a lot of pain not only to his patients but to all of us in our daily lives.
I was reminded of these ideas when joining in a Twitter conversation about DNAs (did not attends), a GP complaining that 4 out of 7 patients hadn’t turned up – blame the patients for wasting GP time, NHS resources and slots which someone in need could have taken.
It all makes sense, until you realise that these were Saturday morning “extended access hub” slots. We know that very few patients want weekend slots, and they don’t like to travel away from their own surgery or see someone they don’t know. They were sent there and then as their own practice gave them that option or nothing.
We know that the longer the gap between the booking and the date of the appointment, the higher the DNA rate. On the same day, DNAs all but vanish. Our practices don’t talk about them any more. If changing the system with the same patients eliminates the problem overnight, it follows that DNAs are a system problem, not a patient problem.
The blame game is very simple: “We tell you when and where you will be seen, by whom. We blame you for not turning up.”
We find the same things happening with all kinds of variation. The most common game for appointments is “Nothing left today, you’d better call tomorrow but make it early as they all go around 8 am”. A friend of mine had the whole family of six call the surgery at 8am to increase the chance of one of them getting through.
Another game is “We’re very busy so we allow booking up to six weeks in advance for routine matters”. The mother would take the slot, and would turn up herself or with whichever child or frail elderly relative was most in need on the day.
A new one on me recently was “If you phone in the morning a nurse will triage you. Phone after 12.30 and a GP will triage you for the next day”. In seven years this is the first ever practice I’ve met which has more “demand” in the afternoon.
Whenever we start work with a practice we ask them how the appointment system operates, and we look at their website. So often they summarise it in the two words, “It’s complicated.”
We’ve reached the point that we know from the rules what games patients will play. Then we get the data on demand patterns and it turns out exactly so.
It’s really “Games providers play”, and the cost they and their patients pay is rework. Everyone gets locked into the game, working like stink, deeply frustrated, achieving little.
I love what Eric Berne says in his field:
“Everybody has a hunger for intimacy, a game free zone where people are straight with each other.”
The alternative for practices is to rewrite the rules very simply:
“Let us know your problem, whenever you like. Tell us who you would like to help you, if not anyone, how you’d like us to contact you, and any issues with timing.
“We’ll work out very fast how to help you. No promises, but we’ll do our best to meet your preferences too.”
What happens is quite astonishing. Not only do patients almost always find their needs met, but because there’s so little rework, it’s less effort for providers.
This week from a Bristol patient: “So much easier as I have time to think what I want to say, and it frees up staff to do what they need to do.” We get dozens every week on the same theme.
At the end of a week of “fun” on the NHS at 70, I want to contrast two views of what it’s about.
Matthew Parris is always thought provoking and he writes today in the Times, “The NHS guarantees second rate healthcare”
In case you don’t have access through the paywall I’ll summarise his thesis. Transport in London is slowed by congestion to the point where people would rather walk. When it speeds up, they will get back in the car/bus/tube. NHS Healthcare is like transport, keeping the waits long and the service cumbersome is a crude way of rationing. If we made it faster, more patients would jump in to the point where it slowed again.
“We’re getting a second-rate health service for the price of a third-rate one. I see no other way.” Meh, as my daughter would say.
The theory is impeccable, just spoiled by an inconvenient fact: it’s not true of healthcare. Easier access doesn’t increase my number of diseases. If the theory were true, lowering the effort to access the GP as close as we can to zero would see demand escalate.
It doesn’t happen. Demand is flat. Patients don’t even need to wait for the phone to be answered, and they are getting a personal response within minutes.
Witley yesterday: “our waiting time for routines is now half an hour. And we’re a partner down this week, unplanned.”
You may have heard of the death last week of Julian Tudor-Hart. So much has been written about him and by him on the NHS, I’m grateful to @mellojonny for a 9 tweet summary (click Show this thread). He starts with “1. A united national service devoted directly and indirectly to care, fully available to all citizens.”
We never met but at 85 he wrote to me in 2012 and I quote:
“So I count on you & others like you to carry whatever is useful from my torch, which I in turn got from my predecessors – my father, Len Crome, Hugh Faulkner, Alistair Wilson, Jerry Morris and a small handful of others.
I wish I could get more people to read the 2nd of my Political Economy of Health Care, especially the final chapter. To act effectively and sustainably throughout their lifetimes, people must have a comprehensive big picture of society, and how fundamental social change actually works. So far, very few people have that. Until they do, we and our descendants will be in mortal danger, worse than 1933-45.”
Matthew Parris or Julian Tudor-Hart: choose your vision.
I’m fortunate rarely to need the NHS, so when I do as this week there is so much to learn. And it touches directly on why we can routinely make life changing efficiency gains in the order of 40%.
Where could that possibly come from in practices who tell us the whole time they are bursting, sinking, drowning or whatever hyperbole they choose? They can only see one way out, recruiting more GPs, and they can’t recruit.
So here’s my story. I need a blood test for schistosomiasis after swimming in Egypt, as another member of the group tested positive. While I explain what happened, tot up in your head the waste…
Weds 27/6 I check online to book an appointment, next available is Friday 29/6, HCAs only this week, but I think, blood test, will be OK, and clearly state the reason.
Friday 29/6 Three phone calls around 8am, all of which I miss, but get a message and call back. HCA can’t do this one, could I see nurse instead, and she’s free at 11.30. I grumble, shorten a meeting and agree to go at 11.30. (wasn’t available to book online)
I’m on time, but she spends the next 15 minutes explaining how unusual this blood test is (me: “but I’ve only got one kind of blood”), nips out to refer to GP. Can’t take the blood, but GP will call me today at 4.30 to explain what needs to happen. (slot wasn’t available online)
4.30pm GP calls and spends 4 minutes explaining what the nurse told me, and that I now need to book another appt with an HCA to take the blood. (what really creased me up was seeing the note online for my 10 minute call: “This was a difficult pt earlier”. Not intended for my eyes!)
Monday 2/7 I book another appt with HCA for Friday 6/7. Today I turn up at 11.50 and the HCA takes my blood, I’m out in 4 minutes and the actual value work is done, at long last. I was a very brave boy and got a badge.
I did everything by the book, all online as Jeremy Hunt wishes, but did you tot up all the waste? 4 receptionist phone calls, only one connected. 15 minute nurse appt, including an interruption to the GP. 10 minute GP slot, achieving nothing.
You missed something – over an hour of my time.
I can hear you whispering that this was a special case but do you know, for the patient every episode is a special case? Other family members get a similar run around pretty much every time they need help from the GP. Then they try going around the system, just because they are human beings, just like all the other human beings who tell me daily about their frustrations.
But have you seen how the magic works?
All we need to do is take out the waste and rework.
I’d go online with askmyGP, answer a few questions to explain exactly what I needed and send. Looks complicated, receptionist assigns to GP who in total peace and quiet looks up the procedure in seconds and messages me to say come in for the blood test, today. Done.
Multiply hundreds of times per week for each practice and millions of times per week for the UK.
Jeremy Hunt wants to automate the waste, creating more waste. Andy Burnham pops up to tweet “This lazy line that the NHS is inefficient annoys me.” That’s not lazy, it’s caring. I counter with Don Berwick: “Efficiency is a moral imperative”
Most of us will be born, live and die cared for by the NHS. That doesn’t make it a religion, just a jolly useful health service. Britain has sadly become one of Europe’s most unequal nations, and the NHS does a little to level opportunities at least in one sphere of our lives.
The NHS at 70 doesn’t need reverence. It needs principled leadership, critical friends, and no-nonsense doers with method.
PS If you’re sick of all the hearting, @jtweeterson’s blog is guaranteed to cure you. Simply brilliant. Sit down first.
PPS My story above shows why our first question in Pathfinder is “What is it like to be a patient? The data we capture make that pretty clear, and it helps to focus on purpose, good preparation for the next step of eliminating the rework.
GPs are talking an awful lot about online consultations these days, with another BMJ article (paywalled) out last month from Martin Marshall.
From many conversations I find most divide into three groups:
- the wishful who expect online access magically to divert patients away
- the fearful, convinced they will be buried in trivia when patients have a new way to get at them
- the conflicted who believe both the above at the same time
if you’re familiar with the published evidence (BJGP on eCONsult 2017) you’d be very skeptical of any claims.
But having managed well over 100,000 online consults in two versions of askmyGP over three years, we’ve gained quite a bit of experience of what doesn’t work. We still have a number of practices where it doesn’t work.
So which group is closest to the truth?
I’ll be examining the emerging evidence in the first of our webinar series next Thursday 3rd May 2018 1pm, 45 minutes
It’s already booking up fast and though free we have limited participants on our new Zoom platform (which we love by the way).
There’s a fourth group of course, and we’ll come on to them in the next webinar but first it’s important to understand what doesn’t work. We’ll look at technology, implementation, even beliefs and I can tell you, innovation is over 90% failure so much of the hard won evidence will be painful to relate.
Do join us next Thursday at 1pm.
askmyGP & GP Access Ltd
PS: I’ve had to update the blog from last week from Dr Barry Sullman at Balaam St Surgery. I would never dare to promise the new life he leads. And he can’t stop talking about it.
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 (resigned 5/8/18) 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 email@example.com”
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?