of Handling Demand

This article first appeared on 1.8.15 on digitalhealth.net.

This month, I was going to finish my discussion of my local GP federation’s IT plans by discussing potential out-sourcing and in-sourcing opportunities.

However, since my last couple of columns, which focused on making general practice more efficient and on improving contact with patients, I’ve been in conversation with a couple of people who seem to “get it”. So, I thought it would be worth discussing their ideas.

Also, we’ve unfortunately heard from someone who doesn’t “get it.” The SecState published his long awaited new deal for GPs. And while this correctly states some of the problems that are facing the profession, it has no answers.

Instead, it seems to be fixated on the bizarre claim that by getting us all to work for seven days a week for no extra funding we will suddenly find thousands of extra doctors wanting to be GPs.

I attended a meeting in a neighboring clinical commissioning group last week and fully a third of the audience of GPs said they were retiring in the next three years.

Even if some of them come back and do some work, it’s not going to make funding 5,000 extra GPs easy; particularly as this year our large training practice has been allocated no new GP registrars. Over half the places are unfilled, while a third of those in post seem to be on maternity leave.

Dealing with the calls

This is why I’ve been so occupied by the idea of making those GPs we have more efficient. My idea of making people use an expert system to direct them to the right appointment/clinician, and improving the communication tools we use with our patients in order to reduce waste, are examples of this.

Well, since the last piece I’ve spoken to a chap called Harry Longman who is becoming quite famous for promoting new ways of working.

I first came across him when several friends starting using his GP Access system. He’s done a lot of work analysing appointment demand – it’s surprising, given the data, that there hasn’t been more work done in this area.

Unsurprisingly, deprivation plays a huge role and there is a huge peak in the morning. To deal with it, his original system flipped the traditional system on its head.

Harry recommends that GPs answer calls themselves in the morning, and use their skills, knowledge and expertise to reduce the need for appointments. The theory is you can deal with a lot of people on the phone and those you can’t you can see, yourself, later.

Some of my friends who use this system love it. Some say that after a while you lose some of the relationships you had with people, as it is harder to develop and maintain these on the phone.

Others warn that you have to be careful not to encourage people to ring up for little reason (some doctors are better at this than others). And GPs with low risk taking behaviour are unlikely to take to the idea; although there seems to be some evidence that you can train people to be better phone consulters.

Getting patients to do some of the work

Harry’s stats suggest that, if done correctly, his original system can save you 20% of the time it would take to see people. However, his next idea is to add in something similar to my online triage.

His idea is if to try and move people away from synchronous communications to asynchronous – meaning that you can flatten out the workload and, essentially, reduce the number of people you need to deal with the demand that underlies the peaks and troughs.

The online website that people would use to make an appointment would not just direct them to the right person; it would ask them structured questions about their problems. Perhaps it would do some health screening and admin functions.

It could allow people to do this 24/7, with the clinical contact happening when someone was free, with the additional data in front of them. The basic theory is that if you can do most of the consultation automatically, you can save bigger chunks of time and make the workforce go further.

It’s great thinking although, personally, I’m a little skeptical. I’ve played with his demo website and the questions it asks are good. The history it takes is at medical student level, and legions of communications skills tutors are no doubt grinding their teeth at the idea that dealing with patients is that easy.

Necessarily, it misses one of the big bits of history taking – which is watching the patient. From the way a patient walks into a room to the way they hold their hand while describing chest / abdominal pain can be very enlightening.

The system also heavily relies on people switching to internet as their main contact. Utility companies and banks nudge us that way by reducing our bills by choosing online – as the NHS is considered free it’s difficult to do that.

I’ve seen figures suggesting that in deprived areas computer ownership is low, but mobile phone ownership is high. Whether these are simple or smart phones I’m unsure.

Good ideas – who pays?

I’ve also spoken to Wiggly-Amps, an IT company (that is helping Harry Longman, although that’s not how I came across it). The people there have an idea around doing something similar, but for patients waiting in the waiting room.

Using their own devices, patients can fill in questionnaires about why they are there, while completing satisfaction surveys and the like. These will be available for the doctor they are seeing; in theory speeding up the consultation.

The app would also give the patient accurate data on waiting times, services available, offer them health screening and education.

I wish both Harry and Wiggly-Amps luck. Innovation is what we need . However, as with a lot of IT initiatives, I wonder who is going to pay.

Practices have been trained to expect all their IT to be bought for them and are going to need a lot of proof that something works before they’ll dip into their own pockets to pay for it.

Integration with exiting IT systems will be key, as having yet another app running will be a problem, and selling to and then supporting 8,000 GP practices is always an issue.

Getting dynamic with appointments

On a slightly different but related subject, I’ve previously mentioned that I wonder if we need more dynamic appointment systems than the sometimes rather rigid ones that we have.  

I’ve also told a story that a colleague told me about working for Sky; but it’s worth repeating. The company issued installers with mobile devices to log-in and out of jobs.

It knew how many boxes were being installed per house, how many flights of stairs their installers had to climb up, and about their parking problems. It built up a database that could accurately predict how long a visit would take and so managed to get two more visits per day per installer.

Can we do something similar with appointments? If we extract information on condition, age, doctor, past medical history and log how long the appointment took, can we work out how many appointments we should be getting through, and how long each one is likely to take?

Could the IT system that asks you why you want an appointment look at your age, other factors, take a history, and book a length to suit you?

In theory, a GP doing a three hour session might not just see 18 patients. They might see a variable number depending on their complexity? I’m hoping the informatics software our GP federation is developing might help with this.

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