Friday, 3 August 2018

Asking the wrong question about GP behaviour is even worse than getting the wrong answer about it

A recent survey based on an NHS England idea suggested that 10-20% of GP appointments were avoidable. But the answer is useless as the wrong question was asked to the wrong people at the wrong point of the process. Worse, the very way the survey was framed was built on false assumptions about how GPs could work leaving the most important question unanswered: what would happen if GPs organised their work differently. It is astounding that such a bad survey was commissioned and has any influence over NHS policy.

That GPs are overloaded with demand and overworked appears to an almost unquestioned belief in the current NHS. So it should be important to understand what can be done about this. We need data. We need good analysis. We need better ideas about what to do.

So when I saw reports concluding that 20% of GP appointments were avoidable, I thought they might be the result of a careful analysis of what was going on.

But I was wary. Similar surveys of A&E attendances conclude that too many people go to A&E instead of other services. This observation is, however, useless as it fails to consider that these people are not the cause of poor A&E performance and we have no idea how to make the go anywhere else. Therefore useless for policy, unless wish fulfillment is now a major element of NHS planning.

Sadly, despite the amount of effort put into the GP survey by The Primary Care Foundation, the same is true of its results. In fact they might be worse.

As far as I can tell the key survey asked GPs at the end of a sample of appointments whether that appointment could have been avoidable. Nationally they thought that perhaps 20% could have been handled by someone else (by which they mean some mix of nurses, pharmacists or other staff). So far so good. The results might even be true.

But they have asked the wrong question to the wrong people at the wrong point in the process.

What if, instead of waiting for patients to get through the typically annoying process to get a 10 minute slot with their GP, they asked, instead, how many of the people granted an appointment actually needed an appointment to sort out their problem? By assuming that every patient interaction has to involve a 10 min appointment we have already made the strong assumption that 10 minute appointments are the only way GPs can respond to demand. And that demand can be mitigated–but only slightly–by using a different mix of staff in the practice combined with better signposting.

We have good evidence from a number of practices that changing the way GPs respond to demand can have a much bigger impact than this. Scores of practices have switched to different processes where the GP interacts with patients before booking appointments and only offers face to face appointments to those where the GP and patient agree it is required. These GPs typically find that 60-70% of demand can be handled without an appointment. In the practices that get this right the GP workload goes down substantially and patient satisfaction soars as they typically get fast on-demand responses to their problems and same-day appointments when they need them (rather than having to wait a week or two for the next available slot). See this tweet from GP Dave Triska, for example (he tweets his experience regularly and it is well worth checking out his feed).

The problem, these GPs have realised, is that the assumption that the only tool they have is a 10 minute appointment is false. There are plenty of other ways to respond to many patient requests and most of them are far more efficient that 10 minutes spent face to face. Sorting this out before spending 10 minutes in front of the patient saves a lot of time for both.

What the Primary Care Foundation should have done is to survey the incoming demand to GP practices and asked whether a face-to-face appointment was the best way to respond to that demand. By failing to do this they embedded the false assumption that 10 minute slots are the only tool in a GPs toolshed. This reinforces the false belief that there is no alternative and that the best we can do is to make minor adjustments inside the practice or, somehow, deflect the demand somewhere else.

The net result of this bad survey will be to blind GPs and policymakers to far better, more radical alternatives. That's really not the best way to get data telling us how to improve GP practice.

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