GP prescribing is one of the few areas of NHS spending that is under control

Last week the government released a report on overprescribing that suggested perhaps 10% of prescriptions issued by GPs were unneeded or harmful. The media headlines tended to frame this as another reason to attack GPs. The Telegraph, for example, had this headline: "GP's needless prescriptions push drugs bill to £9bn…"

This framing was wrong but also led to a huge story being missed and an important lesson being ignored.

While GP overprescribing is a problem that deserves to be tackled, it is a far smaller problem than hospital prescribing and is already being tackled (for example, the report highlights the campaign against antibiotic overprescribing in the mid 2010s that led to substantial reductions). 

The GP prescribing budget is one of the few areas of NHS spending that has been under control. It has been between £8bn and £9bn for longer than a decade and has shown as many falls as rises year on year. Overprescribing by GPs is not driving spending up.

Hospital prescribing, on the other hand, has risen from £4.2bn in 2010/11 to £11.7bn in 2019/20 and is rising at a rate of between 8% and 16% every year (see the NHS Digital data here:https://digital.nhs.uk/data-and-information/publications/statistical/prescribing-costs-in-hospitals-and-the-community/2019-2020 ). See the chart: 

(the numbers above the bar are the annual growth rates in the spending)

This is out of control and, unlike GP prescribing, is a big problem.

We have a good idea why one budget is under control and the other is not. Detailed data about what is happening in GP prescribing in England is available and has been public for more than a decade. Analysts like me can count the number of prescriptions for, to give an example, 20mg simvastatin pills, in every GP practice every month. This hugely rich dataset covering more than a billion annual prescriptions can be interrogated to reveal the differences among practices for every one of the 20 or 30 thousand items they can prescribe (Oxford's EBM Datalab even provides a free interactive tool allowing anyone to analyse the data: https://openprescribing.net/ ).

We don't yet have anything like that for hospital prescribing (the Datalab is working on one but it isn't complete). For many years the only source the NHS had was data bought from an external firm which had restrictive clauses preventing detailed use or dissemination of the numbers (that external firm's primary purpose for collecting it was to sell it on to the pharmaceutical industry for sales analysis, not to help the NHS get a grip on its spend). The NHS has no mandatory collection of data that would give it the same level of insight it already has for GP prescriptions.

Given how little we know about hospital prescribing, there is little mystery why the budget is out of control (and rapidly approaching 10% of the whole NHS budget). When the NHS has exquisitely detailed data about what is happening it can get a grip on both quality and spending; when it doesn't, the budget is out of control and the system has no idea about the quality. For all we know hospitals are wasting gargantuan amounts of money and overprescribing on a massive scale.

We should be praising GPs running one of the most well-managed areas of NHS spending. And we should be scandalised, instead, by the NHS's failure to collect the data necessary to get a grip on out of control prescribing by hospitals. That's what the headlines should have been last week.

Andrew Lansley would have lost the Battle of Britain

In a gobsmacking interview with the Institute for Government, Andrew Lansley revealed his reflections on his notorious health bill. He doesn't seem to have learned much. Had he been in charge in 1940 Britain would have lost the Battle of Britain. This is important as his mistakes are still prevalent in government thinking about how to run the NHS. And we need to learn from his mistakes or we will lose the battle for the NHS.

Introduction: thank you HSJ

The Health Service Journal had an interesting juxtaposition of reports in its regular The Primer column on August 23. 

The column reviews commentary on the NHS that hasn't otherwise appeared in the journal. On that day it mentioned a gobsmacking interview where the Institute for Government has asked Andrew Lansley to reflect on his time as Health Secretary. But it also reported an opinion blog by me published the previous week on the utter lack of any attention to management in the latest health bill. In doing so they also reminded readers of a much older opinion piece I wrote in 2015 about lessons the NHS could learn from the Battle of Britain (the original blog was written in 2015, the HSJ version–thank you for describing it as "legendary"–was published in 2018). 

The juxtaposition of the Lansley interview, my opinions on management in general, and the Battle of Britain in particular set me thinking. My immediate thought was that, if we applied Lansley's thinking on management in the NHS to Britain's air defence strategy in World War 2, we would have lost the battle.

I think it is worth explaining why. Again.

Lansley thinks management gets in the way of effective action

So what did Lansley say?

Not everything he argues in the interview is wrong. For example:

Because in the NHS, there was – and still is, frankly, and it is returning now – a dominance of the provider interest over the consumer interest.

In this, he was and is right. For example, NHS policy for many decades has been to try to move activity away from hospitals and into the community. But the dominance of decisions by big hospital providers has meant that, in decades of trying, hospitals have, if anything, a larger share of the budget than they started with.

And his method was to give decision making power to CCGs not dominated by acute hospitals. And, given the above, this might have been a good idea:

The essential proposition was that commissioning should be led by clinicians and should be the central focus of NHS activity in delivering better outcomes within budgets.

But then he lets his core beliefs out of the bag:

But what you have to understand is that in the Department of Health, many senior positions were filled by NHS managers. And they, of course, had a completely different approach. They hated it all. They hated the reforms; they were the enemy within. Because they saw the reforms as handing power to clinicians, and by extension removing jobs and control from the hands of the NHS management.

His view of managers is something like the Kafkaesque bureaucrats running the world of Terry Gilliam's Brazil.

This is a Daily Mail fantasy rant, not a serious assessment of NHS management. I'm not arguing that nobody in NHS management is like this, but Lansley's view both overgeneralizes and makes a huge error about the role of most managers. The leadership in DH are not like the ward manager who tries to improve patient flow by coordinating the activities necessary to discharge a patient. They are not like the managers who coordinate and schedule activity in operating theatres so all the equipment and people are available at the same time to ensure the surgeon can operate without silly delays. Those managers–the majority of the managerial caste–are more like the transmission in a car: sure, the engine provides power but the wheels don't turn if some of the gears in the transmission are missing.

When it came to his bill, Lansley dealt a severe blow to the managerial caste, attempting to impose 50% cuts in their–already inadequate–numbers by including a limit in the bill for how many managers a CCG could have. 

He still seems to think this was a good idea, claiming in the interview that he saved the NHS £1billion a year in management costs. Which he did, but at the cost of both organisational chaos and the ability of his new decision making clinicians to decide how best to spend their budgets and to implement the changes they wanted. CCGs got a new engine but most of the gears in the transmission were now missing. The general consensus was that the new bodies were the equivalent of a friday afternoon Austin Allegro that got through quality control when the QC team were still in the pub.

He wanted CCGs to think differently (I'm sure his grammar is better than Apple's) and to do differently. But, in his naive defenestration of the NHS management caste, he left organisations with no capacity to think or act differently. And it isn't like he wasn't warned. 

This thinking would have lost the Battle of Britain

This is where it is worth reviewing the lessons I reported in that piece about the Battle of Britain (originating from military historian and management expert Stephen Bungay).

Bungay's key point is that the myths we tend to be fed about the battle deeply misrepresent the reality. We often assume that Britain won because we had better planes (Spitfires!), clever new technologies (Radar!) and more heroic pilots (Douglas Bader!). These make a cool national myth but one which is close to the exact opposite of the truth.

The Battle of Britain was won because the RAF had by far the best organised fighter defence in the world. The Luftwaffe had great planes, radar and equally heroic pilots. But they didn't organise them well.

Organise is the key word here. The RAF had spent years developing a sophisticated operational process to manage its fighter defence. The management system that coordinated the defence was what won the battle. As Bungay remarks:

In their ‘finest hour’ the British behaved quite differently from the way in which they usually seek to portray themselves. They exhibited a talent for planning and organisation which, in its Teutonic thoroughness, far outstripped that of the Germans. They left little to chance, planned for the worst case and did not rely on luck. Given all this, it is hardly surprising that they won. It is, on the other hand, quite extraordinary that they should imagine they could have won by doing the opposite.

But the people who designed and implemented that management system would be exactly the people Lansley would have fired so the front line pilots could make the key decisions. The very people needed to design and implement the processes that deployed the RAF to maximal effect against the Luftwaffe would be the people Lansley hated. I imagine him saying "We don't want bureaucrats telling the pilots what to do". The front line pilots, in his view, would be the experts who know best how to fight the hun.

But they were not. And we know this because a very similar argument actually raged during the Battle of Britain. The two most important men in "management" roles were Hugh Dowding (who designed the system and was in charge of Fighter Command) and Keith Park (who implemented it and was in charge of 11 group which defended London and the South East). Their flexible and selective way of managing the deployment of fighters was strongly disliked by some famous pilots (eg Douglas Bader, a well known public figure even then) and by the commander of 12 group (which defended the midlands), Leigh-Mallory. Bader and Leigh-Mallory believed that an idea called the Big Wing was superior to what they were being directed to do by Park and Dowding. 

Dowding and Park were both moved sideways towards the end of 1940 (luckily after the Battle was won) because the lobby for letting pilots do what they wanted (which included Leigh-Mallory) had better political connections than they did. This was a mistake as later evidence showed Park and Dowding to have been right. And, later in the war, Park did it again in the defence of Malta, thoroughly defeating the Luftwaffe attempts to crush the island's defence. As Bungay remarks: 

What Park achieved in the Battle of Britain is in itself enough to place him amongst the great commanders of history. But his performance in 1940 was not a one-off. In 1942 in Malta, Park took the offensive and turned Kesselring’s defeat into a rout.

He was as adept at offence as he was at defence, and, like Wellington, he never lost a battle. His record makes him today, without rival, the greatest fighter commander in the short history of air warfare.

Andrew Lansley would have sided with Douglas Bader from the start. He would have sided with the opinionated front line pilots rather than the people who had demonstrable ability to find the best way to organise Britain's defence. He would have removed Park and Dowding before the Battle leaving the very real possibility that Britain would have lost because of the inferior systems proposed by Bader and Leigh-Mallory. 

Why Lansley's naive view of management is wrong

Lansley's comments repeatedly demonstrate that he has no idea of the various roles of management. 

One role is to organise the deployment of front line staff. In the Battle of Britain this involved managing the information flow from radar and observers to understand where the German bombers were and deploying the fighters in the most effective patterns to combat them. The naive views of some of the more vocal front line pilots about how best to deploy their planes were wrong. And few, if any, of the front line pilots could have designed the intelligence system that directed them to their targets (Dowding and Park had spent years thinking about the system of deployment not just about how to win a dogfight). Though both had front-line experience, it was their focus on how to manage the battle that made the difference. Lansley seems to assume that front line experience is all that matters and there are no benefits from organising the front line more effectively. 

He also misses the role of management and support staff in implementation. (Arguably "support" and "management" are different but they work together to make things happen). He demonstrates this in this quote:

But there were things like the continuation of commissioning support units and the form that commissioning support units took that I would not have done were it not for David Nicholson protecting his own people in the NHS and in strategic health authorities.

Now I am no fan of commissioning support units, very few of which did good jobs, but Lansley doesn't seem to understand anything about what their roles were. Many took over essential roles like managing procurement and the provision of analytics to CCGs and hospitals. I generally think their ability to do such jobs well was deeply undermined by the compromised and confused way they were set up, but, surely, not bothering to do those roles at all would be even worse?

Were Lansley looking at the huge infrastructure necessary to operate Dowding's system for directing the RAF (huge numbers of observers, multiple control centres, many layers of middle managers interpreting and filtering information before making decisions and sending instructions to the pilots), he would probably have slashed it in favour of "more resources to the front line" and more pilots and planes. 

The key point here is that the role of management is both about deciding the right strategy and having the infrastructure to make it happen. Lansley's own words suggest he understands neither role. And his actions slashed the capacity of the NHS to do either. Sure, he could claim £1billion a year of savings from ruthlessly deploying an axe to managers, but the resulting chaos and performance degradation show that the "savings" came with catastrophic costs. Incredibly, Lansley claims credit for improvements in the system:

...as it happened, we got waiting lists down to their lowest ever level in late 2012.  

which were delivered before his changes were fully implemented and ignores the catastrophic declines that started as soon as his ideas began to take hold (waits for elective treatment and in A&E departments are now worse than they were before the major Labour reforms of the early 2000s). Remember when fewer that 2% of patients spent more than four hours in A&E? Today's NHS in England struggles to get fewer than 2% of patients spending less than 12 hours in A&E.

Lansley would be claiming credit for getting more Spitfires in the air even after the UK had been invaded by the Nazis.

In the interview he demonstrates a stunning naivety about the role of management in the NHS combined with an adamantine refusal to evaluate the real consequences of his decisions. What is worrying is that his views on management are widely held both by critics of his ideas and current NHS decision makers. His structural ideas about the NHS are being dismantled but his naivety about the role of management carries on. The current health bill says nothing at all about management.

Lansley seems unable to learn from his own experience or from history. We desperately need NHS policy makers to do better.

Nostalgia for face to face appointments should not distract GPs from real choices they have to make

[NB this was submitted to the BMJ as a possible blog in March 2021. They rejected it as not topical enough. But the relevance of the topic has increased a great deal in April and May as GPs have seen record workloads. So I thought i'd post it here to to remind me what I was thinking then before I write about the latest developments in the debate.]

There is a lively debate on how GPs should work once the pandemic is over. Many have adopted what NHSE calls "total triage" where patient needs are assessed before booking any appointments and as many requests as possible are handled remotely (online or by phone).

Should they stick with this approach or go back to seeing most patients face to face?

Examples of the debate are this lecture by Kath Checkland titled Who needs to see a doctor face-to-face? Or this Guardian article where Martin Marshall claims most patients prefer face to face (f-to-f) appointments.

The trigger for the debate appears to be the major drive by NHSE to get GPs to adopt non f-to-f ways to handle patient requests during the pandemic. 

But the discussion of the value of f-to-f appointments risks distracting GPs from the reality they have faced and will face again. Sure, there is something special about f-to-f appointments–GPs can pick up body language cues and building a relationship with patients is easier–but this does not imply that every request needs f-to-f or that the tradeoffs achieving high-levels of f-to-f appointments are worth making.

The pre-pandemic reality for most GPs was that the majority of patients did not get a same day response to their requests and the average wait for an f-to-f was more than a week. Is that time tradeoff really worth it for the benefits of a person to person meeting? Worse, the reality of most practices was that access didn't depend on patient need but on their ability to get through a phone lottery at 8am (my GP is still like that: getting a call back on the same day is possible but required me to make 30 attempts over a 1 hour period to get through on the phone at all). 

The world where the default response to every request was a same day face to face meeting has not existed for decades.

The reality is that GPs need to balance the supposed benefits of f-to-f against the tradeoffs. And not just the tradeoffs they desire, but also the ones their patients want and need.

This is where we have to test the attributes of different online triage tools. 

The couple of dozen tools available are supposed to make getting and triaging patient requests easier for the patient and the GP by moving as much as possible online. The major benefit of this is to make the internal flow of work inside the practice much more efficient (but many of the available tools are quite late to that party). This frees capacity, enables the ability to triage based on need, allows more flexible responses based on need and, as a result, improves the speed of response. 

Many object that moving patients online disadvantages the old and less tech literate. But this is only true if being online is compulsory. Good practices don't close down incoming phone calls or walk-ins. Good online tools allow the practice to process phone requests internally using the same tool that facilitates those requests arriving online (again, though, many do not, creating a very different experience for those using the phone).

Others object to the need for online systems to classify the patient request into simple boxes. Patients, as Checkland pointed out, often have vague amorphous requests rather than simple classifiable problems. But, again, this is a straw man that only applies to those systems that insist on asking 20 questions to try to reach a diagnosis before the GP sees the request. Not all systems work like that: some allow a simple free text request to be submitted which a human can assess and triage before deciding how to respond. 

What good online triage systems offer is an easier way for patients to get their request in front of the GP. And they enable the GP to offer a faster, more flexible range of responses (including bringing the patient in to be assessed in person). If anything online tools make getting f-to-f meetings easier for the patients who need them than the traditional phone lottery. 

But they also reveal some truths the fetish for f-to-f obscures. First the majority of patients don't even want f-to-f appointments if a faster useful response is the alternative. Second, patients like being offered a choice of response mode. Third, GPs can be far more effective if they adopt flexible responses as many of these take less time than f-to-f and free up time for the most needy.

The widespread nostalgia for f-to-f obscures all the tradeoffs uncovered by online tools. I'm not even sure that, if we had twice as many GPs who had the capacity to do same day f-to-fs for all, that this would be what patients preferred. But, since we live in the real world, GPs need to judge whether doing far more f-to-fs is worth the tradeoffs in time and convenience for patients. If some patients really need f-to-f assessment, how are you going to identify and prioritise them? Pre-pandemic practice often traded high proportions of f-to-f for long delays and prioritised by lottery not need. 

So what should GPs do? 

• Don't reject online tools because they think they are inimical to good f-to-f practice. Perhaps–even if they love the benefits of their f-to-f meetings–they should choose online triage tools that make it easy for them to identify the patients who will benefit most from f-to-f. 

• Choose tools that ask patients what they want and don't assume everyone wants f-to-f.

• Choose tools that patients like, not ones they won't use. 

• Monitor the results: monitor what patients want and whether they get it; Monitor their satisfaction; check that triage works effectively.

Certainly don't pine for the non-existent days when f-to-f was the perfect solution to everything with no tradeoff in time or convenience.

 

Should GPs turn off their online systems to control demand?

There has been a huge amount of comment in recent discussions about GPs being overwhelmed by the current level of demand. Many have proposed turning off their online systems to hold back the wave. This is problematic for many reasons but has highlighted many deep misunderstandings about total triage and online tools.

The right answer isn't that they should turn off online access, but to test whether or not doing so makes any difference. Or, better, they should design effective triage processes to ensure their limited capacity is used to treat the patients that most need their help without driving all the doctors into burnout.

How did GPs control demand before online systems?

In the world before online total triage solutions were common and before the pandemic changed everything, GPs were used to limiting access as a way of controlling their workload. 

The majority ran systems where the only way to get an appointment was to phone the practice between 8am and 9am. Then, even if you got through to reception, you would often be lucky to find an appointment slot free, especially if you wanted an urgent one. Some GPs offered open access clinics for urgent cases, but those require the patient to turn up in person in a narrow time slot and then wait a potentially extended period of time in a crowded waiting room.

There are problems with the traditional approach. One is that many patients can't get through on the phone because the lines are too busy. We don't know how many requests are lost to the system that way because almost nobody even tries to measure them. Another is that turning up in person for a long, unpredictable wait is often not possible for the patient so this discourages them from going to the clinic at all. Yet another is that the allocation of requests to same day slots is, in effect, unrelated to the patients' need as it depends more on the luck of the draw during the early morning phone lottery than it does on the urgency or severity of their condition.

On the upside, these approaches do allow GPs to limit the demand they see (though partially by making it entirely invisible).

Does turning off online tools work?

The big change from moving significant volumes onto online triage systems is that the capacity of the phone lines is irrelevant: online demand can't be blocked by switchboard capacity. It is far easier to make an online request than it is to make 30 attempts to get connected to reception by phone in the early morning rush. 

So GPs see more of the actual demand. Especially if the online systems are open 24 hours a day and at weekends. Many commentators have speculated that this greatly increases demand. They argue that making it easy for patients to contact the GP must increase demand (and some economists say this is exactly what theory would predict). But few bring data to the argument. 

Not looking at the data risks two serious errors. 

The first is to blame online tools for the increase in demand. The current debate has been triggered because many GPs are unusually busy right now. But many of those GPs have been online for a year and the excess demand has only materialised in the last month or two. The only thing being online has done is to make visible actual demand that would otherwise be lost to the morning phone lottery. It isn't the use of online tools that have caused the demand leap. If demand is going up now, the cause is something else.

The second error is the assumption that limiting the time online systems are open makes any difference to the overall weekly demand. This seems to feel right to many GPs used to limiting demand by limiting appointment slots or rejecting requests that can't get through in the morning phone rush. But we have good data on how patterns of online demand change when systems are turned off. Some smart GPs have run tests of how much demand they get with 24hr systems compared to systems only open in the working day. 

Everyone who has properly tested closing their online system has found that the major effect is not to lower demand but to redistribute it to the times when the system is open. Some, but certainly not all, have found that there is a small reduction in total weekly demand. And, for some, that might be a good outcome (though see what this implies below). 

Absolutely nobody–and this is my most important message here–should be shutting down online access without having done a proper trial to see what the result is. Closing down your online system in the vain hope that it will reduce demand and make your life easier is futile.

In short, limiting access to online systems might help, but no GP should do it unless they know it will, and that requires a controlled experiment collecting good data.

What does limiting access achieve for patients?

The rarely asked question about all schemes to control GP demand is what are the implications for patients? This question is obviously relevant to any debate on online triage tools but it is also relevant to every GP who uses the phone lottery to limit incoming requests or who denies the possibility of appointment bookings when the current slots are all filled.

There are two levels of problem with the traditional "phone the GP between 8am and 9am to get an appointment" model. 

The first is that many patients never even get through to the switchboard. We don't know how many because few GPs have set up their phone systems to monitor that statistic. This has the useful benefit of limiting the demand that reaches the practice. It also has the "benefit" that the unmet need never appears on any report.

The second level, where the patient gets through on the phone but can't get an appointment because all the slots are full, has a similar effect, though the numbers are more likely to be visible somewhere.

If your only concern is to manage the workload, then these methods are fine. The same–apparent–logic applies to limiting the opening hours of an online system (though, as I said above, it is a great deal less clear whether managing access online actually works as effectively as a busy switchboard).

But, if your concern is to actually help the patients who most need your attention, then all attempts to limit incoming requests are very bad. The morning phone lottery at best limits access randomly and, at worst, limits it to the patients with the fastest redial fingers who are, needless to say, not the ones with the greatest medical needs. Limiting appointment slots by a "first come, first served" process has a similar effect. 

The big difference with online triage tools is not that they create more demand; it is that the practice knows what the real demand is. There are no busy switchboards with online demand to arbitrarily reject the request because the patient can't get through. And closing the online system out of hours has a far smaller effect on incoming demand than a busy switchboard (patients quickly learn when the online system is open and make their requests then).

Bizarrely, one of the most common objections to using online systems at all is that they might bias access to particular groups. But compared to the traditional system that randomly rejects patients with slow redial fingers, this is a pretty weak objection (also, for well designed online tools that patients choose to use, the phone lines are far less congested and access for those who don't want to go online gets better). 

There are real tradeoffs to consider when GPs reject online tools. I think they don't increase the underlying level of demand (much of my data says so, but more providers need to release their data to independent researchers to show this is true in general). But they do make that demand more visible. If the response is to reject online tools because they don't arbitrarily limit visible demand, then practices must recognise the cost to patients of the traditional process. The arbitrary selection of requests, unrelated to need. The frustration to patients of the morning phone lottery. And the safety implications of random request prioritisation. GPs sometimes complain that they are overwhelmed by too many trivial, unimportant, non-urgent requests, but it is hard to see how the traditional process solves that when it rejects requests at random not by triage based on need.

And this brings us to a possible solution: effective triage.

If demand is overwhelming then triage is a better solution than limiting access

GPs and primary care researchers sometimes have a strong antipathy to triage (online or otherwise). Helen Salisbury (a GP and researcher) made this argument in a recent BMJ column called Triage is for disasters, not everyday general practice. She argued that, while the idea might be appropriate for front-line military hospitals where there just isn't the capacity to save every wounded soldier, it was completely inappropriate for GPs. But her argument contains several problems.

In a front line military hospital a wide range of injured soldiers arrive. Some have injuries that won't kill them soon and can be treated later; some might die whatever the medics do; some will survive if they are treated immediately. Triage is the sorting process that identifies which is which and allows the medics to focus their limited capacity where it will have the biggest benefit. GPs don't have decisions of the same magnitude, but they do have to see patients with a wide range of needs and should focus their attention where it can do the most good.

Salisbury argues that GPs should see everybody (and should probably do so face to face f-to-f). The implication is that GPs have the capacity to do this and that a one-size-fits-all f-to-f is the best response for every patient. But the whole point of GPs unhappiness with online tools is that they don't have the capacity. We don't seem to live in the world she describes.

She also makes an argument–and one that many researchers seem to agree with–that GP triage actually takes more time than just seeing everyone. This suggests some very deep misunderstandings about what triage is supposed to do or, possibly, how GPs need to do it. The military analogy should make this clear. If sorting the wounded took more time than treating them, triage would be killing more soldiers than not triaging. But triage was invented to save lives by sorting quickly so medical effort could do the most good with the limited resources available. If GPs are taking more time overall with a triage process than without one, then, whatever they are doing, it isn't triage. 

I don't want to pretend that a good triage process is easy. It isn't, especially when GPs are trained to be one-club golfers who only ever handle patients using short f-to-f meetings. But a disciplined process, especially an online one where the patient request can be assessed rapidly and asynchronously, can be fast and effective. The point is to sort the patients by urgency and need. And to use a flexible range of responses many of which are faster than bringing the patient in for an f-to-f. Even better, if a notable proportion of the requests are the trivial sort that GPs complain overwhelm their capacity, they can be dealt with instantly by a simple, pre-written, short message. 

One of the huge benefits of an effective triage process is that it can do a better job of managing demand than a process that involves limiting access. The urgent serious cases can rise to the top of the queue and get an appropriate amount of GP time; the trivial ones can be dealt with by short standard responses; the middling concerns can be dealt with quickly by message, saving the patient and GP the time taken by an f-to-f appointment. 

If the practice finds it is overwhelmed by demand, it can respond by altering the thresholds for each type of response. Why this is widely considered a worse way to handle demand than a system that arbitrarily denies patients–some of whom might have a serious or urgent need–the ability to make a request at all is something of a mystery.

Some experts object to this because many patients won't get an f-to-f response. They argue that patients mostly want an f-to-f response and will be unhappy if they don't get one. Or that f-to-f is vastly safer than alternatives. Martin Marshall recently made this argument in The Guardian and other places. There are two overwhelming objections to this argument. First, GPs don't have the capacity to do f-to-f appointments for all their current demand (that was, after all, how the whole debate about them being overwhelmed by online demand started). And randomly limiting patient access to even make a request can hardly be safer than triaging requests. Secondly, his claim about what patients want is just wrong. I know this because I have the data. AskmyGP is an online triage tool that has handles most of the incoming requests for several hundred GP practices (70% online, 30% by phone). For every request the patient is asked what sort of response they prefer (f-to-f, message, phone call, video call…). Before covid took off only about one in three requested an f-to-f.

In short, an effective triage process can direct limited GP time to those who need it and can also adjust to prevent that demand causing GP burnout.

Conclusion

There are several key themes here:

• Online tools don't create extra demand, though they may make changes in demand more visible

• Limiting access to online tools might sometimes work, but you need to look at the evidence for your practice rather than making knee-jerk decisions

• Traditional methods of "demand management" have serious and often ignored issues

• Online tools alongside efficient triage processes offer a better, safer route to manage GP capacity and avoid burnout

What the military can teach the NHS about how to get the right things done in the most effective way

Everyone has a plan until they get punched in the mouth

Mike Tyson, boxer

...no plan of operations extends with any certainty beyond the first contact with the main hostile force

Helmuth von Moltke the Elder, 19th century Chief of the Prussian General Staff

The NHS swings between bouts of centralised power in the hands of ministers and decentralised decision making by its regions and units in repeated attempts to achieve its goals. But it never seems to achieve the goals desired. I suspect its leaders (both politicians and bureaucrats) have never learned an important lesson that many military forces learned the hard way.

The current NHS white paper proposes a great deal of new centralisation of power in the NHS, a major reversal of Blair-era reforms which tried to decentralise decision-making. My best guess as to why this is happening is that ministers feel the NHS is not achieving what they want and the only effective way to do so is to take back power. This is wrong. Though it is far from obvious that decentralisation worked either and the real problem is a fundamentally misguided view of how to get things done in a big organisation that has persisted in the NHS for decades.

Other big organisations have taken a different approach. Many militaries learned the hard way how to achieve their goals and how they did so provides useful lessons for the NHS.

The fundamental idea that governs the NHS is that people should "follow the plan" and do as they are told. They should achieve things by following the how of the plan and are frequently judged on whether they follow the right process to achieve the goal. Metrics are often if not usually process metrics not outcome metrics. This philosophy of management (or culture) has persisted over time despite major changes in the structure of NHS management which has swung from centralised to decentralised and back over the last few decades.

This follow-the-plan philosophy is how many militaries used to exercise command and control in their troops. This was how the British military worked at the start of WW2 until the outcomes forced a major rethink. 

A good illustration of the problem is the campaign in North Africa. Until the decisive defeat of the Afrika Corps at the second battle of El Alamein, the British forces were repeatedly defeated by a vastly inferior German and Italian force (the Allied forces almost always outnumbered the Axis forces in men, tanks, guns equipment and had far fewer persistent shortages of supplies). According to the insightful analysis of Stephen Bungay (in his books Alamein and The Art of Action) this was not–as is often reported–because their leaders were better (though Rommel was an excellent tactician) but because the command and control doctrine of the German army was far superior.

A simple way to understand why is encapsulated succinctly by the Mike Tyson quote and at more length by Moltke: rigid plans are derailed by the messiness of reality which discombobulates the plan as soon as the enemy doesn't act as expected. The British army doctrine at the start of the war demanded that soldiers follow the plan, in detail. Junior officers were disciplined if they deviated from it. Following the orders in detail was the goal. The Germans didn't do that. They knew what Mike Tyson and Moltke knew: the details of the plan fall apart as soon as you meet the enemy. Instead, the Germans issued objectives for all levels of command about the key goals rather than detailed plans about how to achieve the goal. All levels of officers were given wide discretion about the how. They were expected to innovate when they saw the reality on the ground as long as they pursued the key goal they had been set. This led to persistently better decision making in actual battles leading to their inferior forces often winning key engagements with the rigid, hidebound Allied forces (at least until the allies had overwhelming superiority).

German command doctrine (now called Mission Command and widely adopted as a central philosophy by the modern US and British armies) was that a detailed plan is derailed by real events (like getting punched in the face or when the enemy doesn't act as expected in the plan) so tactical innovation in response to reality is far more likely to achieve the goal than blindly following the details of out-of-date orders cooked up by commanders a long way from the action.

But this is pretty much how the NHS works. Goals are not set in terms of outcomes but in terms of following the plan. Do things the way the centre tells you to. And suffer punishment if you deviate from the process, which we will measure. And they won't measure the outcomes because that is far too hard to measure in the short term. The centraising plan will make this worse, not least because it is the equivalent of a frustrated Churchill demanding direct control of the deployment of individual tanks in the desert because his generals were not winning their battles. The NHS has rarely tolerated local innovation that delivers better outcomes and often seems to regard innovation as "rocking the boat" or "deviating from the process".

This is a critical failure. Unless the NHS radically changes its management philosophy and culture from one where following the plan is rewarded to one where local leaders are rewarded for achieving better outcomes by innovating, it will never get better at achieving better outcomes however the overall structure is changed. 

The NHS plan should focus on the management culture not the structure. It should define the broad goals (outcomes) desired by the government or the leadership and leave the front line leaders to find better ways to achieve those goals. And it should radically cut the process ("do things this way") metrics and use more achieve this outcome metrics. And don't forget culture change: culture may reappear and control the results even if the structure is new. A change in management structures will always be trumped by a persistent management culture.

It cannot be said that the military have always remembered this lesson. An analysis of the army's poor performance in the second Gulf War pointed out that Mission Command is not very useful when you have no idea what your mission is (see the introduction to The Good Operation which also has other useful conclusions about public policy that don't seem to have influenced the NHS plan). Perhaps this too is a problem affecting the NHS. Which suggests that the NHS might have been better analysing why it frequently fails to achieve better outcomes before writing a plan that reinforces the very cultural problems that make innovation and flexibility so difficult.