There's No Efficiency Without Effectiveness

There has been some debate about the workload faced by GPs over recent weeks.  Claims that the level of demand is unsustainable were given a boost by the recent publication by Deloitte's which concluded that primary care needs to work differently if it is to survive the onslaught.  Yet our studies show that getting in doesn't mean getting help and the relentless pursuit of improving access has destroyed value from a users perspective - creating the very problems the report highlights as needing to be solved.  This post details the experience of someone who has studied GP practices and, perhaps surprisingly, shows how a focus on the patient, the doctor and the problem to be solved not the implementation of conventional management approaches might be more effective.

It is so engrained in our society that it almost feels like a basic human right – the ability to see your GP when you need to. However, so dire is the crisis facing our NHS that even this appears to be under threat with Deloitte claiming that soon there will be so much demand for GP consultations that there is an urgent need to change the system. Well, whilst innovation is all well and good, and the unnecessary use of GP time should no doubt be designed out, I still find it hard to read this news without a tremor of moral disquiet. Can it really be possible that things have got this bad? Perhaps more ominously, can we really believe that those who have presided over us getting to this point have the perspective and wherewithal to turn things around?

In the past 18 months I have had the chance to study 3 separate GP practices. In each I have seen the same thing – significant levels of failure demand, that is demand caused by failing to do something or failing to do something right. It is not too much to say that our general practices – alongside our hospitals, ambulances, police stations, benefits offices, citizens advice bureaus and whatever else you care to mention- are swamped by people who are only there because the systems which are meant to be helping them are failing to do so effectively.

Let me quote a few numbers.

In each general practice studied I have seen obvious failure demand running at about 20%. That is, of every 5 or so consultations around 1 will be because of something which was a clear failure in the health or care system (NB not necessarily a failure of the practice itself). Now, I’m not talking about complicated stuff here, just simple, honest to goodness failure such as, “I was discharged from hospital yesterday with these drugs and I’ve no idea what they are for or how often to take them”.

Then there is the more complicated stuff. Scratching the surface of the remaining demand – the demand which doesn’t at first pass look like failure – I’ve found myself wondering at how much of it too may be avoidable. Take this example, which was related to me by a patient waiting in one of the practices (reproduced with permission):

A 9-year-old boy (the son of the lady I was speaking to) had warts on his nose and was very self-conscious about them. Friends at school had commented on them. He had visited the practice 5 times in the past 12 months about the problem but hadn’t seen the same GP twice. Until his 5^th appointment the boy had been told by each successive GP that no treatment was possible and that no referral to a specialist would be accepted. The GPs were adamant that the boy just needed to wait for the warts to go away on their own and to stop bothering them in the meantime. At the 5^th appointment the boy’s parents had insisted on a referral being made and the GP had grudgingly agreed. Within 2 weeks the specialist had seen the boy, treated the warts and they were gone.

Anecdotes can be misleading I accept but they do make me wonder. So too did the data revealed by a sample of the last 90 patients to be consulted at one of the practices I visited. Of these 90 patients only 1/3 had attended just once with the same problem in the past 12 months. The remaining 60 patients had attended on average 4 times but it was statistically normal for them to have attended up to 15 times in 12 months for the same problem. I repeated the same analysis in a second practice and found the average to be 6.8 consultations per year with an upper control limit of 20!

The third practice studied was different to the others. It was a single-handed practice for one thing but more than that, the GP there was truculent about much of what he was encouraged to do by others from outside his practice. They wanted him to have fixed appointment times, same day booking, triage and more besides. He preferred to simply tell his patients to turn up when they needed help and he’d see them as soon as he could and for as long as it took to do a good job.  Despite his practice list being nearly 2.5 times larger(!) than the other practices I’d visited, he conducted the same number of consultations per year (when both the list size and the consultations are normalised to take account of the number of GPs in each practice). It was a straightforward, indisputable fact that this guy's patients simply did not turn up nearly as often as the patients of the GPs at the other practices.

It made me think. What is the real problem that GPs need to solve? Is it that they need to manage access to their service or is it that they have to manage the success of their consultations for their patients? You see, the defining feature of the single-handed practice was that, whilst anything else was up for grabs, the patient consultation was sacrosanct. Nothing could compromise it. There were no arbitrary rules such as ‘one problem per appointment’ or ‘8 minutes only’. There was no handing over between clinicians from one consultation to the next. There were no barriers to access – not even appointment times. Just the patient, the doctor and absolute clarity for both that, by the time the patient left the consultation, everything in that doctor’s power would have been done to understand their problem and to help them to understand it for themselves.

So what can we learn from this? Well, perhaps nothing conclusive without further study but nonetheless it does beg some interesting questions. Has our health system put access ahead of success? Has a preoccupation with productivity replaced or obscured clarity of purpose? Does good doctoring look like going slow to go fast - a focus on end-to-end effectiveness rather than transactional efficiency? There are more besides but perhaps it’s all just as simple as saying that there really is no substitute for taking the time to do the right thing.