Our vision: to transform access to medical care.

Dear Mr Hunt

You told parliament yesterday that it was time for “an honest conversation with the public about their use of A&E“.  Are you up for one too, as Secretary of State?

Unfortunately there is no evidence of honest conversations, cajoling, beating or any other persuasive endeavour having the slightest effect on patient behaviour in seeking healthcare.  You may even be stoking demand simply by talking about it (as the Behavioural Insights Team has shown.)  Dr Taj Hassan is spot on when he says it’s about the system.  As Deming said, 95% of the problem is the system, and that’s where leaders spend their efforts.

You’re fiddling with four hour targets, and the language of targets, but Deming said 35 years ago, “numerical targets must be eliminated”, tellingly calling his book “Out of the Crisis.”  It wasn’t until 1992 and after mental torment over what this meant that I personally got it.  Well, the next principle is to eliminate exhortations…

It’s crucial to understand the difference between targets and measures, and to Deming (a statistician) measures were absolutely critical.  It matters to patients how soon they are seen Mr Hunt, and therefore it must matter to you and all NHS staff:  measure the times, the demands and the flow in A&E and strive continually to improve them.

You’ll be asking me how in a minute, but look, read Simon Dodds on how they did it in Luton and Dunstablehospital.  There’s a very simple parallel to what they did and our work in primary care:  put the senior clinician at the front of the house where the demand comes in.  It saves time for the senior clinicians and saves time for everyone else.

I spent yesterday in Riverside Practice, Portadown, NI, on the day they launched their new system.  Patients reported an average 39 minutes to be in touch with their GP.  81% said the new system was better.  The GPs said it had gone much better than expected, and when they’d cleared the decks, most of them went home early.  Someone please pass this on to Helen Stokes-Lampard who is threatening us with 4 week waits.

Wonderful stories came throughout the day.  The man who got the GP call in the library.  The woman who broke the new rules, turning up in the surgery without calling, but with agonising back pain.  She saw the doctor within minutes.  Any healthcare system which doesn’t have compassion at its heart is worthless.

Riverside GP has gone from having one of the worst access records in NI to one of the best, overnight.  OK, so the preparation took four weeks.  OK, so it took a year for the GPs to overcome their fear of change.  But they changed overnight.

Leave aside political shocks for a minute, there’s a medical earthquake happening in NI right now, standing primary care the right way up.

It’s such a dreadful shame that NHS England is missing out, but I’m sitting by the phone Mr Hunt.

Yours sincerely,

Harry Longman

Founder, Chief Executive, GP Access Ltd

07939 148618

PS You can change patient behaviour, not by exhorting them but by changing their perception of where to get help.  Rapid response from their own GP does it, and don’t worry, it’s less work for GPs.  But please get off their backs, stop the 7 day nonsense and as Deming also said, cease dependence on inspection to achieve quality.

5 responses to “Dear Mr Hunt”

  1. In the late 1800s navy ships had been transformed from sailing to steam vessels. The workflow change required by naval personnel was dramatic. No longer were the skills of sailing with masts to the wind and direct concern for wind direction of great significance compared to mechanical knowledge of the steam engine. The advent of steam power had taken sailors from above deck to below deck. Because of this cultural resistance, it took 30 years for steamships to have the sails removed.

    In that era of change professional sailors resisted advances. One such advance for the U.S. Navy was continuous fire gunnery. William Simms was a U.S. Navy captain with a command in the Far East. Working with Admiral Nelson of the British Navy, they discovered a way to dramatically improve marksmanship of naval gunners.

    The then prevalent method of cannon use from a vessel was to mount the gun fixed on deck. The naval gunner was skilled at adjusting for the roll of the ocean by taking aim just as the cannon’s barrel crossed the horizon. To avoid being thrown backward by the gun’s recoil, gunner would take aim, jump off the cannon sight, and order the firing of the cannon. The idea was that the cannon shot was propelled just as the roll maximized the ship’s nadir. A great deal of judgment was required to allow for the movement of the ship at sea. The skill of the gunner was directly related to the accuracy of the cannon. Accuracy of naval ordinance was poor, at best, with fewer than 10% hits at 500 yards.

    After learning from Admiral Nelson, Simms installed two measures to correct for the recoil of the gun and pitch of the boat. The first measure was a sliding connection between the gun barrel and gunner’s chair for sighting. The recoil of the cannon did not affect the chair that remained fixed for the gunner so he did not have to dismount between shots. The second advance was a series of wheels that controlled gears moving the base of the gun. Instead of being fixed on deck, deck hands could turn these hand wheels at a constant rate in one direction, then the opposite, to compensate for the pitch and yaw of the ocean in any given sea condition. With coordination these adjustments resulted in a relatively stable gun sight.

    Accuracy for the techniques Simms introduced was unparalleled for the day. His gunners often with little training could out perform other more experienced Naval marksmen by 4 to 10 fold. He sent his ideas to Washington where they were repeatedly denied credence by the U.S. War Department. He wrote to his friends, none of who believed him. They dismissed his procedures as a proprietary system applicable only to his small boat with specially trained crew. He complained loudly to his superiors, but he was often rebuked for insubordination and his commission was threatened.

    Finally a gunnery demonstration was arranged. For the demonstration, a gun with the sliding gunner’s sight and gears for changing the gun’s moorings was built on the dock at Annapolis. It was put on the side of the pier and aim was taken at a target anchored in the bay. The deck hands were asked to estimate the waves of the ocean hitting the pilings and move the gear handles accordingly. Since the gun was fixed to land, the experiment was a miserable failure and the Admirals in attendance dismissed Simms’s claims.

    Only when a non-military observer from US President Theodore Roosevelt’s office investigated further was the system evaluated appropriately on water. The technique became the standard of naval gunnery for over a century. William Simms became the “Father of US Naval Gunnery.”

    Dr. Isley Morison’s lectures at the Harvard Business School are published in the book, “Men, Machines, and Modern Times.” It chronicles how Admiral Simms and other vignettes about change and disruptive technologies.

    Has Harry Longman introduced a disruptive approach to healthcare that could transform it?

  2. mark Taylor says:

    Water
    Uphill
    heads
    Sand

  3. Malcolm Couch says:

    Worth another blog to explain what changes were made at Riverside?

  4. Simon Dodds says:

    I’m delighted to hear that the “experiment” delivered the dramatic improvements it was designed to. I have seen this step-improvement effect many times and it still comes as a surprise … not least to the participants! To them it comes as a huge shock! Well done Harry.

  5. Recent news suggests anxiety is massive factor in serious conditions and we already know it affects how people access NHS services enormously. We have seen during trials how patients are receptive to trying technology to improve their experience in the NHS. Data tells us that 12% of people admit to having used A&E in the past even when they knew there was nothing seriously wrong with them; and 18% of GP workload is for common complaints alone. Around two million people each year go to A&E with ailments that they could have either self-treated or used another local service for. [CMFT, Choose-Well]. Around 13 per cent of people who attend A&E are discharged without requiring treatment, and a further 35 per cent receive guidance or advice only (HSCIC 2016). [King’s Fund] This data might suggest anxiety makes people react in certain ways, influencing their decisions about accessing NHS services, even though they know these decisions might be wrong. Less anxious patients using well developed technology are likely to make better choices in how they access NHS services.”

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