In the space of a few weeks, driven by Covid-19, general practice has transformed to an extent that policy-makers had hoped might be achieved in years.
Across the country, a form of general practice previously delivered by a minority group of digital and phone enthusiasts has become almost universal. Practices that had patients queuing at 7am for scarce face-to-face appointments have switched to a ‘digital-first’ service and have empty waiting rooms, albeit in very unusual circumstances.
Like many GPs around the country, the practice where I work – which had offered a combination of face-to-face, phone and video appointments – has closed the surgery doors and introduced a universal digital-first policy. Slots are available during the day for face-to-face encounters, if a clinician thinks this is needed.
For the digital enthusiasts who argue that general practice must learn from this experience and change for good, a range of questions must be addressed to inform a longer-term transformation.
Important discoveries and unanswered questions
First, in line with plenty of emerging evidence, much general practice activity can be managed remotely. Fearing Covid-19 contamination, both patients and clinicians who thought they wouldn’t be able to manage by phone or video are able to do so.
Second, our collective clinical practice styles have changed in various ways. Discussion with colleagues suggests we are issuing more ‘just in case’ antibiotics and painkillers. Prescribing levels were assessed in the GP at Hand evaluation and generally found to be low, but this may well vary between practices. A US study of Kaiser Permanente clinicians reported more antibiotic prescribing for urinary and chest infections in e-consultations.
With multi-resistant infections becoming more common and an epidemic of opiate use, more data is needed about this important issue. So too is guidance about when it is or is not appropriate to prescribe antibiotics and opiates without any physical examination.
Third, the impact of remote consulting on the use of blood tests, imaging and other investigations is hard to gauge. The context of Covid-19 is so atypical that each decision is the product of a conversation about potential clinical risks and benefits – and each patient’s personal balance between worries about their symptoms and exposure to the virus. This is unlikely to be generalisable to ‘normal times’ but, as with prescribing, there is the possibility of increased use of investigations ‘just in case of missing something’, which needs to be quantified through rigorous research.
Fourth, how are people who are potentially ‘digitally excluded’ coping at this time? Who has found a workaround, such as a relative or neighbour setting up technology on their behalf? What was the impact on quality and confidentiality of another person who might not normally be present in your life stepping into a consultation during an emergency? And, of course, who is unable to consult remotely due to isolation and lack of any support network?
Fifth, the extraordinary change in demand we have seen. 40-50% of our appointment slots were unused last week. Several factors may explain this, the worst of which is that people with significant illness were not calling for fear of contact with Covid-19. The best is that people with new and relatively mild or common symptoms were self-managing in order to leave GP services free to deal with more serious clinical problems. The former is of course a significant problem, and it’s essential to promote the message through multiple channels that GPs are still open for business and able to manage acute problems unrelated to Covid-19. The latter represents a form of self-care behaviour that we need to understand, support and encourage in future.
Finally, questions about the place for physical examination and simply being in the same room as a patient. We know that some people with significant health problems prefer and benefit from digital consultations. Then there are symptoms where physical examination is essential, such as new and severe tummy pain.
But 20-25% of GP consultations are for undifferentiated symptoms, for which a specific cause may not be found. Up to 9% of consultations have been reported as related to health anxiety. Managing these requires a subtle blend of physical and psychological approaches to exclude underlying conditions and negotiate management plans. It remains unclear to me what part physical presence plays in these situations and what can be done remotely – without recourse to multiple investigations.
As a digital pragmatist, I look for ways to introduce technologies that preserve the breadth of functions of general practice and its role in a high-quality, cost-effective health system. I also look for opportunities to de-medicalise care and build individual capacity to cope with stresses and anxieties rather than prescribing and referring to other services.
My experience to date has been enlightening. I can certainly do more than I expected through remote consultations, but I also think I am over-medicalising problems for which I would normally try to negotiate a management plan without prescriptions and investigations.
While some may embrace the changes, in more ‘normal’ times some doctors and patients may be keen to go back to previous ways of doing things. However, it is hard to imagine that general practice will revert to its previous form. Even the most digitally sceptical of my clinical peers are impressed by the ease with which they can set up video consultations and send personally tailored information to patients using simple desktop apps. But the issues highlighted above are central to the quality and value of general practice and we don’t yet know enough about them.
Rosen R (2020) “A digital general practice: what have we found out so far?”, Nuffield Trust comment.