We are at a tipping point in the roll-out of digital general practice. In July, the Health Secretary stated that “better tech means better health care”, and that “from now on, all consultations should be tele-consultations unless there’s a compelling clinical reason not to”. But by last week, such is patient demand for face-to-face GP appointments that NHS England wrote to all practices to insist they are provided.
Like much else in Covid times, the situation is confusing. The Royal College of General Practitioners points out that, unless staffed by GPs who are shielding, most practices have offered face-to-face appointments throughout the pandemic.
The letter riled GPs and diverted attention from the question of when in-person appointments are best used – for which there is not a clear answer. Research by the Health Foundation found that practices already operating the Ask my GP ‘digital first’ service before the pandemic have seen fewer patients face to face since March than during the same period last year.
Against this nebulous background, policy-makers must draw on research evidence and the experiences of both patients and clinicians – many of whom are very positive about the switch to digital – as they work to get the best from remote general practice. And while evidence remains limited, the canvas is not entirely blank.
What do we already know
First, there is a risk of creating inequalities through digital health care. Those without a smart phone or digital skills, or those without money for data or a private space to talk, will struggle with remote consultations and experience worse access. So too will those with language barriers, for whom the wordy pages of online consultation questionnaires are hard to penetrate. While this issue is now quite well described, we still need more research on effective ways to mitigate it.
Second, we know that remote consulting increases overall workload. Newbould and others reported an average 8% increase in overall workload associated with total phone triage. Furthermore, modelling work by Salisbury and others suggests that online and video consultation could increase workload by 25% and 31% respectively unless clinicians learn skills to shorten consultation times. This flags the urgent need for training on the safe and efficient management of remote consultations.
Third, we know that very easy access to primary care can increase demand. Studies in ‘walk-in’ GP clinics reported that 16% of patients would have done nothing if the walk-in clinic was not available, suggesting they were attending for minor problems. The ease of remote consulting may replicate or even exacerbate that demand for mild conditions. With workforce shortages in general practice still a pressing problem, this is not a time for policies which drive up demand that could be avoided.
What don’t we know
There is little research to date on the impact of remote general practice on clinical outcomes and missed and delayed diagnoses. Twitter noise about misdiagnosis by computer algorithms exists, as do anecdotal accounts of computer-assisted triage identifying cancers that had been missed during face-to-face assessments.
There is also unknown impact on the 'holism' of general practice – the ability to pick up unmentioned health issues during a consultation that is ostensibly about something else. The soft signals of how a patient opens the door or sits down, which are less readily available through digital media.
Finally, we don’t know how digital consulting affects the ability of general practice to hold risk in the community without onward referral. This role is central to the financial value of primary care in a health system. If digital pathways are risk averse, and GPs refer to tests or outpatient appointments ‘just in case’ because they can’t examine a patient, they could push up overall costs. We urgently need data on this.
Overall, more evidence is needed and a number of studies are in progress, including the ‘Remote by Default’ research collaboration between Nuffield Trust and the universities of Oxford and Plymouth. There is an aim to report quickly, but the policy pressure is on and it’s likely that more digital services will be rolled out before these studies conclude.
So how should we proceed while we await research?
We should keep four principles in mind.
Consult and co-design: Involve end users of all types in the further development of digital GP services and complementary face-to-face access. Draw on existing user experience while we await further research on how to avoid digital exclusion, enhance patient experience, use technology efficiently and avoid overuse.
Test and learn: Roll out new forms of remote consultation in defined areas, and use these test beds to identify situations where digital consultations do and don’t work. Use early learning to develop guidance on the limits to remote consulting and describe the impact on clinical outcomes and on the use of other services.
Integrate and adapt: Ensure that easy digital access to GPs supports the continuity of care and holism that builds trust between patient and clinician. If universal triage and remote care disrupt relational aspects of general practice that underpin the value it provides to patients and the wider NHS, then redesign digital pathways to protect them.
Message carefully: With winter approaching, Covid cases increasing and limited capacity in general practice, NHS comms campaigns have to achieve a difficult balance between encouraging use of digital routes to general practice, informing people who struggle with digital of alternative access options, and advising how to self-care for minor illnesses in order to avoid supply induced demand.
The last week has shown us that we need a balance between digital and face-to-face consulting, rather than a headlong rush to remote. We may not get it right immediately, but if we invest in research to guide choices and define the skills needed by patients and clinicians, we would be off to a good start.
Rosen R (2020) “Digital and face-to-face consultations: finding the right balance”, Nuffield Trust comment.