Digital and remote primary care: the inverse care law with a 21st century twist?

The pandemic has brought significant changes to how people access primary care services, including the rise of online bookings and remote consultations. Are they changes in the right direction? In this long read, Charlotte Paddison discusses whether the shift towards digital primary care risks making access easier for people with less need and harder for those more likely to be in poorer health – and describes the actions that would help in getting access right.

Long read

Published: 04/02/2022

Ensuring everyone can access services on an equal footing is a key priority for the NHS. But with so many changes to the way that patients access care at their GP surgery because of the Covid-19 pandemic – including a shift at pace and scale to online booking, total triage and remote consultations – are these changes to primary care a move in the right direction?  

To answer this question, we’ve looked at the evidence from international and UK research, and this long read draws together key insights along with the lessons for policy-makers and GP practices. You can read our analysis of the evidence, a rapid review using Cochrane methods, in full here.

Rapid changes to primary care, and the picture continues to evolve

The pandemic has revolutionised the way in which patients access primary care services in England, with nearly 40% of GP consultations now taking place remotely, primarily by telephone. But the picture continues to change rapidly. Face-to-face consultations, down to 10% of all consultations at the height of the pandemic, are now back up to over 60%

Whether this is the right balance for the future of primary care is a hotly contested, even toxic, issue. Beyond the headlines there is a real concern: systems for accessing care aren’t right now working well for many patients or staff.

All of this is happening in the context of severe workforce shortages and a burgeoning workload on practice staff. Improving access to primary care had been an area of strategic policy focus consistently over the last decade – in good part because of a perception among policy-makers that this is an effective mechanism for managing demand on hospital services. 

Many GP practices have adopted digital and remote consultations as part of efforts to manage their work more effectively, with the goal of enabling GPs to give more time to patients with complex needs, while providing a more convenient service for patients with relatively simple concerns. At the same time, some GP practices have been keen to adopt digital primary care, hoping that “alternatives to the face-to-face consultation would 'keep patients away'” and “reduce practice workload, even at the price of placing restrictions on patient access”. This points to the tensions inherent between improving access to care and controlling access in order to reduce workload for GP staff.

Rise of the digital inverse care law

Fifty years ago, Julian Tudor-Hart first described the inverse care law – highlighting that patients who are most in need of medical care are, in fact, least likely to receive it. Now it seems that Tudor-Hart’s 1971 inverse care law continues to apply, possibly with a 21st century twist, in the form of a digital inverse care law.

The potential for the shift towards online appointment booking and mandated total triage to increase health inequalities was recognised early. Given that primary care accounts for around 90% of patient contact in the NHS, it’s vital that the impact of changes to access is properly understood.

Warnings from the CQC echo those from the Royal College of GPs and Healthwatch England, who have expressed concern that new patterns of access may – but must not be allowed – to worsen health inequalities. 

Are these concerns justified? 

Good access for all: is the shift to online and remote primary care a move in the right direction?

In our analysis of the evidence, we found that particular groups of patients who are more likely to be in relatively good health (younger, white, highly educated and living in affluent areas) are, in comparison to other patients, more likely to successfully navigate online access to care. They are also more likely to effectively use new forms of online and remote consultation such as asynchronous messaging.  

The emerging picture from UK and international evidence shows how shifting primary care online can create inequalities in access to health care, by making it more difficult for some patients – often those who are less well and already materially disadvantaged – to get access to the care they need. 

That the patients with least need of health care tend to use health services more (and more effectively) was already a known problem before the pandemic. What is new is that our review findings suggest, overall, the rapid shift towards digital primary care in the UK (including a policy-mandated shift to total online triage, and a sudden increase in digital and remote consultations) risks exacerbating the inverse care law by making access easier for people who are more likely to be healthy and have lower levels of need. 

This leaves other patients, including groups already more likely to be in poorer health, to face a double disadvantage: a new digital inverse care law laid over the top of existing inequalities in access to primary care. 

Online access and remote care don’t work well for all patients – as has already been recognised by the Department of Health and Social Care. However, where digital medicine makes primary care more accessible for individual patients, this has the potential to improve not only access but also quality of care. Our review showed that a choice of different modes of consultation can empower patients who were previously disadvantaged by traditional face-to-face primary care in two ways: by breaking down geographical barriers to health care, and by promoting patient autonomy.

The emerging picture suggests that shifting care online has the potential to exchange one set of barriers to care (transportation issues, time constraints) for another (internet access, device capability, digital literacy).

Taken together, these findings imply that digital primary care has some potential to help mitigate inequalities in health and care, but only if implemented in a way that:

  • Tackles existing inequalities in access, and makes the most of opportunities to expand available services (including mental health care), ensuring these reach – indeed are targeted to – those in greatest need.
  • Avoids implementing digital and online access in a rigid way that narrows the choices that patients have about how they can access care, and locks people with more difficult lives out of the care they need. It’s crucial that non-digital pathways to access care are maintained alongside new online routes to make access inclusive.
  • Uses the patient pathway approach advocated by NHS England to identify barriers that may limit access to GP services, and understand how these are experienced differently by patients depending on an individual’s characteristics (including protected characteristics), and to identify what actions are needed to mitigate poor access.   

Implementation of virtual primary care in its current form is not enabling equal access to care, which represents a missed opportunity for primary care and for health policy.

Looking at the evidence also revealed important gaps in what we know. Available evidence fails to provide a comprehensive picture of the impact on many groups of patients with protected characteristics – including for example the LGBT+ community and those with disabilities. We do not have a clear understanding of how multiple different patient characteristics may combine or interact with each other (intersectionality) to exacerbate inequalities of access, but the analysis below shows why it matters.

Why does intersectionality matter?

Nuffield Trust analysis of the GPPS 2020/21 data points to the importance of intersectionality in understanding differences in access to care at GP surgeries during the pandemic. This analysis uses data weighted by age and gender, and shows that patients at GP practices in England who were of Asian or Black ethnicity, living with a disability, and providing unpaid care of 50+ hours a week (N= 61) were:

  • Four times less likely to try to book a GP appointment online via an app or website (4% vs 19%, respectively)
  • One third more likely to be dissatisfied with the choice of appointment offered (25% vs 17%)
  • Much less likely to describe their experience of making an appointment at their GP practice as ‘good’ (57% vs 71%)

This is when compared to survey responses from 54,456 patients in the same survey (GPPS 2020/21) who were young (16-35 years), white, well (no long-term conditions), and working full time.

These results fit with existing literature showing the important impact of different patient characteristics, both individually and in combination, on experiences of access to primary care.

A policy vision for getting the best of both

It is possible to get the most out of primary care while tackling inequalities in access. But we’re not there yet.

What’s needed is a much stronger focus on getting access ‘right’, in both policy and practice. Recognising that this is not the same as a focus on faster access or more convenient appointment times. This means national policy that makes an explicit commitment to ensure everyone can access services at GP practices on an equal footing – with policy-makers re-emphasising that this is a key priority for the NHS. 

Flexibility is needed for many people, including those with learning disabilities, dementia, autism, sensory and communication difficulties, and those experiencing homelessness. The message from policy needs to be that implementing digital and remote primary care in a rigid way that gives patients less choice about how they can access care risks shutting out some of the patients who need care most. 

All of this must feed into priority setting at a national and local level. New priorities set out recently by NHS England for 2022 focus on achieving a core level of digitalisation in all services. While the vision for strengthening a “compassionate and inclusive culture needed to deliver outstanding care” is right, in order to deliver on that, policy needs to put flexibility and inclusive access at the centre of care, recognising that one size doesn’t fit all.

As suggested by National Voices, we need to see policy move away from incentivising specific channels of access (digital or face to face) towards a broader agenda that promotes choice and personalisation with incentives aligned accordingly – building this into the emerging vision for ICSs as it develops.  

Policy has a very important role in setting the tone and getting messaging right. GP practices should be encouraged to adopt a flexible approach to access, with online routes into care positioned as one option rather than as the default expectation. 

Where capacity for GP appointments is very tight, as it is right now, messages aimed at reducing unnecessary health care attendances and promoting self-management (including messages about using digital and online services) must be carefully phrased so that they do not lead to vulnerable groups, who infrequently access primary care, feeling unwelcome or not entitled to health services. This includes messages at a national level directly to the public, and also guidance from national policy-makers on the messages that practices should be sending out to patients, such as on GP surgery websites. 

Policy also needs to support staff to embrace and learn from feedback. This means identifying and sharing good practice, while also supporting GP practices to identify where access is not working well for patients at their practice and what is needed to change this. 

What actions are needed?

Getting access right needs more than just a vision. Enabling good access, especially for vulnerable and disadvantaged groups, is inherently practical work. To be successful, this needs to focus on three things: (1) understanding population needs; (2) tackling barriers to equitable access and co-designing inclusive access pathways; and (3) ensuring access is targeted appropriately.

Understanding population need and use of GP appointments

GP practices and primary care networks (PCNs) have a really important role to play here, first by leading local data-driven work to understand population needs and the use of GP appointments. This analysis should also take a wider angle look at the problems with access at GP practices, including provision of routine appointments, moving beyond the focus on levels of face-to-face care and provision of urgent on-the-day appointments outlined by NHS England in their winter plan.   

As many GP practices and PCNs have only very limited data analytics expertise in-house, it makes good sense for data analytics teams with a remit for place-based care under ICSs to step in to provide support where it’s needed.

Alongside this, action is needed on the development of equality data monitoring information standards, including those relevant to general practice. Lack of good data means we don’t have a comprehensive picture of the impact of changes made during the pandemic on access to care for many groups of patients with protected characteristics, as would be needed in any comprehensive equalities impact assessment. This fits well with the new priorities for 2022 set out by NHS England, which explicitly include using data to improve access and health equity for under-served communities.

Tackling inequalities in access and creating inclusive access pathways

GP practices also need to identify – and take action that directly tackles – barriers to equitable access among their patients.

Using a patient pathway approach as advocated by NHS England is one practical way to do this. This helps GP practices identify specific barriers to good access at different points in the access pathway (from deciding when to seek help, obtaining an appointment, right through to attending the appointment). Potentially such work might be supported through the funding GP practices receive for quality improvement under the revised Quality and Outcomes Framework. 

But it’s not enough to simply identify key barriers to access. We need to see action that tackles such barriers, and is effective in making sure all patients can access care at GP surgeries on an equal footing.

Where appointments are cancelled, many vulnerable people don’t know who with or how to get in touch – living with worsening symptoms because they don’t know how to get help. With almost six million people now on hospital waiting list backlogs – and GP practices left supporting these patients in the community to manage their symptoms – it’s more important than ever to make sure that information about how to navigate access to the system is provided in plain English and in a format that is accessible to vulnerable people. While guidance on good communication has been developed, this needs to be more consistently implemented.

We also need action to tackle problems that make access more difficult for particular groups of patients, with a focus on putting the right practical support in place.

Currently there is widespread variation in the quality of interpreting services and in how patients can book an interpreter. This is important because it impacts on the frequency of missed appointments as well as the effectiveness of consultations. Communication difficulties can lead to confusion over managing conditions, such as taking medication or managing diabetes. Half of all deafblind people have left a GP appointment having not understood what had been discussed.

We also need to see practical approaches to improve access that bring joined-up thinking to bridge health and social care – recognising these are intertwined in the lives of many vulnerable patients. 

For example, this means identifying patients who have carer responsibilities, and making sure respite support is in place where it is needed to enable carers to attend their own GP appointments. With £25 million to support unpaid carers in the government’s recent white paper People at the Heart of Care, this kind of respite – not currently available to most carers – could make a very positive difference to so many carers struggling to attend their own GP appointments because of a lack of respite services.

Getting the right solutions in place means co-designing with service users

It's clear that access pathways must be co-designed with patients if they are to work well, avoiding the known pitfall of confusing what might work in theory with what actually works in reality. This means involving patients and listening carefully to what they say. 

One way that GP practices might take this forward is by working with a diverse group of registered patients to develop and test access routes – ensuring pathways into care at GP practices work for different types of patients and do provide access on an equal footing for all patients. Building on what is learned at practice level, this approach should also include sharing learning across PCNs to generate both a clear understanding of access problems, and also solutions targeted to local populations and their access needs.

To avoid shutting out some of the patients who need care most, GP practices must maintain flexible and inclusive routes to access care, and make reasonable adjustments for people where needed, as suggested by Healthwatch England. These requirements could be implemented into the GP contract to strengthen and further support the Improvement in Access for Patients agreement feature. 

While contracts can help foster an inclusive culture, they are a relatively weak lever for this kind of change. The real work will need to be led by GP practices themselves – by putting flexibility and inclusion at the heart of practice ethos and staff behaviour. This must include non-clinical staff, who as part of the GP practice front door have a leading role to play in implementing access pathways, and in communicating policy about access and appointment booking to patients.    

Targeting access and prioritising appropriately

Finally – and crucial to tackling the inverse care law – we must ensure that access is targeted appropriately, avoiding a misplaced emphasis on fast access for all patients regardless of acuity or need.

We need intelligent models of access that target care to those who need it most, and actively build this as a core principle into access, triage and service delivery models. This may mean shifting away from the current policy push for fast, on-the-day access for all patients – regardless of whether it’s clinically needed or not.

The mismatch between demand for appointments, and capacity for the GP workforce to meet this demand, remains one of the biggest challenges facing GP surgeries. Online and digital access must avoid adding to this pressure on appointments. This means moving away from providing fast online appointment access to patients who are not seriously ill and those with self-resolving minor issues squeezing out appointments for those who are sicker and have a greater need for care.

While many GP practices are continuing to use models of total triage adopted during the pandemic, individual practices have implemented this in different ways. Research to understand variations in appointment booking and triage that helps to identify what works well, and what does not, is urgently needed. This should also consider not only what works well for GP practices, but also for different groups of patients.

“GP triage can act as a barrier for many at-risk groups. Systems therefore need to be sensitive enough to pick up on this and to offer alternatives”
- NHS England

Digital care can help to reduce geographical barriers to care, while making access to specialist services (including mental health) easier. These important benefits should not be lost but rather built in as part of new flexible service models.

Seize the moment

Any independent and comprehensive review of the impact of changes in access to primary care during the pandemic must include the impact on equal access to care. This evidence is needed now to help inform policy choices about the future of primary care in England.

While it’s worrying to see evidence pointing towards the emergence of a new digital inverse care law, it’s just as important to seize the opportunity for primary care leaders and policy-makers to act. 

What is needed now is a forensic focus on tackling inequalities in access to care – acknowledging that one size does not fit all – while at the same time maximising the opportunities and benefits of digital primary care. Inclusion and personalisation are key. We need an explicit commitment from policy-makers to ensuring good access to primary care for all patients, and an emphasis on getting access right.