The coronavirus (Covid-19) pandemic has undoubtedly revolutionised the use of remote care, not only in the NHS but across the globe.
In England, there has been a longstanding aim to harness digital technology to deliver health care, but progress up until this year had been relatively slow. Two years ago, the NHS Long Term Plan set the goal of enabling digital technology to become 'mainstream' in primary care and outpatient services. Alongside this came the promise of increased patient choice and the redesign of services that could avoid the need for up to a third of face-to-face outpatient visits.
Suffice to say, the outbreak of Covid-19 accelerated the use of remote care at a much faster pace than anyone could have predicted. What will be the impact on patients, clinicians and the NHS? The most recent data is only just beginning to uncover the issues – here we explore some of the findings.
The starting point
Around 13% of patients accessed appointments in general practice on the telephone before the pandemic. Data from the 2020 GP Patient Survey shows that, compared to face-to-face appointments, these patients were 2% less likely to have their needs met, 4% less likely to say they were given enough time and 4% less likely to feel any mental health needs were recognised or understood. These are seemingly small differences, but the findings were consistent across measures of patient experience, such as feeling listened to or having confidence and trust in the health care professional.
After the outbreak of Covid-19, changes in the mode of health care appointments came alongside significant falls in the overall number of GP and outpatient consultations. Fewer people accessed care during the first national lockdown and elective care services were cancelled to free up inpatient and critical care capacity.
The data that demonstrate the increased use of remote care in general practice and outpatients are dramatic. In April, almost half of appointments in general practice took place remotely. This includes appointments with GPs as well as other practice staff such as nurses, which are more likely to be face-to-face. However, it should be noted that the quality of this data is likely to be impacted by variations in approach to appointment management between practices. One survey that took place in July found that the proportion of remote appointments specifically for GPs could be higher, with 61% conducted by telephone and a further 4% online via video. Outpatient care shows a similar pattern, with telephone attendances increasing from 4% in February to 34% in April.
Attitudes towards remote care
GPs were told to switch to digital-first primary care in a bid to slow the transmission of Covid-19. In June, a survey of over 2,000 GPs showed that 88% of them felt that greater use of remote consultations should be retained in the longer-term. This hinted towards overall acceptance among health professionals of the recent transformation in mode of appointments.
So what about the public’s attitude towards remote care? In the Opinions and Lifestyle Survey carried out in August, 68% of people said they would be ‘comfortable’ or ‘very comfortable’ attending an online appointment. This decreased for people aged 70+ (61%) and for those with a specific health condition (62%). These figures should be taken in the context of social distancing and the fear of contracting Covid-19. Only time will tell whether the public’s willingness to use remote care will be maintained once a vaccine is rolled out.
Early impacts of the rise in remote care
Analysis of clinical data from primary care enables us to explore whether the shift to remote working has changed how GP practices deliver care. Extending earlier analysis, it shows a sudden increase in prescribing of new medication for remote GP appointments, alongside a fall in the rate of prescribing for face-to-face appointments. It is unclear why GPs’ prescribing habits have shifted in this way. The swift change towards remote appointments may have led GPs to become more cautious and prescribe medication ‘just in case’. It may also relate to the uncertainty surrounding coronavirus and the availability of hospital care should a patient’s condition deteriorate. Or there may have been a shift in 'case mix', where more patients with new symptoms and signs access remote appointments compared to face-to-face appointments.
Another key finding is that the rate of GP referrals to outpatient care shifted after the outbreak of Covid-19 and is now higher for remote GP appointments. This again might be due to GPs erring on the side of caution and referring on more patients so as not to miss something important. However, in the context of the drop in GP attendances at the start of the pandemic, it could also be due to GPs needing to catch up and refer on patients who should have attended previously.
New analysis of what happened to patients who attended outpatient appointments is also revealing. The proportion of patients who were discharged following a telephone or telemedicine appointment fell from 25% in February to 18% in April, where it remained through to September. There was also an increase in appointments that resulted in another being needed at a later date. The same could not be said for face-to-face appointments, where the proportion of patients discharged remained consistent at around 22%. The reduction in discharges following remote appointments could lead to pent-up demand for outpatient care, in a system that is already struggling to cope with a large backlog of cases.
What next?
Radical shifts towards remote care have occurred in both primary and outpatient care during the Covid-19 pandemic. On the whole, GPs say that greater use of remote consultations should be continued in the longer-term. Meanwhile, the negative responses from clinicians to Matt Hancock’s speech at the end of July, where he argued that “all consultations should be teleconsultations unless there is a compelling clinical reason not to” signals that a balance between face-to-face and digital appointments will be needed going forward.
The public’s attitude towards remote care was largely positive during the pandemic, but it is unclear how this will change when social distancing measures are relaxed and life returns closer to normality. The choice between face-to-face and remote appointments will depend on a number of factors, including patient preference, digital access as well as clinical circumstances. Patient experience of telephone appointments in general practice fared slightly worse than face-to-face appointments prior to Covid-19, but more research is needed into whether this has changed alongside the more mainstream use of digital technology.
Early impacts of remote GP appointments show an increase in the rate of prescribing of new medication as well as a rise in referrals to outpatient care. This, coupled with a decrease in the proportion of remote outpatient appointments leading to discharge, could signal even greater challenges in a system that already has millions of overdue appointments. Services will need to increase capacity beyond pre-Covid levels in order to reduce the backlog. It is unclear whether remote care could be used as a tool to help this process – for example, through reductions in patients who do not attend appointments due to time or travel factors.
Importantly, uncertainties remain over the safety and clinical effectiveness of remote appointments, and it is unknown which patient groups will benefit or lose out from these ways of working. There has been rapid progress towards the ambitions of the NHS Long Term Plan for digital appointments, but we are still only scratching the surface of the potential impacts.