CALL TO ACTION! This is an #NHS4All campaign post. If you as an individual – or your local NHS campaign – would like to act on this information, you could ask the public in your area if their GP is using online consultations, and if so, what their experiences are of this. Do they find it useful or not? Or you could simply share your own experience – either with us or by writing to your local newspaper or calling your local radio’s topical phone in show. And if your local campaign wants to inform people about the national policy drivers for the move to online GP consultations, you can find various blog posts about this here.
‘Digital by default’
From April 2020 all GP practices will be contractually required to provide GP Online Consultation.
What’s this going to do to face to face GP consultations? It’s already very hard to get a timely GP appointment so what will happen when the assumption is that patients’ contacts with GPs will be digital by default?
The NHS England quango anticipates that by April 2020:
- all practices will be offering online consultations
- all patients will have online access to their full record, as the default position, subject to existing safeguards for vulnerable groups and third party confidentiality and system functionality
- all practices will need to have an up-to-date and informative online presence, with key information being available as metadata for other platforms to use
- all practices will be giving all patients access to online correspondence as the system moves to digital by default (with patients required to opt-out rather than in)
- practices will no longer use facsimile machines for either NHS or patient communications
- By April 2021 at the latest, all practices will be offering video consultations.
Back in June 2018, a Wirral GP Practice manager sent this email to his patient participation group:
Dear all, you may or may not be aware that Wirral CCG has funded the above econsultation scheme to ease the pressure off general practice. We have opted to become a pilot site and hopefully will go live with this in the next few weeks. I only found out myself today! You can have a look at this and play about at demo.webgp.com
This system is merely meant to target those patients who do not need to see a gp, but who may not know somebody else can help so take an appointment that could be used for somebody who really needs it. A lot of the gp time is taken up by patients who could have been dealt with by the admin staff, e.g. an extension to a sick note, or another service, e.g. a urine infection by the local pharmacy.
Anyway, we can discuss further at the meeting next week.
eConsult allows patients to submit their symptoms to a GP electronically and receive a response in one to two working days.
NHS England’s £45m GP Online Consultation Systems Fund
After a little digging, we found that it was not exactly Wirral Clinical Commissioning Group that funded the scheme, but NHS England, through its £45m GP Online Consultation Systems Fund.
The fund was announced as part of NHS England’s GP Forward View in 2016 and launched in 2017, when eConsult was first trialled in 33 practices in Hull and East Riding.
In March 2108 The National Institute for Health Research published an evaluation of the effectiveness, acceptability and impact of implementing eConsult in GP practices in N Somerset, Bristol and S Gloucestershire. It found that it can’t replace face to face consultations when diagnosing new or complex conditions:
The GP Online Consultation Systems Fund runs until 2020. According to NHS England’s blurb, it
“is available to support digital confident [sic] practices to explore and successfully embed a model(s) of online consultations as part of ‘Time to Care’ to benefit both patients and staff.”
NHS England has made an allocation from this “one-off transformation fund” to each Clinical Commissioning Group.
NHS England expects all Clinical Commissioning Groups to submit coordinated plans for this funding and that in most areas:
“procurement will be undertaken at scale across STP footprints…
“Many CCGs and Sustainability and Transformation Partnerships are already working on integrated digital initiatives building on the implementation of NHS 111 online and may want to use this opportunity to connect GP practices, local neighbourhoods or practices with clinical hubs or urgent care services. It is expected that, in time, this will become commonplace, as part of Sustainability and Transformation Partnerships’ work to improve access, outcomes and efficiency.”
To hell with patient safety, let’s have some disruptive innovation
Like other NHS England Funds for Sustainability and Transformation Partnership schemes, there is a “framework” of approved suppliers. 26 in this case.
The problem, according to a May 2018 article in Pulse, is that NHS England launched the GP Online Consultation Fund before making sure that all the suppliers’ products were safe.
Dr Chandra Kanneganti, GP Forward View lead for the BMA’s GP Committee, said:
‘Before the online consultation fund was launched, on advice from the GP committee and the joint BMA-RCGP IT committee (JGPIT), the BMA requested that NHS Digital delay the fund until it could demonstrate that all suppliers were safe for patients to use.
‘A JGPIT evaluation of existing suppliers used by CCGs and practices revealed significant shortcomings and did not comply with basic safety and governance requirements.’
He added that the GP Committee
‘are working with NHS Digital to develop a dynamic purchasing system that will ensure suppliers are safe for GPs and patients to use, and comply with existing regulations’.
Safety aside (as if), what could be better than freeing up “time to care”, by replacing face to face GP consultations with online consultations?
According to a May 2018 Pulse report, an early adopter of eConsult in a Southamption GP practice found that 1,303 patients visited eConsult in March 2018, with 858 submitting symptoms to the GPs. This avoided 520 face-to-face appointments and patients did not need to return to the GP or seek help anywhere else in the same week.
eConsult can be used in the new Integrated Urgent Care Services too.
Frimley Integrated Care System’s urgent care “innovations” includes use of econsult:
The eConsult online triage and consultation tool is being rolled out across GP practices in the area, enabling people to contact their GP surgery 24 hours a day, seven days a week and receive a response by the end of the next working day.
As well as being part of the new Integrated Urgent Care Systems, econsult is also part of the move to Primary Care Networks which are replacing traditional GP practices and “managing demand” for primary care.
However, online consultations are not universally welcome
Modality, the huge GP company based in the Midlands that also has big practices in 5 other STP areas, does 80% of its consultations remotely by their app or by phone – and has found people don’t like them. This is from a Pulse magazine interview with the Modality executive director, Dr Naresh Rati.
He was frank in his interview that patients didn’t like these arrangements:
“…we are getting ‘push back’ from our patients, who are used to the traditional general practice model, but I think as more and more GPs start to adopt that sort of model, hopefully, society will start to shift as well.”
Margaret McCartney says in “The State of Medicine”(ps 196-198):
“What of that old-fashioned, slightly embarrassing admission – vocation?”…
People do not come to see a doctor to discuss a straightforward symptom but because of ‘upsetting events, social isolation, psychiatric disorder, and desire for health information’. [Barsky, AJ. Hidden Reasons Some Patients Visit Doctors. Ann Intern Med 1981; 94:492-498]…
…there is the door handle moment, when a patient goes to leave but hesitates: ‘Can I just ask you about…’ It is, of course, the real reason the person came, concerning the worry about something – possibly seemingly minor – that has been eating into sleep and terrorising wakefulness, and which the good GP will deal with.
…’Instead, the values of general practice have not been captured in the way the speciality has recently been organised and paid…The increasingly fatigued and stressed GP becomes torn between his[sic] need to obey governance and the wish to create good human sense and connection with this person now. Increasing our mandatory tasks of obedience and administration has crippled our better human capacities and responses…our profession has become humanity-famined.’ [GP David Zygmund]”
She goes on (p198):
“The market structure infers that is it possible to make efficiencies, and those efficiencies make profit, which then becomes the motivation to act. Alternatively, the market works by expanding its reach – and in medicine, that reach can extend into procedures which do not benefit patients, only doctors’ profit margins. On the other hand, vocationally driven healthcare speaks of an ongoing professional responsibility where the values are in the relationships.”
Madder Than Hell from Wirral had his own concerns
He emailed his GP Practice manager to ask about costs, the expected benefits, the process of the pilot scheme etc.
The GP practice manager clearly couldn’t be arsed
He emailed the link to the econsult website and added,
“Not sure why you would want a document outlining costs as we as Practices have not been given that? Hopefully it will be less that the cost of GP burnout and having to employ locums to deal with that and also the costs of training and employing more GP’s to cope with the increased demand on General Practice. The expected benefits are all on the website, but in a nutshell reducing unnecessary appointments would mean more appointments for the patients who really need them, and hopefully eliminating the need to call on a daily basis to try and get an appointment, surely a positive step?”
Madder Than Hell from Wirral was downcast. He emailed STP Agony Aunt:
“Oh god how depressing.
GP practices don’t know the costs of econsult.
Practice manager “hopes” it will be less than the cost of GP burnout and having to employ locums to deal with that and also the costs of training and employing more GP’s to cope with the increased demand on General Practice.
By implication they see econsult as a sticking plaster solution, rather than tackling the causes of GP burnout – which again by implication are shortage of GPs combined with increased demand on them.
Practice manager takes as read that the econsult benefits are what econsult says they are – whatever happened to “buyer beware”?
Practice manager assumes the core benefit is reducing unnecessary appointments – but where is the evidence that online consultations are safe or appropriate? There seems to be a lot of evidence that they miss essential diagnostic opportunities that are only available face to face, and they reduce the patient-doctor relationship to a purely instrumental tick box relationship of symptoms – clinical treatment.
For goodness sake.”
STP Agony Aunt’s reply has been redacted as largely unpublishable. Except this:
Maybe your practice manager needs to be thinking about how market-driven changes to the NHS have created the problems of GP overload, by introducing/expanding procedures that don’t benefit patients? And how the stupid austerity cuts to public spending have worsened people’s health and so increased our need for GP healthcare?
And so on…and on…
If you’re depressed, mad or confused about your STP or Integrated Care System, please email firstname.lastname@example.org
STP Agony Aunt will do her best to reply, hopefully in less than 14 months.