Online consultations: the future of NHS GP appointments?

In 2016, the General Practice Forward View invested £45 million in a national programme to support uptake of online consultation systems in every GP practice. This article examines the progress that has been made so far, and whether this new way of working is proving popular with health professionals and patients.

Growing numbers of people are turning to online banking and shopping, as well as to medical apps that serve a wide variety of needs, including booking NHS GP appointments, ordering repeat prescriptions and receiving healthcare advice on their mobile phones. Should we welcome these changes or be wary?

With the undoubted advantages of online access come some disadvantages: as far as banking and shopping are concerned, the drawbacks – such as widespread closure of our local branches and favourite department stores – are perhaps irritating to the public rather than crucial. However, the stakes for us all are higher for health, and while apps can provide some useful information that may prevent patients seeking unnecessary GP appointments, they can sometimes mislead them into thinking they do not need to see a doctor.1

NHS GP online consultations

So where do online GP consultations fit into the picture? These are a fairly recent addition to the technologies to be adopted by the NHS, and the consensus seems to be that we need to be aware of the issues surrounding online consultations, so we can celebrate the advantages they offer and guard against the possible risks.

NHS England’s plans to roll out GP online consultation systems across NHS general practices are part of the General Practice Forward View (GPFV)2 and are supported by a £45m fund (weighted per capita) towards the cost to practices of buying the systems. They are now well underway.

The aim of the GPFV is to harness the power of technology to help the health service meet the increasing demand caused by the ageing population, says NHS England. It will make it easier for clinicians to deliver high-quality care and empower patients to take control of their health and care through “secure online access to clinicians, personalised and relevant health information, digital tools and advice that helps them to better manage their conditions.”

Latest figures (April 2018) from NHS Digital show that nearly 14.3 million people are now using GP online services to book appointments, order repeat prescriptions, and see their medical record and test results – the highest it has ever been. The figures also show that an average of a million GP appointments are being made or cancelled online every month, and nearly 2.6 million prescriptions ordered online, as practices and their patients are making more use of digital technology to control their healthcare. This means that almost a quarter (24.6%) of patients are now using online services to access healthcare via their GP practice.

While NHS online consultations are already available, they are “subject to local implementation” and the latest figures are difficult to ascertain. Free Wi-Fi, which is also subject to the same condition is, however, now available in most GP practices.

The BMA says the consultation systems, through which online consultations are enabled, are typically “app or web-based systems that facilitate communication and the transfer of information between the GP and the patient”, though some software platforms include algorithm-generated (AI), tailored advice for patients, and some allow patients to book appointments, request repeat prescriptions and access their health records.

Not all online consultation systems offer the same services and there are a number of key issues that need to be considered when choosing the right one, notes the BMA. Many practices and CCGs have no IT lead in place when procuring their online consultation systems so, in a bid to help GPs make an informed decision, the BMA has set out its own advice and concerns about the potential hazards when making a choice, detailing an 11-point checklist of the “safety, governance, legal and regulatory requirements expected of online consultation systems” under the headings of safety and quality assurance, management of data, and risk management.3

The RCGP has also developed, and is disseminating via its website, a wide-ranging series of questions that patients, clinicians, practice staff or commissioners might want to ask about the operation of the new services.4 Questions for all parties include those designed to ensure the safety of the service.

How do online consultations work?

NHS England says that online consultations offer alternative ways for patients to consult a GP or other practice-based health professional via the internet, rather than having to wait for an available appointment, take time off work or rely on relatives to help them to attend the practice in person. Patients who register for online services will be able to contact their practice using a smartphone, tablet or computer to ask their GP about a new or ongoing problem, which will be directed to the appropriate person in the practice team. Sometimes that means a phone call with the GP or nurse and sometimes an appointment at the surgery, which will be arranged as usual.

From the patient’s perspective, the service is free and available to anyone who is registered with an NHS GP practice. The patient needs to sign up to use GP online services, via a registration form given by the practice, providing proof of address and identity. Once signed up, the patient will receive a letter with their unique username, password and instructions on how to log in.

To use the service, patients usually complete an online form on the practice website or through an app, which is then delivered electronically to the practice, from which the GP will provide the most relevant response, says NHS England in their background briefing. Online consultation tools offer functions such as: triage, which captures a patient’s symptoms and sends a succinct report highlighting areas of clinical risk and likely severity so that the GP can quickly assess the right course of action; and alerts, which can flag serious symptoms, signposting patients to seek urgent medical attention and highlighting areas of potential clinical concern in the GP report, helping to diagnose time-sensitive and life-threatening illnesses at the earliest opportunity. Many systems use standard industry scoring systems for conditions such as depression and anxiety.

Dr Mark Harmon, Strategic Director of eConsult, one of the online consultation systems used by the NHS, sounds a note of caution: “Online consultations are a new digital addition to the doctor’s toolkit and have the potential to triage need and manage demand, but they must be implemented properly with adequate training, change management and marketing. It doesn’t work if practices adopt online consultations and just try to do that on top of everything else.”


Figure 1. How eConsult works. Adapted from: NHS England. General Practice Development Programme. New ways to work in general practice5

A summary of how the eConsult system works is shown in Figure 1, and Figure 2 gives advice on how to set it up. NHS Bexley CCG Chair Dr Siddharth Deshmukh is a user of eConsult and a convert to the virtues of online consultation because of the impact it has had on his practice at Sidcup Medical Centre, where he is a partner and lead GP. He says he was sceptical about its use six months ago, worried about “opening the floodgates” to patients who might not genuinely need medical advice. However, that has not happened.


Figure 2. Setting up the eConsult online consultation system in a GP practice: step-by-step. Adapted from: NHS England. General Practice Development Programme. New ways to work in general practice5

He says: “My idea was to use online consultations to try and shift the workload away from the duty doctor directly having to do the daily telephone triage, which is typically what happened before online consultations when patients rang asking for a same-day appointment.”

An eConsult analysis of a five-week pilot at the Sidcup Medical Centre shows that before online consultations began there were 200 telephone triage calls per week, with 40 patients a day asking for urgent face-to-face appointments or telephone advice. Each telephone call lasted an average of four minutes, amounting to 2.6 hours per day on the telephone. In all, the GP was spending 13 hours per week on the telephone, which at £90 per hour equates to a cost of more than £1000 per week.

After the switch to eConsult, the average time spent reading each report is 1.5 minutes, saving 2.5 minutes per patient, or 500 minutes per week and over £40,000 per year. Even with the subsequent introduction of the £25,000 annual cost of a full-time administrator, there is a substantial saving, together with more efficient working and more time for the doctors to see sick patients.

Dr Harmon says that eConsult’s questions are written by doctors for doctors, so the history is taken as they would face to face with the patient; therefore, it is familiar to the doctor and very consistent. If the patient answers a question in a way the clinician finds concerning, there are different types of red flag in the system, very easy to read and in a consistent format. Questions highlighted with a red flag will be followed up.

So how did the Sidcup Medical Centre move from ‘before’ to ‘after’? Dr Deshmukh says: “We started actively saying to every patient that called asking for a same-day appointment or a telephone call: ‘Are you aware we have started eConsult, which is an online consultation system – you can initiate the online consultation and the surgery will get back to you within a couple of hours with the most appropriate advice’.”

He adds: “We knew that if a doctor said it, it would make a bigger impact, so I recorded the message and in it I also said: ‘If you need a routine appointment, typically within five to seven working days waiting time, hold the line and somebody will help you. If you need an urgent appointment, you can do it online and we will get back to you in two hours.’

“When we did that, we managed to shift one in four patients to online and that’s 50 online consultations per week. That’s much more than the other pilots were doing, getting between seven and 10 consultations a week, only because we were actively signposting them on the day, telling the patient: ‘this is what you need to do’.”

The receptionist asks the patient to go to the practice website and click on ‘contact our doctors’, which takes them through a quick triage process – a set of questions that take a history from the patient, which takes about five minutes. Most people do that and submit the eConsult form to the practice, explains Dr Deshmukh. The practice gets back to them in two hours, having reviewed the consultation and decided whether they need an appointment that afternoon, or if everything’s fine, or if they should send a repeat prescription to their local pharmacy. If the patient is describing a life-threatening condition, the GP will check them out and direct them to 999 or to accident and emergency.

In order to help patients who don’t have internet access, Dr Deshmukh’s practice moved to phase 2 of its introduction of online consultations by employing a full-time administrator and training her in how to go through the online database. The administrator calls the patient back and takes them through the history online (ensuring the governance around it is clear). It is submitted to the practice and then a GP or nurse will triage the online consultation within two hours and get back to the patient with an action plan.

What do patients think of online consultations?

Of those using eConsult at one practice in May 2018, 70% reported they were satisfied with the service, while 75% said they would recommend the service to family and friends. In addition, 55% of patients said their issue was completely resolved seven days after using the service and 75% did not have to contact the GP practice or any other health service for the same problem in the week after consulting online; 85% said they were contacted by the stated response time.

The practice’s patient satisfaction comments yielded a mixed response, ranging from: “It is a ridiculous service that is reducing access to the doctors for patients that need it,” to: “It is a brilliant service especially for someone who works full time and has other commitments,” and a rather forlorn: “It works, but I would still prefer to be able to get an appointment with a doctor.”

What are the concerns?

“Research into digital innovation is trailing way behind, unfortunately,” says Dr Harmon. He adds: “We’re lobbying academic institutions to try to think about how they can evaluate the system in a much more rapid way, then perhaps feed back to us every three or four months, so we can improve the products and continually develop and refine them over a period of 12 to 24 months, rather than waiting for two years.”

Dr Richard Vautrey, BMA GP Committee Chair, said: “Online consultations, including those made via smartphone, will become increasingly used as technology improves and if they are provided for practices to use. However, practices have more concerns about email consultations, as they are not as structured as face-to-face or telephone appointments and they don’t provide visual or audible information that can be important to aid clinical diagnosis. It is also not always clear who the GP is engaging with and there are risks if the GP is expected to reply when they are outside the practice and do not have access to the patient’s clinical record.

“Video consultations could be a convenient way for some patients to see their GP, but practices need funding and support to implement the necessary IT infrastructure. We are concerned that one service in London is currently using the out-of-area registration arrangement to fund their provision of video consultations to predominantly younger, healthier patients, and this risks undermining the registered list model that has been the base of general practice for the last 70 years.

“Many patients do not fully appreciate the consequences of registering with this service and that they are in fact de-registering with their local practice, where a GP with an in-depth knowledge of your medical history is able to provide holistic, person-centred care, based in a community where they live. These services may not suit all patients, particularly those with complex conditions that require physical examination and regular monitoring.”

Conclusion

Where does that leave us on the online consultation balance sheet? In banking terms, we must consider the potential profits and likely losses, to celebrate the benefits and guard against the drawbacks. But as Dr Johnson said 250 years ago and is still true today: “Nothing will ever be attempted, if all possible objections must be first overcome.”6

Declaration of interests

None to declare.

Joy Ogden is a freelance journalist

References

1. Wired. Can you really trust the medical apps on your phone? October 2017. http://www.wired.co.uk/article/health-apps-test-ada-yourmd-babylon-accuracy
2. NHS England. General practice forward view. April 2016. Available from: https://www.england.nhs.uk/publication/general-practice-forward-view-gpfv/
3. BMA. Choosing an online consultation system. April 2018. Available from: https://www.bma.org.uk/advice/employment/gp-practices/service-provision/choosing-an-online-consultation-system
4. RCGP. Online consultations in general practice: the questions to ask. March 2018. Available from: http://www.rcgp.org.uk/policy/rcgp-policy-areas/online-consultations.aspx
5. NHS England. General Practice Development Programme. New ways to work in general practice: New types of consultation. 2017. Available from: https://www.england.nhs.uk/wp-content/uploads/2017/10/e-consult.pdf
6. Johnson S. Rasselas. London: Cassell & Company, Ltd, 1889.

Online consultations: the future of NHS GP appointments?

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