Does digital primary care offer a sustainable solution?

After years in which the local GP surgery seemed stuck in the digital doldrums, the last month has seen a digital revolution sweep across GP practices, driven by the extraordinary circumstances of the coronavirus. NHS digital figures show that in 2019 less than one in every 100 GP appointments were carried out by online video consultation, and nearly 4 in 10 people had no access to online consultations at all.

Now, according to a report by the BBC, GPs are seeing just 7 in every 100 patients face-to-face.

The digital revolution

Much of the change is being led by low-tech start-ups like AccuRx, who offer a service that allows GP practices to communicate with patients via text message. These simple solutions have proven popular and easy for GPs to adopt at pace. Responding to the need to deliver care remotely, AccuRx have recently deployed additional features such as video consultations, software to facilitate sending patient documents, and remote patient monitoring. Since launching their video appointments offer at the start of March, more than 90% of GPs across England have signed up, and 35,000 consultations are being delivered a day.

COVID19 has provided an imperative that has removed barriers that previously slowed the adoption of digital first primary care. Early in the crisis, NHSX provided clear guidance on the use of tools such as Skype, Whatsapp and Facetime. NHS Digital fast-tracked the assurance of video products on the new Digital Care Services Framework. A national procurement exercise was undertaken within 48 hours to secure digital primary care providers. Microsoft Teams has been rolled out to 1.25 million NHS staff within a month.

The pace and scale of change is a remarkable achievement.

General Practice is in Crisis

In times like these it is easy to forget that General Practice remains in crisis. Workload has increased substantially, and has not been matched by growth in funding or workforce. The NHS had a target to increase the number of full-time equivalent General Practitioners (FTE GPs) by 5000 between 2014 and 2020. The reality is a falling number of GPs. In 2019 the Royal College of General Practitioners reported the ratio of GPs to population had fallen from 6.56 in per 100,000 in 2007 to 6.19 per 100,000 in 2017. In the 2019 joint report from the Health Foundation, Kings Fund and Nuffield Trust closing the gap, it was reported that the NHS in England has 2,500 fewer GPs than it needs, and a projected gap of 7,000 GPs within 5 years if current trends hold. This does not take into account the policy implications of the NHS Long Term Plan, which aim to shift more activity into primary care.

Can digital primary care provide a sustainable solution?

The question becomes: does digital primary care offer a sustainable solution? It is certainly an ambition of the current Government. The commitment to digital first primary care is clearly articulated in the NHS Long Term Plan, with every patient in England to have the right to choose digital consultations by 2023/24. COVID-19 has transformed that in a matter of weeks, with remote care now the only option for the majority patients. The front door to the NHS is unlikely to be the same again.

However, it was not that long ago that the NHS was caught off guard by the way GP at hand registered large numbers of patients from outside their local community. This approach puts pressure on commissioning budgets, as current rules mean that the Clinical Commissioning Groups (CCGs) where the patient is registered, rather than where they live, is responsible for paying for their care. It also risks creating a two tier system, attracting younger patients who prioritise convenience, while isolating other patients who rely on a multidisciplinary practice team.

In September, NHS England published a response to a consultation that aimed to address some of these issues. Its proposals included requiring digital first providers who register more than 1,000 out-of-area patients to set up a physical practice in that CCG, and that digital-first providers should set up in deprived areas, increasing capacity in communities where there is the greatest need.

These proposals are helpful, but clearly indicate there is work needed to reform the NHS at a systemic level if digital solutions are to be embedded into mainstream care.

The answer lies in a more holistic vision of primary care services. The digital first approach we have seen to date tends to prioritise access and convenience at the expense of other components. Improving access to GPs is certainly helpful, but the development of a two-tier system must be avoided. As we shift towards integrated models of care, a community based approach is going to be more vital than ever. If properly embedded into care pathways, digital technologies have a huge amount to offer. They can support effective information sharing between doctors and patients, support patient empowerment and facilitate the monitoring of a patient’s condition in between appointments. But, the investment into digital-first models must not come at the expense of other areas of clinical practice. It must be woven into a holistic, integrated model of community care.