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How technology is changing the GP consultation

Digital innovation is proceeding apace, but concerns persist. Nicola Merrifield reports

The humble face-to-face GP consultation may be in the process of becoming an anachronism.

Last month, NHS England revealed the first inklings of its new NHS app. It was confirmed that – among other things – the app will include built-in support for GP video consultations.

NHS England is not alone in being caught up in digital fervour. At south-east London superpractice the Hurley Group, ‘the volume of online consults doubled in the past year’, says Dr Murray Ellender, GP partner and co-founder of its online triage and consultation tool eConsult. The group’s long-term plan, he says, is to ‘only see the patients we need to see face-to-face, face-to-face.’

The Hurley Group – which has partners including former NHS England primary care director Dr Arvind Madan and former RCGP chair Professor Clare Gerada – now employs 12 GPs to work on eConsult. ‘Ideally, over the next six months, I’d like to double the size of that team,’ says Dr Ellender.

Dr Mobasher Butt, medical director at Babylon, which runs video consultation service GP at Hand with a west London NHS practice, estimates about ‘85% of cases can be dealt with entirely via virtual consultation’ – a figure he says is based on audits of ‘hundreds of thousands of patient records’.

The use of technology – whether it be video consultations or symptom-checkers (see box below) – to manage the number of face-to-face consultations has support across the board, from the BMA and RCGP to the UK’s four governments. Crucially, it is the second of new health secretary Matt Hancock’s stated priorities, after ‘workforce’.

How the new technology works

Online assessments

How do they work? Patients fill in an online questionnaire about their condition or symptoms, which is sent to a GP, who assesses the information and responds.

Which companies are using them? One of the best-known providers is eConsult, developed by the Hurley Group NHS superpractice in London. It is currently used in 400 NHS practices in 46 CCGs and is available to 4.2 million patients.

Symptom-checkers

How do they work? Patients answer a series of questions through an app or website about their symptoms, and are then given automated on-screen advice about what clinical services are most appropriate.

Which companies are using them? Many providers offer a symptom-checker but private firm Babylon, which also provides the GP at Hand NHS service, has made the bold claim that its version can offer advice ‘on par’ with that of GPs, thanks to the artificial intelligence behind the technology - a claim disputed by the RCGP.

Video consultations

How do they work? Patients book a video appointment via an app or computer and choose a time slot and GP that is convenient for them. GPs then carry out a video call in which they assess the patient remotely.

Which companies are using them? Push Doctor was one of the first to offer video consultations. At launch in 2015, its fee-paying service had a network of more than 7,000 GPs.

Yet some experts are urging caution, citing a lack of evidence and safety implications for patients. There are also fears that online consultations could harm efforts to tackle antimicrobial resistance, and even doubts that the technology will reduce GP workload.

Despite such warnings, there is little doubt technology is set to play a much bigger part in GPs’ lives, most obviously through the NHS app.

Before standing down as health secretary, Jeremy Hunt said the NHS app would allow users to book GP appointments, check symptoms, receive triage advice, access medical records, order repeat prescriptions, change data sharing and organ donor preferences and promote ‘approved apps’.

The Gizmodo website obtained further details on the testing of the app, revealing it would take place in 10 practices this month. In its initial stages, it will allow patients to specify preferences for ‘end of life’ care, which will be passed to their GP.

NHS England’s aims include enabling the app to connect with other devices, such as Apple Watch or Fitbit, share data and, crucially, enable video consultations.

NHS England is serious about this. It committed £45m over three years to help practices implement technology. Practices must put this funding towards systems that allow patients to send a query or symptoms to their GP – and potentially video consultations. A total of 39 CCGs were given funding in 2017/18 to implement new technology.

Safety concerns over remote consultations

However, caution is warranted. When the CQC inspected 35 online providers in 2016/17 it found 43% were not providing ‘safe’ care. Inspectors pointed to high volumes of opioid-based medicines being prescribed without talking to the patient’s registered GP, and inappropriate prescribing for long-term conditions

The CQC report also highlighted inappropriate prescribing of antibiotics – ‘a particular challenge for video-based services’. It cited ‘examples where, because the clinician was not able to effectively carry out the usual clinical assessment… such as examining a patient’s chest, ears or throat, the threshold for prescribing antibiotics had been lowered.’

‘You can’t do a proper physical examination online,’ insists Dr Jackie Applebee, east London GP and deputy chair of Doctors in Unite. ‘If we’re just taking a history and it’s something fairly minor and self-limiting then it’s what we do on the phone. But as soon as we do a physical examination, that’s different.

‘And that’s not just getting our stethoscopes out or putting our hands on somebody’s abdomen, but observing somebody’s demeanour – whether they’re out of breath when they walk down the corridor. We make those assessments subconsciously – and all of that will be lost online,’ Dr Applebee adds.

Claims of symptom checker advice being 'on par' with GPs

Fresh concerns are now centring on artificial intelligence. GP at Hand gives patients advice about symptoms through an interactive symptom-checker that asks questions about their condition.

Babylon claimed in June that the advice was ‘on a par’ with that of GPs, as it had achieved similar scores in GP exams as an average trainee.

This caused a backlash. The firm had used the RCGP’s trainee exams in its testing, prompting college vice-chair Professor Martin Marshall to comment: ‘To say Babylon’s algorithm has performed better than the average MRCGP candidate is dubious. No app or algorithm will be able to do what a GP does.

‘There are many factors to take into account, a great deal of risk to manage, and the emotional impact a diagnosis might have on a patient to consider,’ he said at the time.

Research suggests symptom-checkers cannot always be relied on.

A US study published in the BMJ in 2015 analysed 23 symptom-checkers and found the correct diagnosis was provided in 34% of cases and appropriate triage advice given in 57% of instances. It found the symptom-checker on NHS Choices correctly triaged emergency and urgent conditions in 87% of cases – but also incorrectly triaged non-emergency or non-urgent conditions in 80% of cases.

There is an even more fundamental point here. These symptom-checkers do not reflect the reality of the diagnostic process.

As the King’s Fund put it in 2010: ‘In theory, on seeing a patient presenting with a set of signs and symptoms, a GP may follow a simple, linear sequence from history-taking and examination through to a differential and then final diagnosis. However, the reality of the diagnostic process is often quite different.’ Research has shown that only 30% of face-to-face consultations end with a diagnosis.

Yet these symptom-checkers use this linear sequence – patients input their symptoms and then receive advice. Hertfordshire GP and deputy chair of UK Conference of LMCs Dr Katie Bramall-Stainer said: ‘Patients don’t present in nice neat compartmentalised boxes - so the technology will need to be more nuanced.

'I am not yet aware of robust evidence showing how these platforms materially and safely manage demand and what potential indemnity issues could arise from incorrect diagnoses.’

Indemnity fees 'reflect higher risk'

The medical defence organisations seem to agree on risks to patient safety. The MDU says its fees for GPs ‘reflect the higher risk’ of providing online services. This is ‘because of the limitations it can impose – for example, whether doctors are in a position to make an appropriate assessment of the patient’s symptoms’.

MDDUS medical division joint head Dr Anthea Martin points to ‘inherent risks’ of online consultations, such as ‘lack of prior knowledge of a patient, ensuring adequate consent and providing continuity of care’.

And there are even doubts around another key selling point of technology – that it will reduce GP workload.

A Society for Academic Primary Care study of 36 practices using eConsult found ‘unless use of online platforms increases and integration with IT systems improves, online consultation systems are not likely to have any notable impact on patient waiting times and staff workload and may add to practice workload’. More than a third of online consultations also required a face-to-face consultation, it found.

But with the NHS and the new health secretary fully supportive of increased technology, such concerns look unlikely to stop the march away from traditional face-to-face consultations.

 

The NHS app: what it will involve

The new app is to be tested in 10 practices towards the end of this month. Initially, it will allow users to:

  •  Make GP appointments
  •  Order repeat prescriptions
  •  Manage long-term conditions
  •  Access 111 online for urgent medical queries
  •  State preferences for data-sharing, organ donation and end-of-life care

 

There are further plans for the app to:

  •  Enable GP video consultations
  •  Link to other apps, such as Fitbit and Apple Watch

 

 

Readers' comments (13)

  • Starts of as an advert then the flies begin to land on the polished turd.This is a medico-legal nightmare and will eventually blow up in someones face.Where will the boomers be who made all the money sunning themselves and enjoying retirement.Of course as designers of the new order they will have no liability.

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  • AlanAlmond

    Here we are, the only people who don’t have a right to an opinion on how a Dr should do their job is the Doctor themself.

    Patients, politicians, business people, political figureheads dressed up as ‘top’ medical big wigs, and magazine editions. Only these people really know what a GPs job involves and only they get to decide how it’s done.

    Isn’t it marvellous, these self important Drs always pissed me off anyhow, all up themselves telling us what might help when we get sick, and insisting on making us come to see them when I’d rather be at home or at work. It’s high time they started getting used to doing what they are told. I want illness to light, easy and convenient. These Drs make it all so difficult. They need to wise up and get on line.

    It’s inevitable, because it’s what we want. It the 21st century for god sake, life should be easy, convenicence is a right and illness shouldn’t be so difficult, death won’t happen to us. Our apps will see to that.

    Inevitable? If you say so.

    Symptomatic of today’s population - self obsessed, indulged and lost, blissfully unaware of the nature of their fragile mortal existence.

    Dumb..oh but it’s gonna happen anyway. Sad , but what do I know, all you need is google and protocols. Medicine is easy. Life is easy. Death is someone else’s problem.

    Urrr no it isn’t. But what do I know. I a dumb self important specialist in how folk end up dead.

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  • AlanAlmond

    It’s Darwinism. You car starts making a terrible rattling sound every time you dash down the motor way at 80? What do you do, take to a mechanic so they can take a good look, or wip out you phone , shoot a video of what you think might be the problem and email it to kwikfit?
    Feel comfortable with the same approach when you climb aboard that Boeing 747 on the way to your holiday in Ibiza? A video check up is all that’s needed surely? Roll the Darwin dice, make your choice.

    Anyway we’re just taking about our health, video consults are fine. Everybody knows the only Drs you actually need to see face to face are the real ones in hospital. People don’t get real illness in the community, all the heavy stuff happens in doors. Everybody knows that. Don’t they.

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  • Back in the real word the it wouldn’t even show proper records today.

    You show me that I can do this job to the safety standards required by internet and I’ll gladly do it.

    But so far it’s all just bull, creaming off the self care stuff for profit . Fair play to the money hongrey entrepreneurs doing it, I understand their reasons.
    But it’s not real healthcare

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  • Am I the only one who went into general practice to see real life patients? If all we left with it online and video consultations, General practice is gonna be even worse off!

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  • Just Your Average Joe

    Just go with it - find your most complex, housebound and frail, as well as heart sink, multiple attending patients and give them the on-line application to join these parasitic companies posing as wolves in sheep's clothing.

    Then sit back and relax, when they try and re-register and tell them your list is full!

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  • "NHS England is serious about this. It committed £45m over three years to help practices implement technology."

    Very, very, very serious - about 30p per patient per year.

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  • One thing that you can always count on is an ample supply of Judas goats in the profession

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  • Just Your Average Joe

    Babylon and all the private services looking to skim off money from the NHS - need to be reported to the GMC for effectively breaking the requirement to do no harm.

    If the RCGP criteria of community orientation is look at - they are harming the overall health economy and directly causing harm to patients at neighbouring practices - as they steal valuable resources which in turn will reduce the ability to recruit and keep staff who may also be poached off.

    BMA report them and help your members by protecting them from this DOH led and supported policy - as the GMC can for once show itself to be protecting patients and supporting doctors.

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  • Agree with AlanAlmond at 5:32pm
    The cadre whose opinions are openly ignored are those providing the actual services. They're a pesky recall to reality and the entrepreneurs only want positive press which is likely to increase the share price (or similar). Few of us want to be managed as mere functionaries (and risk-sump targets) by corrupt corporations run by medical Quislings. Hence the recruitment and retention crisis.

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