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Independents' Day

Should remote consulting remain the default option post-Covid 19?

Two GPs debate on whether remote consultation is convenient, or whether it will ramp up demand on GPs

simon hodes photo

 

YES - They are popular and convenient

For many years, my brother-in-law Ben has teased me that the NHS is the only place left on Earth that uses fax machines and that he still can’t email his GP practice. He insists the occasional visit he has had to make could have been conducted via video.

Coronavirus has sorted all this out for him. The pandemic has rapidly brought sweeping changes to the NHS, triggering, it would be fair to say, a digital revolution. A phone call is the first point of contact now, augmented either by photos via SMS or email, or by conversion to a video consultation. My own rough audit over the past few weeks shows around 64% of my contacts were dealt with by phone alone. Some 18% needed video, around 10% a photo, 2% video and photo, and 6% face-to-face review.

We’re also doing weekly ‘ward rounds’ by video in our nursing homes to review the patients and support staff at this time. Patients are emailing us more than ever, for example with blood pressure readings, using our website for chronic disease monitoring and contraceptive checks, and taking advantage of software solutions like AccuRx.

Video consultations look likely to be a legacy of Covid-19

On becoming health secretary in 2018, Matt Hancock signalled his passion for digitising the NHS. The growth of the video consultation service GP at Hand suggests this is popular with patients, although its rapidly growing list size – as the BMA and others have noted – consists mostly of younger patients, leaving more complex cases for regular practices.

Video consultations look likely to be a legacy of Covid-19. They feel much safer and can give far more information than a phone call. Of course, we must note that our hospital colleagues are adapting too, with some clinic letters now referring to ‘remote review’; antenatal care is just one area where this has been embraced.

Maybe in future, patients calling their practice will be offered a telephone, video or face-to-face consultation. In essence, we’re all GP at Hand now, which is clearly popular with our regular patients. If anything, this might just improve continuity and access for the younger ‘digital’ cohort that the BMA mentioned.

And by the way, the fax machines have gone at last. Ben – you win.

Dr Simon Hodes is a GP partner, trainer and appraiser based in a large group GP practice in Watford

katie new

 

NO - They will simply increase demand

‘We need to encourage people to book more appointments’, as no GP ever said.

Demand and rates of consultation have been on the rise for decades. So what do we expect to happen when a GP consultation is available at the touch of a smartphone? GP services are not like online shopping – ever-easier access is not the priority. As doctors who care for the health and wellbeing of whole populations, we know it is essential for our services to be available for those most in need.

Coronavirus has given the Government, and those in big business, the opportunity to capitalise on the need to consult remotely. The cynic in me was not hugely surprised to be told we could sign a death certificate only if we had seen a patient in person, or via video consultation. Why not via a phone consultation? Perhaps some are eager to ensure we all move to video, and hope we won’t look back.

Video consultation is likely to be another Government fad

Make no mistake, there is a lot of money at stake. GP at Hand parent company Babylon Health is now valued at $2bn (£1.65bn) and many other video consulting apps are emerging. Many very rich and very powerful people would like GPs to roll over and accept a move to online consulting en masse.

Video consultation is likely to be another Government fad, much like seven-day access, that will do little to improve general practice. Until independent research shows it eases demand on GPs, we should reject wholesale moves to this model. Video consultations are likely to increase demand for our services, discriminate in favour of younger, fitter people and even increase consultation length.

The indemnity risks also need to be considered. E-consults frequently contain reams of text, which I may not have time to read as carefully as I might like. A video consult could also be covertly filmed or watched by a third party. Should an already overstretched workforce really accept a model that will put us at greater risk of being sued?

We must not be blinded by tech firms who have not done our job and do not share our priorities. I’m sorry, but neither they nor the health secretary know what they are talking about.

Dr Katie Musgrave is a GP trainee in Plymouth and quality improvement fellow for the South West of England

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Readers' comments (18)

  • Agree with Katie, convenience is good when selling something but not when trying to limit the hoardes of patients trying to get through to the surgery. Someone has to deal with the demand at the end of the day, whether it be face to face or virtual. Opening another "door" to the surgery will not fix that.

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  • Money is language. It tells of time preference, transfers energy and points to opportunity costs.
    In free markets the intersection of 'supply' and 'demand' leads to a 'price' and drives resources to supply more of the good if something is desired above other things.
    In socialist markets 'price' is fixed, sometimes even at 0, thus leading to a breakdown of the information flow, with inevitable queues, shortages and, most importantly, no mechanism to increase supply in the face of unmet demand.

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  • The price the patient pays is an opportunity cost so if the consultation is on the phone or video done from home then it is very convenient for the patient but the opportunity cost is zero to the patient so hoards will take advantage of the completely free service and it will be overwhelmed in time.
    That’s why I like sit and wait clinics- with boundaries like being limited so any patient arriving after 10:30 has to come the next day. But sitting for an hour to see the doctor means it costs something.

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  • A fair point Mark. However, phone consults have allowed some of us to work remotely at times and reduce our personal risk from stepping into the surgery, particularly significant for older BAME clinicians.

    In my area home visits have significantly reduced and often replaced by phone or video consults which has freed up time. Shielded patients in particular have appreciated this.

    Some clinicians are clearly more confident than others on the phone. Those that are skilled in this area can often deal quickly and efficiently with queries and challenge inappropriate patient behaviour.

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  • I miss the people. I just like people. I miss hugging the bereaved, taking the hand of the dying, shaking a hand to conclude a transaction, holding the newborn. I miss the sharing of the moment. I miss singing with my choir

    If I want to solve puzzles without meeting people I can do sudoku

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  • Perhaps if we were selective with which patients were called, we could take some of the sheen off babylon if we are all doing it. Might make their business model a little less viable. Perhaps each surgery should have its own little digital branch so patients can stay digital if suitable and remain with their local practice than joining a purely money making scheme known as Babylon. Generally I prefer face to face, you pick up more clues, spot more skin cancers, etc Again as a profession we are allowing ourselves to be exploited by other professions... such as Dr (I'm not a medical doctor) Parsi......

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  • I think it's great. Why cant you limit phone demand ? we are. If anything it has seen my workload go down, reduced those who come round for a social chat and made the psycho dependant patients less so as the physical element has been removed. massive drop in home visits, no need to trawl round nursing homes physically every week and if I need a F2F then bring them in. of course you want to see skin cancers, you don't want to see I think I have hayfever doc...

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  • Thanks for the discussions / comments - for the reord I was asked to debate one side of this for the opinion piece - and was really focused on 'will we use video consults post covid'- hard to capture everything in 350 word article.
    Meeting demand is a concern - always has and will be. At present we have all adopted 'new ways of working' which is phone or eConsult 1st and only seeing limited F2F as really necessary.
    It is likely that at least some patients will want to continue with phone / video consultations in the long term. It is likely that footfall will be down for some time to come, and we will all have to balance service demands vs delivery of safe effective patient centred care. There are benefits to GPs who can now work more flexible / from home - which was never an option in the past (BC).

    Interesting twitter discussions on all this here if you want to join:

    https://twitter.com/keester76/status/1268836173826396160?s=20

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  • I think it’s one of the positive things to come out of all this so far. Yes there are some limitations but you can always bring in those patients that need F2F reviews in a more controlled and safe way and arrange home visits etc. Telephone triage is a good way to filter out those patients that can be dealt with remotely and those that need to come in. Also I’ve heard so many patients say they like the fact that they are not sitting in a waiting room with people coughing and sneezing and I think the rates of respiratory tract infections etc will hopefully come down in general due to less contact. It seems a sensible and safe way forward. The pandemic has forced us to work in more innovative ways and to think outside the box for once which is a good thing for patients and practitioners alike.

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  • I’ve come to the view that the grind of face to face 10 min consultations and a crowded waiting room are no longer fit for purpose, safe or enjoyable as a job. Our intention is to incrementally rebuild to replace this old model with a mix of far longer face to face slots, phone clinics, video surgeries and online consulting with all the work-time accounted for and insofar as possible, a capacity cap implemented. We think that’ll create an increased breadth to our patients and better job satisfaction for clinicians.

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