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Preventing access is no way to deal with rising demand

It was no surprise to hear the BMA GP Committee recently call for an assessment of online consultations. During lockdown, most surgeries trialled digital care in some form. Now is the time to step back and ensure that we get the transition right.

What I do find surprising is the support for a bottleneck, advocated in Pulse. Jaimie Kaffash’s editorial argues that a natural barrier between GP and patient prevents surgeries from being overwhelmed with unnecessary requests for appointments.

As a practicing GP, I cannot agree that the best way to deal with rising demand is to prevent access. Forcing all patients back on to busy phone lines might dissuade some time-wasters from crowding the appointment schedule, but in reality there is no way of knowing how many patients in urgent need of access are simultaneously failing to get through.

There is risk hidden in every waiting list, and that risk increases the longer the waiting list grows. Is a patient’s headache simply a migraine, or is it a subarachnoid haemorrhage? Is the pain in your patient’s stomach something trivial, or acute appendicitis?

It is true that some digital health services actively increase the demand for primary care. In fact, a direct line of access often makes it too easy for patients to contact their doctor. When we surveyed 250 GPs about their experience of digital consultation, more than half told us that new digital channels had increased staff stress levels.

Adding email or text without digital triage prioritises ‘want’ at the expense of ‘need’ because it doesn’t enable staff to assess the nature of the patient enquiry before it reaches the GP. This inevitably leads to unnecessary appointments, which create added stress for already overworked staff.

Many eConsult users tell us that when they first added extra channels, such as text and email, they were overwhelmed with requests for appointments. It’s only when they added eConsult to triage these requests that the enquiries became manageable.

This is hardly surprising. Trained staff are much better judges of need than patients. But in the age of Google, many are self-diagnosing and demanding appointments, while the backlog caused by the pandemic has stretched practice resources even further.

Managing demand effectively means that need must be accurately assessed before an appointment is made. But this must be done fairly. Let’s not return to a system that rewards the patients with the greatest tolerance for hold music.

At a fundamental level, the role of primary care is to control access to more expensive (and increasingly stretched) secondary care. That means accessibility to primary care is a principle on which the entire system depends. Preventing access because demand is too high makes about as much sense as removing the cutlery at an oversubscribed restaurant.

GPs are motivated by a desire to help as many people as possible. They hate seeing queues of disgruntled patients. The role of digital should be to help overworked and understaffed practices prioritise the patients who need to be seen. But digital triage can only manage demand against available resource. It cannot lower demand or magically produce more doctors out of thin air.

I believe that digital triage is a route to more GP face-time for patients who need it. Yes, that’s right: digital should create more physical appointments, not fewer.

I have read incorrect and damaging articles accusing GPs of hiding behind pandemic restrictions to deliberately prevent access. Practicing GPs know the truth. None of us want an end to face-to-face consultation. It’s resource we lack – not courage.

Dr Murray Ellender is chief executive of eConsult and a GP in London


Dr N 2 July, 2021 4:24 pm

No surprises for your love of eConsult….chief executive.

Your welcome to come and manage the daily dross that comes my way on eConsult.

Large amounts of the eConuslt dross is for self limiting illness that never needed to have my or anyone’s involvement. When I get paid per consultation I will embrace this dross feeding nonsense.

John Graham Munro 2 July, 2021 5:09 pm

It’s articles like this that stress me out—-not patients

M C 2 July, 2021 7:48 pm

Let’s see the evidence, not cherry picked examples, of econsults on practices. My hunch is there is not a single shread of robust evidence that econsults make any difference compared to usual care. They are being pushed by special interest groups like Econsult the company and the only person who benefits is then.

Let’s see the evidence. Come on Murray, where is it? And if it’s there why haven’t we seen it already? Spoiler: because it doesn’t exist….

Patrufini Duffy 2 July, 2021 8:04 pm

Currently, GovUK is trying to operate a world-accessible health system, available to 9 billion people on a “see a GP for free within six hours, or complain” warped basis. I can’t believe Pulse gave this advertising space. Procurement lobbying has gone well. Someone is creating misery, hypochondriasis and trivia, to create lucrative plaster “innovation” and “solutions”. As you know, solutions can dissolve a problem, not augment it. It is like some bombing a country, and then saying oh, we can help now. Let us in. EConsult and Arvind Madan always smell off. As does condoning health anxiety, and finger twiddling. Less access, does actually create opportunity for self-awareness, responsibility and time. The treatment of 80% of UK issues. I do not belittle nature, at the expense of doing something that never needed doing.

David Mummery 3 July, 2021 8:35 am

Murray what about the huge number of people who use it contact the GP surgeries in the very early stages in the natural history of a simple self- limiting illness? ( diarrhoea for 1 day, simple muscle strain etc); do you think that’s good medicine? GPs are being swamped by the mainly younger patients, many with very simple self-limiting illness, to the detriment of other patients with serious medical problems. AI can’t safely do self care, or any form of clinical decision : it nearly always tells patients to discuss with or see a doctor.

James Cuthbertson 3 July, 2021 2:04 pm

Lots of evidence of too much care causing problems, massive overmedicalisation and patient entitlement probably the biggest issue affecting healthcare. Every healthcare encounter has a potential to harm. The article does have some good points but endlessly increasing access to gp’s whilst specialists hide behind waiting lists is unhelpful.

Muhammad Akunjee 4 July, 2021 8:07 pm

eConsult will not be available between 18.30 on Friday and 08.00 on Monday.

Most of hurley group surgeries have econsult switched off still after 6.30pm and weekends

Reply moderated
Muhammed Akunjee 4 July, 2021 8:27 pm

Most of Hurley groups surgeries have econsult off after 630pm and weekends. Do as i say ; not as i do

Darren Tymens 5 July, 2021 12:29 pm

Jaime, it is good to have a range of opinions, but this is basically an advertorial for a single product. Was Pulse paid? (I suspect not, which is another reason why the largely content-free puff-piece is so remarkable)
I think it would have been sensible to preface the piece with the conflict of interest, and not leave it at the bottom. Additionally. Dr Ellender should really have made his COI clear in the article.
Lots of opinion pieces seem to get published about digital providers across the medical media – and they are usually authored by the same digital providers; but there are surprisingly few objective articles or attempts to analyse the actual data and impact on services. Either it isn’t being collected, or the results do not suit the providers’ preferred narrative and so do not get published.
What little objective information is available seem to indicate they deliver an increase in workload for no clinical gain, and there is hardly consumer clamour for it – so why are we doing it at all?.

Guy Wilkinson 6 July, 2021 9:49 am

Some very good points made by the commenters.

Fundamentally the demand problem is that the system is unconstrained by the usual forces, specifically lack of
– payment for service at point of use
– or copayment self insured model
This will inevitably lead to any new form of access being flooded, while not having the benefit of reducing conventional activity – phone/F2F etc

Monica Stevens 6 July, 2021 6:09 pm

Unfortunately we cannot service this extra demand, not without losing even more GPs as they throw in the towel due to burnout. We cannot afford to lose these GPs.

Dave Haddock 7 July, 2021 9:53 am

Free at the point of abuse. The solution is obvious.