Whisper it quietly, but the biggest change to the NHS since 1948 took place last week and consisted of one sentence. Speaking at a meeting of the Royal College of Physicians, Health Secretary Matt Hancock said ‘From now on, all consultations should be tele-consultations unless there’s a compelling clinical reason not to’.
He went on to say there had been a hugely positive response to virtual appointments during the pandemic and there needed to be a shift towards more ‘Zoom medicine’ although anyone who needed urgent care or who was unable to access their doctor by phone or video would still be seen in person.
So, almost at a stroke the monthly 26 million GP appointments in this country have now been digitally transformed. Gone are the days of waiting in a GPs crowded waiting room reading old magazines, to be replaced by the new sunlit uplands of digital medicine – and speaking as a GP who has spent the last 30 years trying to find the perfect appointment system for patients (spoiler alert; there isn’t one) – there are obvious advantages to digital technology-focused medicine. Greater time efficiency is perhaps the main one here, along with sweeping away the first-come, first-served appointment system that is often so frustrating for both doctors and patients alike.
People in remote locations, or with potential barriers to accessing health support (such as disability issues or mental health problems) can also benefit from accessing their health professional from their home. I have found in recent weeks that many older patients with long term conditions or complex medical problems putting them at high risk from Covid-19 remain keen to avoid walking into a surgery but still want regular advice and routine support with their health and have embraced tele-consultations as a means of doing this.
The UK is not alone in pushing tele-medicine during the pandemic with Ireland, France and Sweden all now offering free online and video consultations to patients and it feels quite liberating being able to deal easily with minor problems and requests, which would normally have filled much of the working day, over the phone or online.
And yet, before we all start to imagine that the future world of general practice will consist of both GP and patient staring at each other over a Zoom screen, it is glaringly obvious that this system is not suitable for everyone and – perhaps most importantly of all – there will never be a substitute for seeing a patient face to face and physically examining them when making a diagnosis.
Although remote consultations are likely to now make up the majority of a GPs working day, we are already seeing an increase in demand for traditional face to face appointments particularly in those with complex medical needs. Taking a straw poll of my peers, a figure often quoted by them as their ‘best guess’ as to how the system is likely to settle down over time is often 60 per cent remote consultations with the rest being face to face. This may end up being wholly inaccurate (and will vary because of geographical and social parameters too) but in my bones I suspect this is likely to be about right.
One unexpected silver lining linked to online consultations is that patients do not have to take time away from their work in order to see their GP. One of the criticisms often levelled at NHS appointment systems is that they suit the doctors work schedule rather than the patients so being able to Zoom your GP from your office desk if privacy allows (or from a smartphone if it does not) during work breaks or in work hours suits both the patient and employer far more than having to take extended time out of a working day – especially important for people who work many miles away from their local surgery and who would otherwise struggle to access medical advice near their place of work. This now makes for a far more consumer-friendly appointment system and in the post-pandemic world I suspect some GPs will also increasingly look at doing teleconsultations from home, often outside conventional working hours which will further benefit the patient.
As a breed, general practitioners are above all pragmatic and have quickly embraced this new way of working but are already pointing out reasons for caution. One of the first typically causes GPs the most anxiety on a daily basis, which is missing a critical diagnosis.
A phone call or video chat can easily hide the verbal cues, throwaway remarks or subtle physical signs that can suggest a serious problem and most GPs are likely to be cautious here and revert to a face to face consultation if at all concerned about making a mistake – and the subsequent litigation that may arise as a result. The technology required also needs to be suitable for purpose, and this has to be at both ends of the consultation. I have had problems where patients with low quality software have tried to send me images of skin lesions, and have ended up having to see them in person because the digital resolution was too poor to be safe.
For many patients, human contact with their doctor can be both therapeutic and reassuring in itself, and the personal relationship built up with their GP – sometimes over many decades – is at risk of being eroded by telemedicine. There is also little point in primary care adopting this model of working if hospitals do not adapt and integrate teleservices into their dealings with general practice, and if my experience of the NHS trying to practice seamless ‘ joined up’ technology between primary and secondary care is anything to go by then this is likely to be a huge stumbling block.
The one thing that will not change is workload. Access to phone or video consultations from wherever a patient may be physically situated is likely to increase demand over time as people get used to the new system, and it is a myth that remote consultations are quicker than face to face ones since safe, effective telemedicine needs to have high quality at its core and not speed. Complex cases can often be managed remotely but do need the appropriate amount of time in order to be worthwhile for the patient.
Primary care will never be the same again and we are all trying to work out exactly how the future is going to look in the coming years. The pandemic is not going away any time soon, local lockdowns will certainly continue to be increasingly rolled out, and the Prime Ministers hope that normal life will resume by the end of the year now has the feel of the 1914 belief that the Great War would all be over by Christmas. Politics will not defeat coronavirus but mass immunisation, strict social distancing policies and high quality test and trace systems will. Digital consultations between a patient and their doctor simply reflect the scale of how much our lives have irrevocably changed in recent months and why they are now required in the NHS to provide effective and safe health care to the country as a whole in this new global pandemic era.