Dr Nick Harvey is a GP in Eastbourne and CEO of a GP Federation in East Sussex. He is on twitter: @DrNickHarvey
In our desperation to meet patient demand, we are cannibalising General Practice. We have desperately swum towards perceived lifelines thrown in our vague direction. They bring the danger of dependency – stopping general practice drowning but not pulling us out of troubled water. The numerous platforms providing video consultations are a case-in-point. There are many reasons why GPs do not use them often.1 They are billed as digital solutions, but they simply offer a locum GP, restricted to video. My experience over the last 3 years leading a GP federation has opened my eyes to the long-term perils of short-term solutions such as this.
Employment lifeline for a GP
They are billed as digital solutions, but they simply offer a locum GP, restricted to video.
From an online general practitioner’s point of view, this is an employment lifeline that does help them get out of the storm. Temporarily at least. At a time when all GPs are under pressure, who can blame them for opting for a fair wage which can be earned while consulting from home. Minimal administrative burden. No significantly complex care which would require a face-to-face appointment.
If a face-to-face appointment is required, it is handed on to a local healthcare professional who starts again. Conversion rates to face-to-face appointments are often monitored and there is a tendency to refer on instead – an x-ray, scan, blood tests or even visit to A&E instead of a good old GP examination. These decisions are also in the context of the GP not knowing the locality (Which I see time and time again). This is not a new observation.2 It is tempting to call this approach risk averse but, for patients, it brings plenty of risks and, for the system, it creates a fresh demand through our failures to deliver the right management first off.
The commercial entities seek high satisfaction scores to drive more business and investment. This potentially drives several behaviours, the first of which is to hive off the patients who will be more easily satisfied. Much more dangerously, there is a temptation not to challenge patient ideas and expectations – becoming patient-led rather than patient-centred. Good healthcare doesn’t always create high satisfaction3 but does require patient empowerment and does not always feel comfortable.
It is in the interests of the providers of these services to create a dependence. First, they generate a demand. Investment can mean they charge less to start with than other traditional organisations providing general medical services. By using a digital platform that requires registration, they can communicate directly with patients with information about various diagnoses, highlighting that they can book an appointment with a GP. Never mind that self-management or seeing a community pharmacist might be an equally safe but more appropriate allocation of resources. Direct booking bypasses the advice of an experienced receptionist, perhaps better identified as a care navigator.
The system has also developed a dependence. Those with their hands on the purse-strings have seen the huge uptake of these solutions. They have made the interpretation that they are fulfilling a need so more funding has followed. The need is capacity but not in that form. In fact, it is implicit in the capacity problem – taking front-line GPs, generating failure demand and new demand.
Inverting the Power Pyramid
This phrase refers to the move we are trying to make as a health system from ‘control over care’ to ‘facilitation of self-care’ – empowering patients. This is widely regarded as the way in which we can make healthcare sustainable.4 The only way we can do that is to invest in a personalised, localised, multi professional general practice and not through individual ‘cannibalised’ services that seem good at first.
Direct booking bypasses the advice of an experienced receptionist, perhaps better identified as a care navigator.
The other power pyramid which is experiencing flux is that on the side of providers, from how general practice is commissioned to how it is delivered. There is a lot of evidence in the business world that empowering front-line staff,5 and holding them and their organisations accountable, to achieve meaningful outcomes effective and efficient – more so than a commissioner wielding all of the power by holding an organisation responsible for delivering on key performance indicators (KPIs) that create perverse incentives. Performing video consultations is a good example of a KPI (‘to provide x number of video consults’) that is perceived as good until we understand that it is being offered in huge volumes yet doesn’t add value for most consultations, excludes the most vulnerable, is more expensive and less efficient. The dependence on the volume of work performed by these organisations also awards them power over commissioners.
The way in which the online general practice organisations described here are set up means that the power within them is less likely than in general practices to lie with those on the front-line. A key benefit of general practice is that the way in which it is usually commissioned is more likely to promote a sustained culture with a ‘Founder’s mentality’ – another principle shown to achieve better long-term outcomes.
1. Greenhalgh T, Ladds E, Hughes G, Moore L, Wherton J, Shaw SE, et al. Why do GPs rarely do video consultations? qualitative study in UK general practice. British Journal of General Practice [Internet]. 2022 May 1 [cited 2022 Dec 26];72(718):e351–60. Available from: https://bjgp.org/content/72/718/e351
2. Han SM, Greenfield G, Majeed A, Hayhoe B. Impact of Remote Consultations on Antibiotic Prescribing in Primary Health Care: Systematic Review. J Med Internet Res 2020;22(11):e23482 https://www.jmir.org/2020/11/e23482 [Internet]. 2020 Nov 9 [cited 2022 Dec 26];22(11):e23482. Available from: https://www.jmir.org/2020/11/e23482
3. Sitzia J. How valid and reliable are patient satisfaction data? An analysis of 195 studies. International Journal for Quality in Health Care [Internet]. 1999 Aug 1 [cited 2022 Dec 11];11(4):319–28. Available from: https://academic.oup.com/intqhc/article/11/4/319/1827935
4. Ferguson T. Consumer health informatics. Health Forum J [Internet]. 1995 [cited 2021 Jun 2];28–33. Available from: https://pubmed.ncbi.nlm.nih.gov/10154286/
5. Zook C, Allen J. The Founder’s Mentality: How to Overcome the Predictable Crises of Growth. Harvard Business School Press Books; 2016.
Featured photo by Tyler Franta on Unsplash
The key problem with video is that you are unable to examine the patient. That means that for a large proportion of consultations it is useless eg ear pains/abdo pains/lumps and bumps/pulse rate and rhythm/neuro examination etc etc etc