Scoping out the Issues in the Rapid Scaling Up of Remote Triage and Consulting in the Covid-19 Pandemic – November 25th 2020
Public Health England’s ‘Open for Business’ campaign has been an attempt to reassure the public that they should still access primary care services if they have concerns about their health. However, as practices attempt to reduce the footfall into surgeries the route of access, or mode of triage, for many practices has changed almost overnight. Minal Bakhai, Deputy Director and Clinical Lead for Digital First Primary Care at NHS England recently informed us that pre-pandemic only 30% of primary care practices offered online consultations. Online consultations are now available in 90% of practices. It is not clear how many of the new online approaches result in satisfactory online responses or turn into other remote consultations (telephone/video) or require face to face surgery consultation.
We were interested in hearing the barriers and challenges to digital access for different patient groups to primary care as well as the workaround solutions to problems, and what could be done to optimise remote triage and consulting. To explore these issues further, the Remote-by Default (RbD) research team hosted the first of a series of workshops on September 9, 2020 exploring the effects of digital system changes on different patient groups. We were joined by: GP practitioners, primary care support staff, practice managers, patients, social care agencies and regional and national stakeholders.
Is Primary Care Business Open for All?
The workshop highlighted a concern that communications from local GP practices to patients were not always clear on care pathways and how to access an appointment. There was a particular concern that marginalised patient groups may not be able to access digital notifications and information is not always delivered in accessible formats. Marginalised* groups may welcome the opportunity to use digital tools to connect remotely with their GP practice, particularly if they are shielding. It is unknown whether there is appetite for the provision of devices or interventions to help upskill digital literacy to use web-based services. There was general agreement that there needed to be a more detailed exploration into the acceptability of digital care amongst marginalised groups and thinking about the solutions to ensure their inclusion.
The Scope of Primary Care Business
Primary care may be open for business but the business scope is perhaps less clear and varies across practices. Some attendees felt that remote consulting opened opportunities for primary care staff to develop specialisms. Digital platforms such as e-consult may enable GPs to work in interdisciplinary ways and draw on expertise within the team. The ‘asynchronous’ communication created through online or telephone triage can potentially offer a reflective space for practitioners preparing for the next appointment.
There was lively discussion about a disconnect between meeting the needs of diverse population groups and the work primary care practices are contracted to deliver. The resilience of NHS practices to withstand crises within the system relied on efficiencies to manage patient expectations about when face-to-face contact with the GP is necessary and appropriate. Digital platforms have been used by some practices to redirect patients to other allied health professionals (nurses, pharmacists, social prescribers etc) to create efficiencies and protect GP time. Such practices, lack of joined up technology and contractual constraints may make coherent ongoing multiprofessional digitally enhanced care for those needing it unlikely in the short term even if it is at odds with professional commitments of GPs and other professionals.
Furthermore, there is a risk that redirection to allied health professionals could be internalised as a rejection and effect the relational trust between the patient and their GP; which is an important factor in early diagnosis of acute care conditions. Relational disconnect between GPs and patients was also indicated in comments about how remote working might lead to compassion fatigue in clinicians and their capacity to respond well to patients. There was a particular anxiety that patients with as yet undetected cancer may feel unable to contact their GPs to raise concerns about symptoms, potentially causing critical delays to cancer diagnosis. The initial ‘protect the NHS’ rhetoric that aimed to caution the public about the burgeoning effects of contagion on the NHS system appears to have led to an unintended consequence where patients may not see themselves as legitimate candidates for GP attention and fail to seek help.
The opportunities and consequences of changes to primary care procedures and the rapid scaling up remote consulting in the Covid 19 pandemic is still unknown. Our aim is to explore how digital care is being experienced by the patient and the GP, so it can be optimised to enable equity of access for all patient cohorts. For each step in care, initial access through to joined up encounters across teams, we will identify both the barriers for different groups and the solutions coming from practice. Workshops are identifying areas that need exploring and the four case study sites provide practice based evidence from which to build practical theory for optimising the system.
*Marginalisation is an umbrella term to describe populations that are outside mainstream society and experience health inequities (see Cheraghi-Soh et al. 2020).