Despite the rapid and seemingly makeshift take-up of remote consultation by GPs and patients during the covid-19 pandemic, preparations for this ‘off site’ revolution have been quietly underway for some time in the UK. 

In September 2019, six months before the first pandemic-inspired lockdown hit, NHS England (NHSE) laid out its aspirations for online consultations in primary care in a ‘digital first’ guidance document. 

Building on a survey earlier that year (by NHSE and NHS Improvement) that showed 67 per cent of a patient sample would be comfortable having this type of interaction with a GP, and looking to fulfil a commitment in its Long Term Plan, NHSE decreed that all practices were to offer online consultations by April this year and video consultations by early next year.

The health service was therefore already primed to roll out remote interactions between patients and their GPs or consultants ‘at scale’ – whether by phone, online or via video – when the lockdown began in March. And the take-up has been remarkable, despite concerns over a corresponding decline in face-to-face consultations.

Research from the Royal College of General Practitioners (RCGP), based on a limited survey of its members, showed that by mid-July, shortly after the peak of the pandemic, almost 70 per cent of GP consultations were conducted remotely and just 29 per cent face-to-face – a reversal of the proportions a year previously.

And more recently, NHS Digital statistics released at the end of November offered hard data to back up the RCGP survey results – revealing that around 60 per cent of appointments were conducted face-to-face in October, down from more than 80 per cent a year earlier, while those conducted over the phone and by video had nearly tripled (from 13 per cent to 36 per cent) over the same period. 

More than 75 per cent of GP respondents to the RCGP survey said that phone triage actually increased their efficiency, although RCGP chair Professor Martin Marshall added a note of caution, saying, “Telephone consulting does pose a challenge for GPs, not least the lack of visual cues that we often use to help us make a diagnosis – we can’t do physical exams over the phone, we can’t give vaccinations or take blood tests… [and] the biggest challenge is when patients have complex health needs, as being in the same room as a patient is incredibly useful and difficult to replicate remotely.” 

And regardless of the growth in take-up, lack of access – ONS data suggests 4 per cent of households still don’t have internet connections – and mental or physical disability are all factors arguing against the blithe assumption that remote consultations are the future for everyone. 

Echoing those concerns, one GP from Oxfordshire recently highlighted the lack of research (readers might want to check out this study) into the impact of remote consultations on health outcomes, as well as on staff wellbeing and retention. She told GP Online,  “I think we are already seeing stress levels rise in both patients and GPs with [the] current massively increased levels of remote consulting.” 

Other downsides of the wider adoption of online consultations were identified by GPs in the NHSE/NHSI survey, in which respondents said that workload and capacity issues were likely to be key concerns if – as was highly likely – patient access to local services was increased in this way without a corresponding rise in capacity at GP practices. 

Nevertheless, the widespread adoption of online consultations has been embraced enthusiastically by health secretary Matt Hancock, although that enthusiasm has been tempered somewhat in the face of a strong push-back from the medical profession.

His statements in favour of a 100 per cent take-up of appointments being delivered remotely caused an outcry among GPs. One doctor told GP Online, He has clearly not grasped the breadth of our practice”. And the RCGP’s chair felt sufficiently moved to say, “The RCGP does not want to see general practice become a totally, or even mostly, remote service post-pandemic.”

As a result, in evidence to the Commons health and social care committee last month, Hancock rowed back on his earlier statements and reassured committee members he was now content with the current level of 45 per cent.

The most positive noises being made about the future potential of remote consultation, perhaps inevitably, emanate from the commercial sector and those within the public sector involved in commissioning services.

Last week the online news site HSJ hosted a roundtable discussion on digital and AI tools, during which a representative from NHSX highlighted the benefits afforded by this technology for remote monitoring of patients: “We can position some really small pieces of technology in patients’ homes and monitor patients. We can pick up patients deteriorating in a much speedier way than the traditional model of a patient visiting healthcare every three months.”

Some respondents in the 2019 NHSE/NHSI survey made similar observations, suggesting ‘patient wearables’ provided an extra level of insight during remote consultations. 

And in June this year EMIS Health announced a tie-up with Arc Health which – through the use of ‘connected’ stethoscopes and ‘contactless’ thermometers, as well as pulse oximeters and blood-pressure monitors – it claimed would allow GPs to undertake virtual ward rounds in care homes, thereby reducing the transmission of covid-19. 

An increasing number of patients are already remotely accessing primary healthcare services offered by private providers like Axa and BUPA, but the recent growth in the ‘remote’ sector derives from smartphone app development.

Babylon Health’s GPatHand brand is perhaps one of the best-known products (largely down to health secretary Hancock’s ringing endorsement a couple of years ago, and since featured in the NHSE guidance document mentioned above), but there are others equally disruptive to the status quo.

Push Doctor and Livi, for example, are both partnering with the health service, offering NHS-linked online GP appointments and prescriptions, as well as spearheading a move into the commercial pharmacy sector. Push Doctor recently announced it was linking with Well Pharmacy to offer a ‘digital pharmacy first’ platform for NHS patients, while Livi has just joined with Boots to launch an in-store video GP service. 

In late 2020 we don’t know how far the Department of Health & Social Care is going to go in embedding commercial operators in the NHS’ remote access IT infrastructure, especially with self-confessed techie Hancock in charge, but given the presence of Serco, Deloitte and co elsewhere in the NHS the signs aren’t good. 

A brief look at Amazon’s move into the US healthcare sector offers some valuable insights as to how things might pan out this side of the Atlantic.

Why look at Amazon? Because last year Hancock proudly announced that a new ‘partnership’ between the NHS and this global behemoth – allowing its Alexa voice-assistant devices to offer health advice to users – would reduce pressure on “our hard-working GPs and pharmacists”, neglecting to mention the fine details of the deal.

Those details, revealed by the Sunday Times, included the right to access “all related copyrightable content and data and other materials”, allowing Amazon to create “new products, applications, cloud-based services and/or distributed software” which the NHS would not benefit from financially.

That’s just a taste of what might be on its way from Amazon’s Seattle base, where the company recently launched Amazon Care, a virtual health clinic that includes an “in-app video visit with a doctor, nurse practitioner or registered nurse… for advice, answers, diagnosis, treatment or referrals”. An online prescription service also came with the package. 

As CNBC noted at the time, Amazon has a record of experimenting with new products on its employees first, before launching them to a wider public. No surprise then that in November this year the company launched a prescription fulfilment brand, Amazon Pharmacy, as an add-on for a much wider audience: 120m Prime subscribers in the US.

Reporting on the news last week, Forbes magazine saw this latest launch as an indication that it wouldn’t be too long before a broader range of healthcare services – ie Amazon Care – could be available to Prime subscribers too.

How does this all relate to remote GP consultations in the UK? Well, if health secretary Hancock’s ambition of 100 per cent take-up is ever realised, responsibility for these GP-patient interactions could easily be taken away from local practices and transferred to more centralised NHS entities – clinical commissioning groups, integrated care systems or even sustainability and transformation partnerships – and then, in this era of emergency procurement policies, who knows where that responsibility might end up?

That’s something to think about the next time you access your Amazon Prime account for that must-buy or must-watch experience…

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