The need to protect the population from infection during the pandemic accelerated the uptake of new digital systems in nearly every practice in England throughout 2020–2021. These systems give patients the choice to use an online form on the practice’s website to seek help, instead of having to phone for an appointment or visit in person. The forms gather structured information from patients, which in turn helps practices to triage requests and provide the right care. Some systems also support experienced practice staff to capture important information systematically when patients phone or attend in person. Many practices, including my own, had started to use these systems, alongside our non-digital pathways, prior to COVID-19. However, the pandemic significantly increased usage – with over 2.5 million online requests now being sent by patients to practices every month.
Many general practices have been using a hybrid approach, combining digital and non-digital pathways, to support development of more responsive, equitable and personalised models of care. Having more information up front makes triage easier so that people with the greatest clinical need can be prioritised. In my practice, based in a very deprived area, we’ve certainly found it has helped to pick up urgent and serious requests more quickly, and to ensure consistency. Regardless of whether patients contact us by phone, online or in person, it’s easier to direct people to the most appropriate health care professional and type of appointment – offering flexibility and opportunities for improving continuity of care and efficiency.
At NHS England and NHS Improvement, we have been working with the Improvement Analytics Unit (IAU) to understand how these tools are used and what they mean for general practice and patients.
This study, carried out independently by the IAU, highlighted the complex interplay of multiple determinants of ‘good access’, including factors such as service responsiveness, flexibility and choice (for example, between digital and non-digital access routes and consultation types), the type and complexity of the problem, continuity and communication, and the wider social context. Importantly, to better meet people’s needs, we must take a holistic view of how general practice services are delivered, rather than focusing on any single aspect or target.
Interestingly, and in line with previous findings, the IAU study found almost 40% of all requests (regardless of the access route) were from the top 10% of attenders and, of these, more than 45% were from people asking about existing medical problems. Being able to visualise a more complete picture of demand offers opportunities to improve our understanding of users, identify health needs that require collaboration (and at what scale), and explore how services can both proactively meet their needs and best help them when they make contact. Research shows high frequency users of general practice include people struggling to cope due to challenging life circumstances (such as poverty and limited social interaction). For many of them, holistic community-led support may be a more helpful first point of call, rather than pharmacological or traditional ‘medical’ approaches. There are great examples of innovative service co-development between primary care and community organisations that have demonstrated how they help to address some of the causal issues.
Making change while ‘doing the day job’ is of course challenging. However, the pandemic response shows that change can be achieved – provided there is the right level of support, when there is shared purpose, and when local organisations have agency to drive innovation and quality improvement. To make the most of opportunities to improve services, we need to coordinate and invest in resources such as analytics, quality improvement, organisational development, service design, communication and project management. This will help ensure that practices and primary care networks (working with their patients and communities) are provided with data and tailored support to design the right model of care to address need and make successful change. The 2021 General Practice Patient Survey highlights the importance of helpful reception staff and effective communication in shaping good patient experience. In my practice, care navigation and communication training for staff have been key to doing this. However, we cannot innovate without any slack, and it is important we ensure primary care is provided with the time and capacity needed to adapt, and with space for peer-to-peer learning.
While the IAU study examined practices using an online system from only one provider, there are a wide range of digital systems in use in general practice, with different functionality, usability, integration and implementation. It is therefore not surprising that different systems have variable impacts in different practice and patient contexts. Going forward, we must foster a learning approach while continuously improving products and service design to meet the needs of patients, carers and staff. Their experience must be central to decision making.
Alongside further work with the IAU, at NHS England and NHS Improvement we continue to explore the usability of different website and online systems in real world situations, and to research the experiences of different groups of patients, carers and staff. We are committed to understanding the needs of patients with lower levels of ‘digital confidence’ and to taking an evidence-based approach that ensures groups of patients are not left behind as new technologies become more widely adopted.
Providing high quality care in the context of workforce shortages, increasingly complex health needs and significant inequalities is challenging. At my practice, we’ve used these challenges to motivate us to change how we work and try to improve our offer to our local population. Though making improvement is far from easy, the IAU study further supports our experience that there are worthwhile changes to be made in general practice that benefit both patients and staff.
To find out more, please read the full IAU report. NHS staff can also join our Digital Primary Care FutureNHS collaboration workspace for resources and support for practices, details of other research projects and to get involved!
Dr Minal Bakhai (@MinalBakhai) is a GP in North London and Director of Primary Care Transformation for NHS England and NHS Improvement.