Digital-first primary care: helpful disruptor or unnecessary disruption?

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Digital-first primary care – a model of general practice where patients use smartphone and desktop apps to book and conduct their consultations remotely – has generated a huge amount of interest and debate. Is it the Uber of general practice that will make it easier for people to get hold of a GP? Or is it going to cause the demise of general practice as we know it by creating a two-tier system? 

The first of these models in the NHS, GP at Hand, has proved very popular, so far registering around 60,000 patients across London and planning expansion to Birmingham and Manchester. Using the existing primary care payment and contracting system, it offers 24-hour access to a GP partly by using GPs’ time flexibly (providing them with the tools to consult patients from home or from a location convenient to them).

'Digital-first primary care... is it the Uber of general practice that will make it easier for people to get hold of a GP? Or is it going to cause the demise of general practice as we know it by creating a two-tier system?'

The NHS was caught out by this rapid innovation, and the way in which GP at Hand has registered large numbers of patients from outside their local community has created several issues. It puts pressure on local commissioning budgets, as current rules mean that the clinical commissioning group (CCG) where the patient is registered, rather than where they live, is responsible for paying for their care. It also adds complexity to screening processes and referral pathways and, most importantly, changes the ‘place-based’ nature of general practice, which works with patients as part of a local community.

NHS England and NHS Improvement recently published a response to a consultation that aimed to address some of these issues. Its proposals include introducing a rule that when digital-first providers register more than 1,000 out-of-area patients in another CCG, they will be required to set up a new practice in that CCG, connecting those patients back to their local community. It also proposes requiring digital-first providers to set up in deprived areas, to bring in additional GP capacity and to have patient lists that represent the community. 

But for me the answer lies in the wider vision of general practice as a community-based service providing person-centred, holistic care to patients. In our 2018 report, we identified five core components of general practice (see figure). 

Core attributes of general practice: accessible care, continuity, person-centred holistic care, co-ordination, community focus

The digital-first approaches we’ve seen to date prioritise access at the expense of the other components. That might work for some patients, some of the time (an evaluation of GP at Hand found that the model seemed to attract younger patients who prioritised convenience). But it isn’t clear that the model works for other patients – for example, those who need regular physical access to a GP; who are waiting for a diagnosis, for whom continuity of GP/clinician might be really important; who need a GP who knows them, their community and the local services available to them; who need a multidisciplinary practice team who know and trust each other; or who are digitally excluded.  

Digital technology can help to deliver all the components of primary care – there are many examples of its effective use in traditional general practice, for example, using Skype to consult with patients and with staff in care homes, allowing patients to email queries to their GP or even to use that cutting-edge technology the telephone. But I think digitally enabled approaches to improving access must be woven into a holistic model of general practice, rather than segmenting out different offers that erode the community-based component of general practice. There is a danger that by focusing on digital-first models we end up with investment and innovation in only this component of general practice while other areas are neglected. 

So I’d prefer to see much more investment in effective technology to support all GP practices to deliver the best possible care to the patients in their community. Traditional primary care has been slow to adopt digital access channels for a variety of reasons, including a lack of support for implementation, workforce capacity and the outdated ways in which GP IT systems are commissioned. The new GP IT Futures Framework, which is changing the way IT systems are commissioned, will need to support practices to have the technology at their fingertips to offer digital consultations, integrated with their clinical systems.

'I’d prefer to see much more investment in effective technology to support all GP practices to deliver the best possible care to the patients in their community.'

NHS England and NHS Improvement say in its consultation response that helping practices to digitise is its priority and that ‘health systems will receive funding to provide the implementation support, training and backfill required for PCNs [primary care networks] and practices to redesign how they deliver services to make best use of the technology provided’. This is fundamental. Without it, neither patients nor professionals will be able to take advantage of the benefits that technology can offer. 

So in answer to the question I posed – if the response to the emergence of the GP at Hand model really is investment in technology within traditional general practice then I’d argue that it has indeed been a helpful disruptor.

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