Electronic consultations offer few benefits for GP practices, says studyBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5141 (Published 07 November 2017) Cite this as: BMJ 2017;359:j5141
All rapid responses
eConsult has developed at pace and scale since researchers undertook this helpful evaluation, and we thank One Care and CLAHRC for their pioneering approach to online consultations. The study, which was taken over a 15 month period in an early pilot phase (April 2015 to June 2016), completed almost 18 months ago, and was made available to us a year ago. Since then, we have implemented many of its recommendations, specific examples including: allowing patients to consult with multiple symptoms for both new and existing conditions, enable photo uploads, ability to nominate a GP, simplifying language, improved system interoperability and additional long-term condition content.
The Hurley Group is an innovative NHS partnership led by practising GPs. eConsult was initially developed as an internal tool to give patients within our 15 practice partnership the option to seek advice from their own GP online. Word spread and in response to requests from local CCGs, it was licenced for wider use. Hurley Innovations, in which The Hurley Group holds a significant shareholding, was established as a trading vehicle. If and when surpluses are made, monies will be reinvested in our practices. We have turned down offers of venture capital. Our ambition is not limitless or global. We want to transform primary care from within, keeping patients connected within their own GP, improving access to, and reducing pressure on, the general practice team.
Innovative disruption is by nature at odds with empirical evidence. A new approach takes time, observation, feedback and constant recalibration to deliver ongoing improvement and data. But, even across the small 36 practice sample, evidence shows that nearly seven in 10 consultations were dealt without need for a face to face appointment, and there was no indication of the significant uplift in queries many GPs fear when a new access door opens. Data on return on investment is building, and importantly, patients really liked it, and our own patient evaluation in the past 18 months bears this out. 90% rate it as very good or good.
eConsult is now the digital triage tool of choice, live in more than 400 NHS practices in 40 CCGs across the country. In York, Unity has made eConsult a front door to their practices for all but a small number of patients with complex conditions, who were identified through collaborative work between Unity and the patient participation group. We have learnt the importance of a robust communications plan, and responding to real-time clinical and patient feedback so the tool continues to recalibrate.
Competing interests: Co-Founder of eConsult GP Partner Hurley Group
The headline may be read by some to suggest that no electronic consultations offer benefit to GPs. This was a study specifically of eConsult, and our evidence shows very different results in comparison, which might be expected as the detailed design and implementation of the system has large effects on usage and outcomes.
The reported study only looked at eConsult and usage rates were very low (about 18 consultation a month per practice). This is a poor basis for judging the possible effectiveness of such systems. There are several alternative systems with very different philosophies and it is wrong to assume they don't or can't work.
A proper judgement of the effectiveness of online consultation needs to consider the alternative philosophies of the different systems. eConsult uses a structured questionnaire to elicit the patient history and provides rapid contact with their GP. Babylon's online system GP at Hand uses AI to evaluate the patient's symptoms and puts the patient in touch with a live GP via video. askmyGP and PushDoctor focus on putting the patient in touch with a GP as fast as possible. askmyGP and eConsult work with existing GP practices and cost the patient nothing. GP at Hand and PushDoctor use their own slate of GPs. PushDoctor charges the patient per consultation; GP at Hand requires patients to switch their registration to their GPs and has some restrictions based on condition and pre-existing issues.
Most systems, including the original version of askmyGP, use machine learning or long structured questionnaires to elicit detail about the patient's symptoms and problems. This leads to a preliminary diagnosis available to the GP during a consultation or can also be used to offer advice directly to the patient. The new version of askmyGP uses a much shorter sequence of simple questions allowing the patient to describe their problem in their own words and focusses on getting that information to a GP as fast as possible so the GP can make a clinical judgement.
We changed approach at askmyGP because the algorithms for diagnosis have poor performance and patients often don't like the long sequences of questions they have to answer. And we realised that improving the process of getting in touch with the GP was far more important than trying to use technology to replace the GPs' clinical judgement. GPs make much better clinical judgements than any system we have seen. The simpler questionnaire has proved more popular with patients and achieves much higher levels of use. Despite the system only having been launched in the middle of the year in about a dozen practices, usage is already >1,000 online consults per week.
In our experience what really matters for online consultations is improving the speed of patient access and the ability of GPs to respond to demand quickly. The system works when it lowers the overall GP workload and improves patient access. It can achieve this when the GP can make an intelligent judgement about whether to see the patient face to face instead of seeing every patient. Often only 30-40% of patients need a 10 minute face to face appointment which can lead to major savings in GP time; many of the remaining cases are resolved by a short secure message from the practice to the patient or in a short phone call.. Most patients get a response from the GP on the same day, the majority in less than 2hr. This is far better than the performance of standard appointment booking systems which often make patients wait days or weeks for a face to face slot and typically reject about 10-15% of requests because no slot is available ("please call back another day" is the equivalent of "sorry we can't help you"). This makes the reported criticism that online systems allow patients to queue-jump the existing booking system look a little odd since the whole point of an online system is to do better than the existing process.
Online systems like askmyGP won't work for every patient. But they can work for a large proportion (so far we have seen as much as one third of all demand going online and, contrary to many expectations, it isn't just the young and fit who use it). Since the system focusses on improving the speed of access for patients and helping the practice be more efficient, the benefits accrue to the patients who don't use it as well as those who do.
It is early days for online GP access. The goals of faster access and more efficient GPs can be met if the developers of the systems learn from experience (as askmyGP has done) and adapt their systems accordingly. It is wrong and misleading to write off the whole idea as a failure on the basis of a small study of a single system.
Competing interests: One of my roles is chief analyst for GP Access who provide an online consultation tool, askmyGP, to GP practices.