Online consulting in general practice: making the move from disruptive innovation to mainstream serviceBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1195 (Published 26 March 2018) Cite this as: BMJ 2018;360:k1195
- Martin Marshall, professor of healthcare improvement and vice chair12,
- Robina Shah, chair, patients and carers partnership group2,
- Helen Stokes-Lampard, chair2
- 1Department of Primary Care and Population Health, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London NW3 2PF
- 2Royal College of General Practitioners, London, UK
- Correspondence to: M Marshall
People are familiar with using digital technologies to make their lives easier. The health sector has been slower to adopt technological innovations than the banking, retail, and travel industries, but it is catching up. In 2017 the global digital health industry was worth £19bn (€21bn; $25bn) and over 320 000 mobile health apps were in regular use.1
Online consulting is one of the fastest growing technologies. In the US it has been commonplace for over a decade, and many health insurers, emboldened by some supportive research evidence,2 offer such services routinely to reduce costs. Similar services are now being established in the UK, driven by rapid developments in the supporting technologies, consumer demand for convenient and accessible services, and the need to find solutions to rising workload and constrained resources.3
We examine how online consulting is developing in UK general practice and its emerging benefits and risks. We focus on text and video based online technologies, which are being used as alternatives to face-to-face consultations. In addition, we explore a number of complex questions that the emergence of online consultations is raising for policy makers, practitioners, and patients.
A rapidly expanding market
The online consultation market in UK general practice is expanding at pace: eConsult, Babylon, askmyGP, Dr Matt Ltd, Push Dr, Doctor Care Anywhere, GP at Hand, Anytime Dr, Dr-Plus, and many others have been established in recent years. Most of the online systems have been developed by private entrepreneurs and some have substantial backing from private investors.4
No independent national data exist on the relative uptake of these different systems by individual patients or by service providers. Such data would be rapidly outdated as new providers regularly emerge, change, and disappear. In December 2017, 34 online digital providers had been inspected by the health regulator, the Care Quality Commission (CQC), to provide services in England.5
Broadly, three categories of online services are emerging. Firstly, systems such as eConsult or askmyGP are integrated into the electronic medical record systems of established general practices, and the online service is provided by the practice staff as part of a comprehensive NHS funded service (box 1). Secondly, systems such as GP at Hand offer online services delivered by clinicians operating separately from established general practice teams, though they might be working in a business partnership with established practices. The services are funded by the NHS but may only be available to specified low risk patient groups or may be limited to specific activities, such as prescriptions or fitness to work certificates. Some of these online providers offer follow-up face-to-face consultations when required. Thirdly, private services are available on a payment scheme, on a pay per consultation basis, or as an employment benefit.
Examples of online services
eConsult is a digital platform developed by a group of GPs in London and launched in 2014. It delivers a range of online services including symptom checking and self help information for patients, signposting to services outside the practice, and text based consultations. Patients are invited to complete a “responsive” online form that seeks information tailored to the patient’s demographic and presenting problem. The technology bolts onto the practice’s existing website and is linked to the patient’s medical record, and the consultation service is provided by existing practice staff. Information provided by the eConsult team indicates that online consultations last for an average of 3 minutes, and 70% of presenting problems can be managed remotely. eConsult is currently used in 388 practices across the UK and is available to 3.5 million people.
askmyGP is a GP led online service launched in March 2015 and developed by a team led by Harry Longman, an engineer with a background in systems thinking. The main focus is to enable triage of patient contacts and management of flow, carried out by the patient’s own GP. Data provided by askmyGP show that about two thirds of requests can be managed remotely, and one third face to face. The technology is currently used by 15 practices covering over 100 000 patients; about 2000 online requests are received a week. Online consultations are only one component of the programme offered by askmyGP.
GP at Hand
GP at Hand is an online service launched in November 2017 and delivered by the technology company Babylon in partnership with an NHS general practice in west London. It is now expanding to additional locations in other parts of London. The practice uses flexibilities in the GP contract to register patients living outside their usual geographical area. The service proved very popular, with the registered practice population increasing from 4970 at the beginning of November 2017 to 16 117 just two months later. 90% of the new registrants were aged between 20 and 44. Although GP at Hand says it offers all core NHS services, it says that online services are “less appropriate” for people who are frail, elderly, pregnant, or have serious long term illnesses or major mental health problems, leading to claims that they are selectively choosing to register healthy people. The service is designed for use with smartphones, though face-to-face appointments are also available in a limited number of centres across London. Consultations can be replayed after they have taken place. Symptom checker services are available, and Babylon claims that its technologies are making increasing use of artificial intelligence. An independent evaluation is currently being commissioned by NHS London.
A growing number of online services are developing advanced technologies such as artificial intelligence (AI) and machine learning to support or replace decisions made by clinicians. Although AI has the potential to make faster and perhaps better decisions than the human mind because it can rapidly process vast amounts of complex data, little evidence shows that it is currently able to do so, and some commentators are sceptical that its benefits are being exaggerated.6
Disrupting the established system
Digital online consulting and associated technologies are “disruptive innovations” with the potential to disturb and perhaps displace current ways of working. Established power brokers in the system are either promoting or responding to the disruption in different ways.
The UK government is promoting the use of new technologies as a central plank of its industrial strategy.7 Policy makers see online consulting as a way of reducing GP workload and providing more accessible care at lower cost. For this reason, they have provided financial support to increase uptake of online systems by established general practices.89 At the same time some GPs are suspicious that policy makers are quietly encouraging private providers to shake up the established system.
Industry and private investors are making considerable investments in both the technologies and the promotion of online services. They will expect a healthy return in the medium term from the UK and other developed countries and in the longer term from the growing middle classes in emerging economies.
Regulators—primarily the CQC, the General Pharmaceutical Council, and the General Medical Council—are playing catch up as online providers test legal and ethical boundaries. In its first round of regulation of online providers in 2016-17 the CQC found that only four of 28 providers were fully compliant with regulations, and 15 required enforcement action owing to a failure to meet fundamental standards.5 Problems were found with confirming patient identity before prescribing drugs, unreasonable assumptions about mental capacity, failure to seek informed consent, poor safeguarding procedures, and inadequate communication with patients’ registered GPs.
The British Medical Association and the Royal College of General Practitioners state that they are supportive of new technologies in principle but also express concern about the negative effects of emerging online services on patient safety, equity, and on the sustainability of the current model of general practice provision. Some question the legality and morality of emerging practices; one commentator criticised “a cynical exploitation” of existing regulations relating to advertising and patient selection.10
What are the benefits and risks?
Advocates and sceptics of online consulting are inclined to express highly polarised views about the benefits and risks for patients, carers, health professionals, and the health system (table 1).
The emerging models of online consulting are lacking rigorous, independent research evidence about their cost effectiveness or adverse consequences from a UK general practice setting. Technology is highly culturally dependent so the relevance of international evidence is questionable. Some commentators ask whether conventional approaches to evaluation, particularly ones focused on linking rapidly changing interventions to health outcomes, are incompatible with or, by stifling innovation, possibly detrimental to a fast moving innovation culture.1112
Notwithstanding these criticisms, the rapid growth of online consulting and its potential risks for patients and negative effects on established services indicate the need for a systematic approach to evaluation—not least because in the absence of rigorous research, anecdote and partial marketing data are being passed off as evidence by those with commercial interests.
Research carried out in UK general practice settings show that:
Patients make use of online consulting services, but the uptake is currently low (two online consultations per 1000 patients per month in one study),13 particularly at weekends.131415 Most online consultations are conducted during normal general practice opening hours.13
Online resources are most commonly used for administrative purposes (repeat prescriptions, test results, fitness-to-work notes). Musculoskeletal conditions and infections are the most common clinical reason for consulting.13
Online consultations are more effective for discrete and straightforward problems and less effective for complex issues.13
32% of online consultations result in a telephone consultation and 38% in a face-to-face consultation.13
General practices are motivated to establish online services because they want to be seen to be progressive and because they think it may be a way of managing demand.14 (Atherton H, personal communication, 2018)
Some additional insights can be gained from research carried out in related fields. Evidence shows that the pace of uptake and the effect of new technologies in the health sector, such as NHS walk-in centres, was often overstated in the early days; their unintended consequences were poorly understood, and they were more likely to generate demand than to reduce it.16 Telehealth technologies in general have less impact and higher costs than established care.17 Some evidence indicates that new technologies are more effective when they are integrated with established services, rather than set up in parallel to them.18
The current evidence base does not provide a glowing endorsement, but the continued growth of online consulting is inevitable, whatever its merits and risks. Despite the hyperbole—one advertisement claimed “you will never go to the doctors again”—the roll-out of online consulting is likely to be less disruptive than some people hope and others fear. Online providers are developing partnerships with general practices, finding common ground with the regulators, and considering offering their services for underserved populations such as the homeless. In a few years’ time online services may be fully embedded in established general practices.
This is more likely to happen quickly and effectively if current initiatives are rigorously evaluated—in particular examining the effects on demand, workload, and equity—and the evidence heeded. It is also more likely if health service staff are properly equipped and trained to use the technologies safely and to their full potential, if funding mechanisms are reformed to incentivise online services integrated with conventional ones, and if regulators have more powers to tackle unacceptable performance, particularly when services are provided from geographical locations outside their jurisdiction.
The rapid growth of online consulting is revealing some new ethical and philosophical questions. Firstly, general practice is designed to provide comprehensive services for all patients in a geographical locality, a model that even when implemented imperfectly has been shown to deliver good outcomes at low cost.19 By contrast, private online providers detached from conventional general practices explicitly segment the population, providing services primarily for the healthy working population and excluding people with long term conditions, multimorbidity, and mental health problems. Proponents argue that doing so frees up resources for the NHS to focus on those with greatest need and improves access for some populations who are historically poorly served, such as adolescents. Opponents claim that it generates new demand and unrealistic expectations and disadvantages groups who are unable to use online services. The effect of the new technologies on different population groups needs to be carefully evaluated.
Secondly, online provision of care adopts a different stance from face-to-face care in terms of the balance between the sometimes competing domains of quality. When a patient is prescribed antibiotics for a sore throat by an online GP, without having access to the patient’s records or examining the patient, the doctor may be favouring patient access and experience over safety and cost effectiveness. This may be what patients want, but whether they are making an informed decision is unclear.
Thirdly, encouraging, albeit implicitly, patients to pay for some online GP services touches on the debate about how best to fund the NHS and raises concerns that such services may act as a vehicle for privatisation of the NHS by stealth. The business model underpinning some of the private online providers is essentially one of co-payment, a model that challenges one of the founding principles of the NHS—that care should be free at the point of delivery.20
Finally, the provision of online services challenges established thinking about risk. In conventional face-to-face consultations the clinician holds most of the information necessary to manage clinical risk—the patient record, data derived from a full assessment of a condition, and clinical expertise. The clinician is therefore held in law to be responsible if something were to go wrong. Online consultations may be operating in a different arena. Patients have chosen, knowingly or otherwise, to seek help from a clinician who has less information at their fingertips. Online consultations may therefore be more risky for both parties, but clarification is required about who bears this risk.
Online consulting in general practice presents real benefits for patients and opportunities for clinicians and for the health service. But it comes with potential risks for all parties. These risks could be minimised by ensuring that rigorous evaluation takes place and that people using online services are fully informed, and by developing online services as an integrated part of established general practice and not in competition with it.
Opportunities to access primary care online are developing at pace and offer considerable advantages for some patients over traditional models of service provision
Online services may also be unsafe for patients, exacerbate inequalities, and risk destabilising established services
The benefits are more likely to be realised, and the risks minimised, if online services are integrated into the established model of general practice, rather than set up in competition
We thank Helen Gracie, RCGP policy officer, for her support in drafting the paper
Contributors and sources: This paper is based on extensive discussions between the authors and wider members of the Royal College of General Practitioners on how general practice might respond to the emergence of new online providers of general practice services in the UK. MM had the original idea for the paper and all authors contributed to planning the content, with RS leading on the patient and carer viewpoint, HSL the professional perspective, and MM the academic and policy perspective. MM wrote the first draft and all authors contributed to subsequent drafts. MM is the guarantor.
Conflicts of interest We have read and understood BMJ policy on declaration of interests. All three authors have senior leadership roles within the Royal College of General Practitioners. MM uses eConsult in his own practice but neither he nor HSL or RS have any commercial interest in it or any other online system.
Provenance and peer review: Not commissioned; externally peer reviewed.