GPs have been Luddites for too long and must embrace new technologyBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2206 (Published 22 May 2018) Cite this as: BMJ 2018;361:k2206
All rapid responses
Last week eCONsult chief Murray Ellender revealed some actual numbers concerning patient usage of eCONsult.
The figures were given to Pulse online http://www.pulsetoday.co.uk/news/gp-topics/it/leading-superpractice-plan...
Ellender claimed 1,158 eCONsults had been received from Hurley Group’s 100,000 patients in May.
This enables us to calculate the % of total demand via eCONsult, starting from the average demand for help from a GP as a proportion of registered patients, per week. From our work over 7 years we know this to be 6.5% (for GP, not including admin or other clinician bookings). For the younger London population it may be a little less at say 6%. May had 22 working days which is 4 weeks and 2 days in 5 day weeks.
The total demand for GP from Hurley Group patients in May would therefore be 100,000 x 6% x 22/5 = 26,400.
As a proportion, eCONsults received were 1,158 / 26,400 = 4.4%
On Hurley's own patch, with their own younger urban patients, where they have executive power on how to manage themselves, where patients have had the service for five years since its launch in 2013, 96% of patients were unwilling or unable to seek help via eCONsult. Further, Ellender claims requests have doubled over the year, meaning that only a year ago while Ellender and his colleagues Clare Gerada and Arvind Madan were proclaiming the transformative effects of their software, 98% of their own patients didn’t use it.
The point of the Pulse story is that they are attempting to increase usage, and recruit GPs to deal with them, “eliminating unnecessary face to faces”. One way to do this has been well known for many years through our own and others' work on telephone consulting (as Aneez Esmail explains in his rapid response above), even without software. The improvement in patient service and efficiency has been well documented, maintaining continuity within the GP practice. What is very concerning about their intended model is made clear in their blog: What’s not to love about the eHub?
They want to put 100% of their eCONsults through this, a factory mentality where requests from all 14 practices are managed centrally. If they decide a face to face is necessary, it will be sent back to one of the sites, losing continuity even within the episode. Relational continuity is one of the best evidenced aspects of quality in general practice, often trumpeted by Clare Gerada. She is still doing so as she calls GPs Luddites in the BMJ here.
To date, five separate independent academic studies have been been published on eCONsult, collected here.
All of them say in different words the same things:
- usage is tiny
- it doesn’t work well
- benefits of efficiency, time and cost saving, have not been achieved.
We have now learnt that the same findings apply to Hurley itself, in its own back yard.
PS By contrast, Balaam St Surgery has 5,600 patients in Plaistow, close to Hurley practices and a similar demographic. The GP responds to most requests within minutes, can always see the patients the same day, and receptionists pick up the phone straight away too, because not many patients call nowadays. They launched askmyGP in April. In May they received 1,121 online requests, by the same calculation as above 76% of total demand.
Competing interests: Chief Executive of GP Access Ltd, which supplies askmyGP, a competitor product to eCONsult in which Dr Gerada has a shareholding.
Whilst Clare Gerada is right to accuse GPs of being Luddites and being slow to embrace new technology, she fails to mention one specific technology which has been around since at least 1876. The telephone is poorly utilised in General Practice and in her clarion call to embrace e-consulting she falls into the trap of encouraging a new technology when an existing one (the telephone) could be just a s good. Its also important to realise that the introduction of any new technology without adapting and changing the broader system is probably doomed to failure and probably explains the Luddite behaviour that she alludes to in her article.
In our large inner city practice we faced multiple problems with access and in 2009 our practice nearly collapsed under the strain of not being able to meet patient demand.Numerous tweaks had been made to the appointments system over the years, but all had only a short-term benefit. Faced with unrelenting demand we began a comprehensive review of our approach to meet patient needs, using a demand led approach.
This involved measuring contacts at reception and consultations with clinicians, and involving the whole practice team in discussing the data and finding solutions.
It was a different approach, to first understand demand, then adapt services to meet it (rather than expecting patients to fit themselves around what was being offered - and getting frustrated when it was a bad experience for both us and them).
Measuring demand revealed several issues:
• demand varied considerably during the week, but had predictable patterns, with a big peak on Mondays and in certain months of the year, yet appointments were spread evenly during the week and there was no effort to schedule routine work during quieter months
• GPs were being used as the first port of call for the vast majority of first contacts by patients, in spite of the fact that many could have been handled by someone else
• about 50-60% of contacts were for a same day appointment, yet most appointments were pre-bookable. Surgeries were generally booked over two weeks ahead, there was a high DNA rate and the nominated emergency GP was single-handedly handling 70 or more overspill contacts per session. Continuity was poor and patients were often frustrated at having been forced to define their need as urgent just to get an appointment. This further added to the emergency GP feeling overwhelmed and unable to do a good job.
Over time, a number of major changes were made:
• a phone first system was introduced for unplanned GP care – this was not triage, but a full consultation on the phone wherever possible
•capacity was more carefully matched to patterns of demand through the week and year. This involved adjusting GPs working week to provide more appointments on Mondays, moving some routine follow-ups to quieter months and using locums to add acute care capacity for the busiest weeks of the year. This avoided queues building up, and reduced the need for patients to book ahead just in case.
• receptionists were trained to ascertain the patients need and, where appropriate, direct them to someone else in the team other than a GP who could help, as well as to reinforce the importance of continuity for people with complex needs
• the use of advanced nurse practitioners was expanded, the senior practice nurse was trained in diagnosing and prescribing for minor ailments
• healthcare assistants were introduced, to allow practice nurses to take more responsibility for uncomplicated chronic disease management, freeing GPs to deal with more complex issues
• a number of processes were redesigned, to direct patients and paperwork to the usual GP more of the time, and to anticipate needs where possible
Putting in these changes increased our appointment capacity by nearly 40% and we were able to grow our list size by 14%.
Patient and staff satisfaction improved with patient satisfaction with access rated consistently over 90% (good or very good).
Sickness absence amongst staff has reduced
When we first introduced the system, A&E attendance by practice patients reduced by 53% from 2008 to 2014 though has crept up again (but not to the levels in the period before we made the change)
Emergency admissions for our practice reduced by 22% from 2008-2014 and the use of out-of-hours is about 24% lower than the local average.
The key lessons that we learnt were that introducing a simple change actually needed a much wider system change (lesson to all those who want to stop being Luddites).
And sometimes the technology already sitting on top of the desk can make a much greater difference than the promise of a new and expensive e-consulting technology.
Competing interests: No competing interests
Gerada's call for GPs to embrace new technology is timely and persuasive. With the never-ending organisational changes in the NHS, it is understandable that GPs are suspicious of changes, and clearly the changes she proposes represent a major change of organisational culture. All organisations, not just general practices, are typically inherently resistant to radical change. Johnson  believes that one of the reasons for this inertia is that managers responsible for change share common beliefs and assumptions about the organisational culture. This paradigm of beliefs is part of a wider cultural web of an organisation. The interaction between the paradigm and the cultural web leads to an assumption that “this is the way things are done round here”. In general practice, the assumption is that face-to-face consultations are the gold standard and other consultation methods are seen as ways of managing the workload. 
For change to be successful, there must also be positive consequences for all the stakeholders concerned.  So, for a change to digital consultations to be successful, improvement in clinicians’ workload is necessary but not sufficient. Patients need to see tangible improvements in the way they access healthcare, so digital models which act as a barrier to accessing face-to-face consultations are likely to fail. Despite these caveats, I have personally found a decision to embrace technology rewarding and fulfilling.
I decided to start emailing patients in late 2015 after reading a paper describing the poor communication of test results to patients in primary care . Simply relying on patients phoning a receptionist to check that a result was normal was unreliable, unpopular with patients and would often generate further telephone or face-to face consultations. I began to email patients about their results. It has been very well-received by patients and has improved the reliability of test result communication, but it has also brought other benefits: it has reduced follow up telephone calls and face-to-face consultations, as well as freeing up administrators' time conveying results. Patients have naturally started to email about other matters. Virtually all consultations have represented appropriate uses of the medium. It appears to enhance continuity of care and patient agency.
I have mentioned my modest innovation to many other doctors and have frequently encountered the suspicion that Gerada describes. The assumption is that it will add extra workload, rather than modifying it. But this resistance to embrace email is culturally bound; in other European countries GPs have embraced use of email, as indeed have British GPs in their personal lives.  It will clearly take time to change the face-to-face consultation paradigm, but when change eventually comes, I believe both patients and doctors will enjoy the benefits.
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5. Dash J, Haller DM, Sommer J, Perron NJ. Use of email, cell phone and text message between patients and primary-care physicians: cross-sectional study in a French-speaking part of Switzerland. BMC health services research. 2016 Dec;16(1):549.
Competing interests: No competing interests
We include competing interests statements in the online versions of articles. We do not routinely include them in the print edition of The BMJ because of space limitations. You'll find Clare Gerada's competing interests statement for this article here: https://www.bmj.com/content/361/bmj.k2206. It states: "I am a former chair of the Royal College of General Practitioners, a partner of the Hurley Group, and shareholder of eConsult."
Competing interests: I am employed by The BMJ and commissioned and edited this article.
I am concerned about the potential conflict of interest in Clare Gerada's advocacy of using IT for GP consultations. Prof Gerada was described alongside the article as a GP Partner in the Hurley but no mention was made of the Hurley Group's ownership of e-consulting software. Presuming the Hurley Group's ownership of the software, which is in usage already within a number of UK GP surgeries, is for-profit, then it seems that there is a risk that this would be a 'direct financial interest' under the NHS Conflict of interest guidance. If the market for IT based consulting were to grow to, say, £100 million in the UK, then even a 10% market share would be considerable financially. It may be, of course, that the Hurley Group software is delivered through a not-for-profit vehicle, although in this case they are missing the opportunity to advertise such altruism.
I am a huge admirer of Prof Gerada and she has been a great champion for many causes: mental health - both patients and staff - and health inequalities, to name but a few. I am also sure that she is not writing in support of e-consultations just to increase the value of her company; rather through a genuine believe in the benefits of IT and desire to shake up primary care from it's tech slumber. But to not adequately manage any conflict of interest risks compromising both her integrity and that of the BMJ. The editorial process should be changed to mitigate against such risks.
Competing interests: Gp partner CCG clinical lead GP appraiser
Clearly not all GPs as we welcome electronic advancement in our practice in South Wales. The key phrase with any innovation is 'ok, instead of, not as well as'.
A recurring comment from patients during a telephone consultation is that they didn't want to waste my time with an appointment, so they would rather discuss the problem over the phone. The implication is that telephone calls take no time and generate no extra work.
I well remember when I was on an MRCGP course a phrase I learned that was useful in negotiation - 'That's a very good idea, and we might adopt it, but before we do, what would you like us to stop doing to make room for it?' Improving availability for patients is to be encouraged, but it must be work neutral as we are already working close to capacity now. As a colleague in neighbouring practice put it, General Practice is full.
Competing interests: No competing interests