COVID-19: Is Primary Care Ready to Switch to Telemedicine? 

Anna Sayburn


March 27, 2020

For decades, we've been promised that telemedicine will save primary care money and time. Yet somehow, for most NHS GP services, face-to-face consultations have remained standard operating procedure. Why go to the hassle of introducing video consultations, when everyone can pop down to the surgery?

The COVID-19 pandemic has abruptly changed all that. Practices across the country are hastily setting up video links, introducing universal remote triage and discovering ways for staff to work from home in self-isolation. Could this be the end of the GP surgery visit?

What's Happening Now?

London GP Dr Farah Jameel, a member of the BMA's General Practice Committee executive team, says practices have moved to triage first, so patients are not offered in-person appointments until they have had a remote assessment of their needs.

"How you choose to triage patients is down to you as a practice. You could telephone patients, you can use online assessment forms, you could choose to provide a video consultation. You could literally send emails back and forth."

The key point is to make a quick clinical assessment of who needs to be dealt with, by whom, and what is the best format for the appointment. Not an easy task, with "unprecedented demand" when "anxiety levels are through the roof".

It is "a different way of dealing with patients", she says. "But it's not something that will come as a complete surprise or shock to practices – they will have been using different modes of online triage and consultation for years." Telephone appointments are not new, and Dr Jameel says there has been a push since 2018 to get practices signed up to online consultations.

"It's the lacking infrastructure which is the main problem, not the will to use it," she says.

Professor Trisha Greenhalgh, professor of primary care health sciences at the University of Oxford, has produced a guide on introducing video consultation for practices during the COVID-19 pandemic. She agrees that infrastructure is a problem: "Some of them [GPs] are making it work and some are really struggling because they haven't got the infrastructure. Infrastructure issues are going to be mission critical."

Technical Issues

The move to online working has exposed weaknesses in the technology available to primary care, says Dr Jameel. "For instance broadband. We've got areas in London that have terrible speeds so they don't support proper video consultation, and that's just in London. Forget about the rural areas." She says that practices connected to NHS WiFi have been discovering it has "woefully inadequate speeds".

"Large numbers of practices across the country don't have the best hardware; they've got old computers that are slow."

Professor Greenhalgh adds: "People are talking about [insufficient] VPN terminals across hospital trusts, but also big GP practices; rules and regulations not being relaxed by CCGs [clinical commissioning groups]; things like not being allowed to download new software – also people trying to use a piece of technology and it just doesn't work on their phone or terminal."

Some practices do not have enough landlines to support the current demand for phone appointments and triage. "It's just shocking that these are the types of conversations we are having at this moment in time," says Dr Jameel.

Finding Ways Around It

In the absence of other support, GPs and practice staff are using their own mobiles, tablets or laptops and improvising with readily-available video technology such as Skype or Zoom.

"Practices are just getting on with it, they are using their own mobile phones, they are increasing their data packages for their staff so they can just get on with ringing people," says Dr Jameel.

Professor Greenhalgh adds: "We're in a major crisis. You've got somebody at home who's immune suppressed, you need to see their face and the only thing they know how to use is Skype – why don't you just Skype them on your phone? That's the sort of thing people are saying now, because the benefit-harm ratio is so overwhelmingly in favour of not going to visit them that people are just dropping all the rules and regulations."

The Information Commissioner's Office and the Secretary of State for Health Matt Hancock have made clear that data sharing for direct care purposes will not be seen as breaching GDPR and data security regulations, enabling people to use whatever technology is best for the job.

Working From Home

For the doctors who have to self-isolate, working from home is one way to enable them to continue to help manage the enormous demand on primary care. It is also, Professor Greenhalgh says, the best way to make use of the 'Dad's Army' of retired GPs volunteering to come back into the workforce.

"Probably the best way to use those doctors is to say stay at home – you've all got houses, unlike the young ones – we'll connect you up to the clinical records system for the practice and then you can consult by video from home."

However, she adds: "That read and write access to practices' clinical records system is totally key."

Dr Jameel warns: "One of the things we're finding with the self-isolation advice is the inability for the NHS to move quickly enough to enable large numbers of the workforce to remotely access their systems." She says there are insufficient laptops configured with GP systems or with the right VPN connections.

She makes a plea to the UK Government: "They need to enable remote assessment of patients through tools they supply us with, and they need to enable remote access for clinicians and healthcare workers, so we can carry on delivering care outside of the boundaries of the GP surgery."

The Patient Experience

But do remote consultations work as well as face-to-face visits, even when the technology is in place? Primary care researcher Dr Helen Atherton, from the University of Warwick, had been investigating patient and clinician experience of using video consultations before the COVID-19 outbreak began. She says people interviewed after using it tend to be satisfied, although they may be less keen beforehand.

"On the whole, patients are quite happy with it as a method of consultation. I think if you asked them before whether they wanted to do it – we're all a bit nervous about doing things we've not done before. When people do use it they are satisfied with it and it does offer that communication."

She warns that "technical issues can really derail this type of consultation. It was true before COVID-19 and it's true now". She said that people were working to fix the glitches exposed by wobbly broadband connections and a general upsurge in online demand. "We might sort out some of these technical glitches out of necessity."

She said that people with long-term conditions tended to do well with video consultations, perhaps because they are already familiar with the practice, their GP and their condition. "So they've got these skills already. It sounds like it might be a promising way to manage those types of [long-term] conditions."

In the current situation, with GPs needing to manage both regular patients with long-term conditions and patients anxious about COVID-19 symptoms, "video perhaps offers a way to provide some continuity with the patients that you are not going to see for a few months that have serious long term conditions".

What Are the First Steps to Take?

With the situation moving so quickly, says Professor Greenhalgh, the advice she produced last week about holding practice meetings to work out how to introduce video consultations may no longer apply. "That's all out the window because things are moving so fast."

The first thing is to make the "strategic decision that this is going to happen", she says. Practices then need to source kit that works with the GP medical records and administrative system. If there is time, setting up a practice run with a dummy patient is a good way to ensure people know how to set up the audio and video links and adjust them.

However, "things are so critical at the moment that people are taking deep breaths and not worrying about it and saying, well, needs must".

Dr Atherton recommends ensuring you have the patient's phone number, so the video call can be converted to a phone call if necessary.

Will This Change the Future of General Practice?

Now that practices are being pushed into much bigger use of remote consultation, will they continue to use it after the crisis has passed?

Dr Atherton says her previous research showed "it's really hard to get practices to implement it, they don't want to change their behaviour".

But "practices are now being forced to do remote consultations. It's making it happen. I think that's really fascinating", she says.

"It's hard to say how it will work in the long term but there are probably a lot of practices out there who would never have considered using video consultations with their patients who are now doing it and may well continue to do it after this calms down a bit."

Professor Greenhalgh has been involved with the roll out of video consultation as part of the Attend Anywhere project in Scotland, which also included hospital care. She says the initial response – before the COVID-19 crisis hit – was: "We never needed to. That's what GPs were saying in Scotland. GP surgeries have had less need to do it because they're on the street corner and people live locally and the patient who can't get to the surgery it's not that much of a hassle to go and visit them. It hasn't been worth the hassle to set up for video."

After the project was introduced, patients were much keener on it, she says. "People are saying why on earth did I drive for 2 hours to get to the hospital when actually it's a 10 minute appointment and now I haven't wasted any time, I just sit here waiting for the doctor to pop up. I think there will be a big change, definitely."

However, all the doctors agreed there will still be a place for face-to-face consultations once the crisis passes, not least because some will need physical examination.

"I think we're never going to replace face-to-face consultation. There will be a period when we need to find a happy medium between the two," says Dr Atherton.

Dr Jameel agreed. "You've got to put the patients' needs first and then determine what the best mode of delivery is. It's not always going to be through technology. Sometimes you've got to get on and see the patient."


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