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Published 9 April 2019
The commitment to digital-first primary care is clearly stated in the NHS Long Term Plan. What are the challenges and opportunities for digitally enabled primary care?
Within five years all patients will have the right to use digital-first primary care, NHS England has promised under its NHS Long Term Plan, either from their own practice or from one of the new digital-first providers.
A new framework will be created for digital suppliers to offer their services to primary care networks on standard NHS terms. Furthermore, NHS England says, this will ensure new ‘digital first’ practices are safe, while the whole NHS current out-of-area arrangements will be reviewed and the GP payment formulae adjusted.
The ability to share patient information across several services is key for NHS England’s vision, which centres on expanded multidisciplinary teams of community and social services aligned with groups of GP practices. Alongside this, outpatient pathways will be redesigned to avoid unnecessary appointments, meaning more care and follow up will take place in primary care with online support from consultants, and rapid referral to virtual clinics when necessary.
Some GP practices already offer patients the option of telephone or online consultations, saving waiting and travelling time.
AT Medics, London’s largest primary care provider, cares for over 270,000 patients and is one of the growing number of GP Practices that use telephone triage, says Susan Sinclair, Chief Executive for AT Medics. “Telephone triage helps patients get support quickly and get a resolution to their query without having to come in and have an appointment.”
Sinclair applauds the inclusion of a dedicated chapter in the NHS Long Term Plan on digitally-enabled care, saying this shows recognition that it needs to be a ‘key enabler’ to NHS reform.
While early adopters of digital health have tended to be younger, older people will eventually get on board, predicts Sinclair. “Digital care has a huge amount to offer people with long-term conditions who spend more time in GP surgeries, and other health appointments. Digital support can give the patient autonomy, and allow effective information sharing between the patient and their healthcare team. Digital healthcare provides the opportunity for patient empowerment, allowing them to monitor and manage their condition.”
West London NHS Trust is working with the GP-led social enterprise London Central and West Unscheduled Care Collaborative (LCW), which runs NHS 111 and out-of-hours GP services in parts of north-west London, to provide video conferencing support to care homes. Rather than call the rapid response team or an ambulance immediately, care home staff can now bypass usual 111 pathways and discuss a patient, in some cases by video conference, with an advanced nurse practitioner, who could perhaps also have some face-to face contact with the patient to support the discussion.
“As we test new infrastructure deployed across north-west London’s care homes, we can see huge potential for this. We have worked hard with commissioning groups, supported by social finance, to put all of the necessary information sharing protocols in place, and we’re engaging with the staff in the homes themselves. We’re already seeing promising results that this new tool will improve care for this population, and reduce historically high use of emergency services” says Christopher Hilton, Director of Strategy and Clinical Director for Integrated Care at the Trust.
Dedicated digital-first providers are emerging. One of these is GP at Hand, which has more than 40,000 people registered as NHS patients through its central practice in Hammersmith and Fulham, west London.
There has been some initial resistance to digital-first providers based on concerns that digital-first services favour younger and healthier patients, potentially creating a two-tier service. NHS England is reviewing whether any changes need to be made to the general practice funding to address this. However, the commitment to digital first primary care is clearly articulated in the NHS Long Term Plan, with every patient in England to have the right to choose digital consultations by 2023/24.
“The barrier to upscaling innovation is people’s willingness to judge that a service is at least as good as the alternative and so let it go live, whilst improving the legislative, regulatory or IT framework in parallel versus hiding behind the fact that everything isn’t yet perfect” says Paul Bate, Managing Director, NHS Services at Babylon Health.
The technology developed by Babylon and used by Babylon GP at Hand also helps GPs work more efficiently, Bate says. Eventually, the computer will produce a transcript, auto-code the notes and extract any information required for Quality and Outcomes Framework payments… all for validation and sign-off by the GP. Video consultations are already all recorded and stored, and so can be reviewed by patients and doctors as required.
During video consultations, Bate says: “In future we will be able to run scanning over the patient’s face, so, if they are concerned about anything the doctor says, or they might be in pain and have not said, it’s another clue for the doctor.”
Normally an audit of a past consultation would have only the limited summary made by the GP, Bate explains. “In our situation you have all the information that the AI provided, as well as what the person provided to the AI. You also have a full video recording of the GP appointment – there is no ‘he said she said’.”
GPs providing video consultations must have indemnity coverage like other GPs, and Babylon has “very significant insurance for anything that might go wrong with the technology”, he adds.
Babylon has recently launched an AI-powered health check that helps its registered patients understand how their physical and mental health may be affected by current and past lifestyle choices, as well as medical and family history. Currently this is questionnaire based, but in the future the aim is to incorporate information from genome analysis and wearables. That information is then used to build a digital twin that assesses the patient on their risk of 20 diseases, how that compares with risk in others of the same age and gender, and what they could do to reduce their risk.
AT Medics are also increasingly using data to support the care they provide.
While data from wearables is available to such practices, it is rarely used to inform care at an individual level. Sinclair predicts that will change with increasing patient expectations, and as devices and systems for integrating data evolve.
However, what has been ‘a game changer’ for AT Medics, which has 270,000 registered patients, is its development of its own analytics tool to look at population health data to improve care at scale.
“The use of large-scale data to evaluate, plan and improve care has been a game-changer for us, and we’ve invested significantly in developing our own in-house tool for population health management. Our analytics focus has been clinically driven by expert GPs, embedding effective design and visualisation to make it easier to use. This has been extremely useful, enabling us to prioritise care and make decisions based on the data. It has enabled us to deliver significant improvements, for instance in diabetes and public health,” says Sinclair.
In just over a year, the provider turned around its diabetes management from average to top in the country, for the proportion of its patients, receiving all the recommended care processes and for triple target management.
“We have done the same in public health, improving shingles, influenza vaccination coverage and cervical screening uptake. Once you see the data, you are able to work out where you need to improve, what capacity you need and you can monitor the improvement. You’re also able to get people collaborating and to some extent competing with each other to improve,” she says.
The provider is now using the approach for medicines optimisation by looking at best practice in terms of medicine safety, and taking a very symptomatic approach to ensuring patients are on safe drug combinations.
AT Medics is continuing to look at ways to track the impact on emergency admissions. “We want to integrate hospital data within our analytics tool in order to see what is happening to our emergency admissions over time. We are working within the wider commissioning landscape to achieve that.”
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