By Dr Francesca Properzi, PhD, Research Manager and Krissie Ferris, Research Analyst, Centre for Health Solutions
Primary care, particularly general practice, has been the cornerstone of the NHS since its inception. Over the past decade, increasing demand and capacity challenges have left many staff with unmanageable workloads. In recognition of these challenges, the NHS Long Term Plan, published in January 2019, identifies digital transformation as a national priority. Our latest report, ‘Realising digital-first primary care: Shaping the future of UK healthcare’, highlights the challenges in achieving the policy ambition for a digital-first, primary care service and the key steps needed to speed up the adoption of technology by patients, staff and the wider healthcare system.
The rationale for transforming primary care
In 2019, general practices provided some 312 million appointments, four million more than the previous year. A growing proportion of these appointments were for patients with more complex conditions. However, half of GPs report feeling unable to cope with their workload, third have reduced their hours and another third have plans to do so. Moreover, fully qualified GPs are leaving the workforce faster than they can be replaced. Surgery closures between 2013 and 2019 have affected around two million patients, and, in 2019, the average waiting time for an appointment rose above two weeks (Figure 1).
Figure 1. The growing imbalance between demand for consultations and the capacity of GP practices to meet the demand
Our report examines how digital technologies can address this imbalance between demand and supply, improve access to general practice, improve the clinician and patient experience and equip primary care to deliver integrated care, based around population health management (PHM). Our primary research for the report comprised: responses from 240 general practitioners (GPs) and 260 practice nurses; interviews with 65 key stakeholders; and responses from 4,165 UK respondents to Deloitte’s Global Survey of Health Care Consumers. We also undertook an extensive literature review and analysed the past five years of the annual NHS GP Patient Survey.
Digital-first general practice
We asked our survey respondents what first three words come to mind when thinking about the NHS’s journey towards digitalisation The top three responses were ‘slow’, ‘expensive’, and ‘challenging’ (Figure 2). We also asked respondents to identify the top three challenges their organisation was facing in implementing digital technologies; the overwhelming response was the cost of technology (46 per cent), followed by finding the right technologies (13 per cent) and bureaucracy (12 per cent). Our interviewees identified funding, leadership and interoperability as the top three challenges.
Figure 2. Current state of healthcare digitalisation in clinical practice
We also asked GPs and practice nurses what digital technologies they were using the most. While 98 per cent said electronic health records (EHRs), 75 per cent e-prescribing, and 40 per cent point of care diagnostics; less than two per cent said they used next generation technologies such as robotics and Artificial Intelligence. A stark finding was the fact that some 29 per cent of GPs and 22 per cent of practice nurses’ reported that they received no formal training or support in the use of technologies.
While general practices have provided advice and support through telephone consultations for many years, the past few years has seen an increase in independent and NHS-funded online primary care providers. There is a growing body of evidence that these services are beginning to have a positive impact on helping practice staff manage their workloads more efficiently and effectively. However, research by NHS Digital in 2018 showed a wide variation between clinical commissioning groups in the use of remote appointments; and a 2019 report by the Social Market Foundation showed that whether individuals receive a digitally-enabled service depends on where they live.
A digitally-enabled patient experience
A key ambition of the NHS LTP is to improve the patient experience. However, our analysis of the GP Patient Survey shows that patient satisfaction with general practice has declined over the past five years as patients find it more difficult to see the GP they are registered with and face longer waiting times. Implemented effectively, digital services can improve the patient experience and reduce demand for face-to-face appointments, but to date, awareness and use amongst patient’s remains low. In England in 2019: 44 per cent of patients are aware they can book appointments online, but only 15 per cent have done so; 41 per cent are aware they can order repeat prescriptions online, yet only 16 per cent have; and 15 per cent of patients are aware they can access their medical records online, but just four per cent of patients have accessed them.
The finding from our Global Survey of Health Care Consumers suggests that UK citizens have mixed feelings about trying new digital technologies and sharing health data with their doctors. This together with the low awareness and use of online GP services means there is an urgent need to improve communication about these services at the local, regional and national level, and also improve the digital and health literacy of citizens.
Solutions for delivering digital-first primary care
Our June 2019 publication, ‘Closing the digital gap: Shaping the future of UK healthcare’, identified five steps to help deliver digital transformation at scale (Figure 3), including transformation of primary care. Specifically, general practices require a solid IT infrastructure, reliable network connectivity, interoperability and data storage capacity. Importantly, interoperability and accessible EHRs are needed for seamless data flows to improve outcomes for patients. Key to the delivery of digital-first primary care is a change in the mind-set of general practice staff, dedicated financial resources to invest in training, and an enabling infrastructure. Our report features eight specific examples of online-GP services with evidence of improved outcomes for both staff and patients.
Figure 3. Key steps to achieve a digital-first general practice
Primary care’s role in diving integration and innovation in healthcare
Since July 2019, in line with the expectations in the LTP, all general practices have formed part of one of some 1,260 Primary Care Networks (PCNs), serving around 30-50,000 patients. PCNs together with other providers and commissioners are also forming into geographically based Integrated Care Systems (ICSs). The LTP expects PCNs to be the driver of PHM for their ICS and, over the next five years, to optimise the use of data analytics to help delivery new preventative and personalised models of care. This will require uninterrupted data flows across PCNs and ICSs, based on a solid IT infrastructure and fluid interoperability of data across organisations and sectors.
At the same time, AI, genomics, and digital technologies supported by open application programme interfaces, cloud technology and radically interoperable data, will shape the future of healthcare delivery. These technologies will increase accuracy and speed of diagnosis and decision making, and ultimately the quality and cost-effectiveness of care. They will also utilise state-of-the-art AI algorithms and technologies. Programmes and initiatives to promote and support collaborations between primary care, medtech, tech companies and academia will also be important for primary care’s digitally-enabled future.
Figure 4. The future of primary care-led healthcare