By Arvind Madan, Co-founder of eConsult, Practicing GP and Deloitte senior advisor and primary care lead

In February, we published our report ‘Realising digital-first primary care: Shaping the future of UK healthcare’, discussing the current state, challenges and potential of digital transformation in general practice. We also featured eight good practice case examples with evidence of how technology was helping clinicians manage their workloads more effectively, and improving access and support for patients. One such example is eConsult, co-founded by our colleague Dr Arvind Madan, who is a senior advisor and primary care lead for our Deloitte Public Sector Health practice, and who was also an advisor on our report. As part of our follow-up, we have been catching up on all of our case examples to understand the changes they have experienced in the weeks following the WHO’s declaration of the COVID-19 pandemic on 11 March. This week’s blog follows our previous blog, COVID-19: Accelerating digital transformation in healthcare¹, and provides a first-hand account from Dr Madan on how the GP online evolution has become a revolution.

Over to Dr Madan

Based on the laws of probability, I am told aliens exist. Experts have been telling us for years that a pandemic virus is coming, but we didn’t quite believe that either. Now we know that an event that featured as the fourth item on the nightly news late last December has, for the past few months, dominated every media channel across the world and caused every country to rethink ‘how it does healthcare’!

The evolution of online GP consultations

In the spring of 2011, GP blackjack dealt me three consecutive patients with hay fever. Each was generally well, and each had taken time off work to see me for the same advice and treatment. It set me to thinking about whether there was a better way to do this, for both me and them. That week I sought out a software engineer and asked him whether I could collect their history online, in a standardised format, and also deliver the advice and treatment remotely. He opened my eyes to the technological capabilities commonplace in other industries.

We teamed up on developing the perfect history take for as many of the common general practice symptoms, conditions, and administrative tasks as we could. We then compiled them into a growing library of dynamic algorithms in an online platform. We added self-help options, accredited clinical scoring questionnaires, photo upload (and later video) capability, and created red-flag questions to intercept and redirect serious cases. We loaded them on to our practice website, encouraged patients to consider using them and I asked my fellow clinicians to process the software-generated summary reports with me. Thus, the eConsult online consultation platform was born.

Between 2012 and 2014, we piloted, refined and enhanced the model continuously, using safety, user feedback and practice efficiency as our key steers. The availability of 24/7 access to their own GP proved popular with patients, and GPs were able (within an average of 3-4 minutes per case) to close 60-70 per cent of cases without a GP appointment. Pretty soon other practices wanted in, and between 2014 and 2015 some 1,300 practices signed up to the eConsult platform, providing their patients with a suite of online services through their own practice’s website.

Along the way we discovered some key insights:

• It is essential to balance patient convenience with clinical productivity, as there is a real trade-off between the two. Make access too easy, like patient-instigated video, and practice productivity worsens due to supply-led demand. Mandate every patient to go digital-first, to drive practice efficiency, and you alienate patients and reduce access for vulnerable groups. Therefore, a truly nuanced approach is required, informed by how patients and clinicians behave and how practices work.
• We found that patients present differently online, with some stigmatised conditions such as mental and sexual health issues presenting sooner – a phenomenon we dubbed ‘digital disinhibition’. This challenges the concept that the face-to-face consultation, on its own, is still the ‘gold standard’.
• We took the view that self-help tools and online consults should be a choice for all patients and clinicians to use as they saw fit, and found patient utility related more to symptoms than their demographic profile, dispelling myths that older people won’t ever go online.
• Our initial pilots were in very ethnically diverse populations. Surprisingly, uptake was high as they were from digitally savvy households (from skyping internationally), they also had extended family members keen to support their engagement. They also appreciated the extra time they had to explain their issue online more fully.
• In some practices patient utilisation plateaued at around 8-12 per cent of all consultations, but this was also because GPs didn’t push the option for fear of supply-led demand. But practices that used it to manage large volumes of patients saw significant access, efficiency and financial gains, with happier receptionists overseeing quieter phone lines and emptier waiting rooms.
• ‘Asynchronous consulting’ proved popular with clinicians, as they had more control and ability to plan their daily working day, including some who were then able to work from home.

From evolution to revolution

By February 2019, our online consultation platform was one of 47 GP online consultation platforms, albeit the largest. However, as illustrated in Deloitte’s ‘Realising digital first primary care’, patient report, awareness of the extent to which practices offered online services was very low. Moreover, only 54 per cent of patients over the age of 74 have internet access in their homes; and whether patients can receive a digitally enabled service depends on where they live. Consequently, there was significant variability in take-up of, and access to, online services.² Today, the emergence of COVID-19, has shown how, in the space of a few weeks, the GP online evolution has become a revolution.

With GPs managing over one million appointments each working day, NHS England has advocated that every practice should adopt a ‘Total Triage’ model to reduce avoidable footfall in practices and protect patients and staff from the risks of infection.³ This means every patient should be clinically assessed either online, by phone or by video, before any face-to-face contact.

Today, most practice waiting rooms sit empty whilst the dwindling clinical workforce sits alone in their consult rooms, or increasingly work from home. They plough through lists of online consults, phone calls and occasional video calls. A handful of pre-vetted patients attend the surgery for urgent routine care. Clinical Commissioning Groups, Primary Care Networks, and GP practices are setting up cold hubs to aggregate their work and their staff to fewer sites, and hot hubs for patients not well enough to leave unassessed, but not so ill that they go straight to hospital. This has accelerated the adoption of remote management of primary care. GPs are no longer having forty 10-minute meetings with patients a day, as their armoury for providing safe effective care has irreversibly expanded.

Until recently, our eConsult platform used to run at 10,000 remote consultations a month, this has now risen to over 30,000 a day, with Monday morning peaks of over 3,000 per hour. We used to onboard 50 new practices a month, but now onboard over 50 new practices a day, taking us to over 2,450 practices covering over 21.5 million patients.

Operational processing of workload is changing too. Many areas are choosing to aggregate their online consults from groups of practices to a single eHub. This comprises a home working multi-disciplinary team of clinicians specialised in closing cases safely without the need for an appointment, through remote training and peer-support. Pre-COVID they were closing 87 per cent of cases remotely. This has risen to 95 per cent, with only 1 in 20 patients needing to come in. The next stage will be to use AI to read and route the online consult to the right clinician, for processing in the right timescale, through the right modality (SMS, online message, phone, video or face-to-face). Work is also well underway to transform care in a variety of other settings. This includes capturing the history, observations and pre-ordering of investigations using self-check-in arrival screens in Emergency Departments, and revolutionising first and follow-up outpatient appointments using online consults, clinician crowd-sourced advice, remote biometric monitoring and predictive technologies.

As the COVID-19 black swan event unfolds, we are witnessing the reinvention of healthcare. We are fast-forwarding through a decade of development in a matter of weeks and months. Mind-blowing, but overdue.

Dr Arvind Madan - Senior Advisor, Primary Care lead

Dr Madan has been a practising GP for 23 years, and continues to undertake a regular clinical and managerial commitment for the Hurley Group in both general practice and urgent care settings. In 2013 he co-founded eConsult and in 2015 Dr Madan was appointed National Director of Primary Care and National Deputy Medical Director for the NHS in England. In these roles he helped shape and implement national NHS policy.

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¹ https://blogs.deloitte.co.uk/health/2020/04/covid-19-accelerating-digital-transformation-in-healthcare.html
² https://www2.deloitte.com/uk/en/pages/life-sciences-and-healthcare/articles/realising-digital-first-primary-care.html
³ https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0098-Total-triage-blueprint-April-2020-v2.pdf