‘GPs are doing too many face-to-face consultations’

Dr Murray Ellender is the co-founder of eConsult and a GP partner in the Hurley Group GP partnership, South London. He speaks to senior reporter Jess Hacker about digital transformation

Why is there so much variation practice-to-practice when it comes to digital transformation?

The NHS has been quite good at procuring the technology – paying for the tech – without thinking about the transformation that needs to go with it, and that leads to real variation in how it’s used. The result is relying on a practice or PCN to do the transformation work itself. Some practices will do that but many don’t because they need help.

There’s no point having digital tools if practices don’t use them very well.

The transformation piece is key because what we’re asking general practice to do is really change fundamentally how it works, moving from a system where most patients were seen face-to-face to one where most practices will now offer some kind of telephone triage. But telephone triage is more inefficient, because staff have to ring everyone back – you need to move toward online triaging.

Practices need transformation funding: a one-off cost surgeries can invest to ensure they use these tools effectively. That’s crucial at a PCN level when you’ve got networks asking practices to not just change their model of working but also learn how to work as a group of three or five. Digital transformation leads are a good example of that investment.

Some PCNs will have a population more receptive to digital healthcare. How does the NHS address the variation at a patient level?

We have to be cautious about blanket statements. There might be a tendency to say a practice Eastbourne, for example, won’t accept digital appointments because the population is mostly elderly, when that really isn’t the case.

There is a proportion of people who aren’t very digitally adept but about 90% of the UK population is now online and around 75% are comfortable online. But when you look at most practices or PCN, they’ve likely shifted about 10% of their activity online. That means there is a huge opportunity to get the 75% who are adept to interact with their practice remotely or digitally: they will be comfortable using appointment booking and messaging systems.

There is the question of health inequality but if you move your digitally capable patients online, it should make access to other routes easier. Rather than funnelling everyone through the reception phones, you can free up phone lines for your less digitally adept patients.

There are plenty of patients in their 60s, 70s and 80s who are comfortable using this, not all of them clearly, but that doesn’t mean these tools don’t work in certain areas with certain people. We haven’t done enough to shift them online yet.

Data shows the number of GP consultations has returned pre-pandemic levels with the help of remote consultations. Is that reflected in patients’ attitudes to digital general practice?

There is a media-driven push that we should all be getting back to doing face-to-face appointments, even though data shows GPs are doing in-person consultations. I’d argue they are actually doing too many. Between February and April 2023, 70% of all practice appointments were face-to-face: that shows we haven’t really succeeded in using technology well enough, I’m not saying you should get face-to-face down to 10%, but seven-out-of-10 seems pretty high to me. That shows us that there are still a lot of patients we are unnecessarily dragging into practices.

The Nirvana here is you offer them a choice: how would you like to be consulted? Whether we have enough capacity in the system to do that is another question. But in a well-functioning practice that has a digital front door, patients can get same-day access.

When you’re completing an eConsult you can, as a patient, submit a preference for how you’d like to be dealt with: SMS, email, phone, face-to-face. After that it’s very much up to the clinician. When you look at most patients using eConsult, the majority of patients are quite happy.

If a practice has an eConsult come through for a child with abdominal pain that can be scheduled in for the afternoon. Face-to-face should be for people who need it or people who want it. We shouldn’t stop doing it but we have to consider if we are doing too many.

There’s been a negative response to remote consultations, particularly in the media. What is the cause for concern?

It’s about change, and that’s concerning for patients and clinicians. We’ve trained patients over many years that if they have something wrong with them they need to go into a GP surgery and sit in front of a doctor who will then fix it.

If we tried to move back to 100% face-to-face, we couldn’t. It would fail. There is not enough capacity in the system. So we do have to embrace these digital tools, and when you do, quite a lot of patients like it. There are a lot of people who prefer not having to take half a day off work to see their GP to get a repeat prescription for the contraceptive pill. We see a lot of patients with mental health conditions or with conditions they find embarrassing – rectal bleeding, sexual health – and they’d much rather interact digitally than in-person. Here it’s a good thing.

Where has the narrative that it’s a bad thing come from? It’s because it’s changed. The response to reflect on every other aspect of your life: we use online tools. Why aren’t people as comfortable using them in healthcare? It’s a loud minority that are resistant to it. You should be able to access your GP in any way, phone, online, face-to-face. That’s what good looks like.

Should funding and policy be directed to restoring face-to-face or digital transformation?

I’m biased, I’m always going to say that we should be doing more digitally. We work with 2,500 practices and the surgeries that are keeping their heads above water are the ones that have employed digital tools. They’ve got that digital front door and so they can manage their workload.

Particularly for the PCN, it’s essential when you’ve got a team that’s made up of with its ARRS roles and is no longer just GPs. How do you get the right patient to the right clinician? Frankly, the only way to do it is by gathering information from that patient upfront. If you have more information before they come to the practice you can send them to the right person. You can send a patient with back pain to a physio and prescription queries to a pharmacist. Digital triaging supports the PCN way of working. That’s what we should be getting everyone to do: trying to get more people to do more face-to-face is a non-argument.