by Dr Jeremy Horwood and Professor Chris Salisbury, Centre for Academic Primary Care and NIHR CLAHRC West

NHS England’s long-term plan released on 7 January sets out a commitment that over the next five years every patient will get the right to telephone or online GP consultation as part of its ‘digital first primary care offer‘.

Online consultations are seen as a solution to improve patient access to primary care, increase convenience (saving time waiting and travelling) and reduce face-to-face appointments, freeing up GP time. But our research has found that unless these systems are carefully implemented, the benefits policy makers are hoping for in relation to reductions in GP workload and increases in available appointments for patients might not be realised.

The Centre for Academic Primary Care-led Alt-Con study examined how a variety of technological alternatives to face-to-face GP consultations were being used in eight GP practices in different areas of the UK. The study found that although there were some potential benefits, there were also significant barriers to implementation, with practices often responding to incentives to introduce new technologies without a clear rationale or clearly thinking through the likely costs and benefits for patients and practice staff (1,2,3).

There was a clear tension between the hope from patients (and many staff) that providing online consultations would make it easier to contact a GP, while the GPs also hoped it would reduce their workload. For some patients the priority was to be able to make some form of contact, with a telephone or online consultation not necessarily their first choice but better than nothing (1,2).

Our NIHR CLAHRC West evaluation of online consultations examined the effectiveness, acceptability and impact of implementing a GP online consultation system in 36 GP practices in Bristol, South Gloucestershire and North Somerset. Patients accessed the system via their GP practice website where they could submit their symptoms via an online form, creating an ‘e-consultation’.

Over half of all patients using the system were aged 25–44 years (4). Patient satisfaction with the system was high with most saying they would use the service again instead of booking a face-to-face appointment. When patients were dissatisfied this was usually because of a lack of interaction with a GP, missed or delayed communications, or thinking that their query could be answered remotely, and then being asked to book an appointment (5).

The staff cost of dealing with an e-consultation was higher compared to a standard GP face-to-face consultation (4). This was driven mainly by the time spent dealing with e-consultations and that most online consultations resulted in GPs needing to follow up with a telephone (32%) or face to face (38%) appointment, which could duplicate workloads (4,6).

Staff felt that online consultations worked well for straightforward queries such as prescriptions, fit notes and follow-up from previous consultations (6). These enquiries didn’t need direct contact between the patient and the GP. However, GPs often needed to see or speak to the patient when patients had multiple symptoms or had conditions which were new and complex (4,6).

Our research demonstrates the tension between the desire to make access to health care easier and more convenient, while at the same time aiming to reduce GP workload.

New ways of accessing health care advice could be helpful for some patient groups and for straightforward medical enquiries. However, they cannot replace face-to-face consultations in situations which are more complex, and may end up increasing rather than decreasing GP workload. Increases in workload could reduce the time GPs have for face-to-face consultations, which could disadvantage other patients.

In conclusion, alternatives to face-to-face GP consultations need to be carefully implemented, effectively marketed and rigorously evaluated before widespread adoption, to yield the benefits policymakers are hoping for.

We hope that clinical commissioning groups and GP practices planning to introduce alternatives to face-to-face consultation will consider the advice from our Alt-Con and CLAHRC West studies to help improve implementation.

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Further information

Read our guidance on how to improve implementation – Alt-Con and CLAHRC West

Watch our CLAHRC West video summary – How to improve online GP consultations

Download our CLAHRC BITE summary – Evaluating an online consultation system in GP practices

Read our policy briefing – Online GP consultation systems

References

1. The potential of alternatives to face-to-face consultation in general practice, and the impact on different patient groups: a mixed-methods case study. Helen Atherton, Heather Brant, Sue Ziebland, Annemieke Bikker, John Campbell, Andy Gibson, Brian McKinstry, Tania Porqueddu, Chris Salisbury. Published in NIHR Journals Library.

2. Alternatives to the face-to-face consultation in general practice: focused ethnographic case study. Helen Atherton, Heather Brant, Sue Ziebland, Annemieke Bikker, John Campbell, Andy Gibson, Brian McKinstry, Tania Porqueddu, Chris Salisbury. Published in the British Journal of General Practice.

3. Receptionists’ role in new approaches to consultations in primary care: a focused ethnographic study. Heather Brant, Helen Atherton, Annemieke Bikker, Tania Porqueddu, Chris Salisbury, Brian McKinstry, John Campbell, Andy Gibson and Sue Ziebland. Published in the British Journal of General Practice

4. Use of a primary care online consultation system, by whom, when and why: evaluation of a pilot observational study in 36 general practices in South West England. Hannah Edwards, Elsa Marques, Will Hollingsworth, Jeremy Horwood, Michelle Farr, Elly Bernard, Chris Salisbury, Kate Northstone. Published in BMJ Open.

5. Implementing online consultations in primary care: A mixed method evaluation extending normalisation process theory through service co-production. Michelle Farr, John Banks, Hannah Edwards, Kate Northstone, Elly Bernard, Chris Salisbury, Jeremy Horwood. Published in BMJ Open.

6. The use of electronic consultation in primary care: views and experiences from general practice. John Banks, Michelle Farr, Kate Northstone, Elly Bernard, Chris Salisbury, Hannah Edwards, Jeremy Horwood. Published in British Journal of General Practice.

Acknowledgements

The Alt-Con project was funded by the National Institute for Health Research (NIHR) [HS&DR programme] (project number 13/59/08) and hosted by Bristol NHS Clinical Commissioning Group. The online consultation evaluation was part-funded by the One Care and supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West at University Hospitals Bristol NHS Foundation Trust. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR programme, NIHR, NHS, the Department of Health and Social Care or Bristol NHS Clinical Commissioning Group.