Phone, video and online consultations: will Covid-19 change general practice for ever?

 

 

 

by Chris Salisbury, Mairead Murphy and Polly Duncan, Centre for Academic Primary Care, University of Bristol

Because of the COVID-19 pandemic, general practices have rapidly shifted to offering consultations remotely by telephone, video or online messaging rather than face-to-face. Many general practices are considering whether they should continue these new ways of working into the future and some commentators are arguing that general practice will be changed forever. Remote consultations could be more convenient for patients and reduce workload pressures on general practices.

Just before the COVID-19 pandemic we wrote a paper which modelled how an increasing use of online, video and telephone consultations would affect GPs’ workload. Our conclusion was that a reduction in workload should not be assumed, and remote consulting could instead lead to an increase in GP workload over time. It all depends on how remote consultations are used.

The paper has now been published, and what had been informed speculation when we wrote the paper has now become the norm. Because of the lock-down, face-to-face consultations with GPs have become rare, and most consultations are now conducted remotely. Some GPs who previously resisted greater use of remote consultations are finding that many problems can be managed without face-to-face contact, while our concerns about increased workload don’t appear to have been justified.

Our paper was based on modelling using estimates from a systematic review of previously published studies, all conducted at a time when remote consultations were not the norm. Perhaps the evidence on which we based our workload model is now outdated, and the conclusions from our modelling are misleading? Or perhaps experience gained during the exceptional circumstances of a pandemic is equally misleading.

During the lockdown, the volume and nature of demand for medical care has changed dramatically. Many people are seeking advice about symptoms that could indicate coronavirus infection, but many other people are not getting advice for problems that would usually require medical care. Assessing symptoms of a single problem might only take a few minutes and be achievable over the telephone, but modern general practice is mostly about managing long-term health problems rather than advising about symptoms. Agreeing treatment plans with someone with multiple problems and a poor memory takes a lot longer and is hard to do remotely. Also, it is notable that doctors have sought reassurance from their regulators that the difficulty of consulting during the pandemic will be taken into account in any future malpractice claims. Accepting a lower standard of care and tolerance of risk in the current exceptional circumstances should not be used to justify similar standards in future.

Mathematical models have become a regular topic on the news and on Twitter, with different models about the trajectory of the pandemic reaching widely varying conclusions. Models tell us what will happen under different scenarios but depend on the data fed into them. Although the baseline assumptions in our model may have changed in the last few weeks, the underlying mathematical equations have not. In our paper we showed how GP workload is the result of a combination of factors including the demand for consultations, the proportion that are managed in different ways, the duration of different consultation types, and the proportion of consultations which resolve the problem rather than leading to another consultation. If video-consultations take as long as a face-to-face consultation but are more likely to lead to a subsequent consultation, then GP workload will increase.

One important message from our paper is that GP workload is strongly determined by the number of people seeking consultations, and this is likely to be related to accessibility. Just as doctors are learning from the experience of conducting remote consultations, so patients are also learning to appreciate the speed and convenience of being able to contact a doctor without leaving their home. It would be surprising if this doesn’t result, eventually, in an increase in requests for consultations.

The great thing about a model is that it is possible to change the assumptions and see the impact on the outcome. We have made our model available for download, so anyone can enter their own assumptions and see the effect on workload. Try it here. It does seem very likely that the pandemic will lead to major changes in how people contact general practice in future. This could have a range of advantages and disadvantages for different groups of patients. There are likely to be benefits in convenience for some patients, but potentially an increase in health inequalities if new models of care favour the young and healthy over those with greater needs. Whether it leads to an increase or decrease in workload for GPs in the long run remains to be seen.

Paper: The impact of digital-first consultations on workload in general practice: modeling study. Salisbury C, Murphy M, Duncan P.  Journal of medical Internet Research 2020;22(6):e18203. http://dx.doi.org/10.2196/18203

Acknowledgements

Professor Salisbury is a National Institute for Health Research (NIHR) Senior Investigator. The views expressed in this article are those of the author(s) and not necessarily those of the NIHR, or the Department of Health and Social Care.

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