by Sophie Park, Professor of Primary Care and Medical Education, Research Department of Primary Care and Population Health, University College London, Yathavan Premadasan, BSc Medical Student, University College London and Chris Salisbury, Professor of Primary Health Care, Centre for Academic Primary Care, University of Bristol
The COVID-19 pandemic has changed primary care dramatically, with most consultations conducted remotely by telephone, video or online messaging. But is this a short-term adjustment or the future norm? In general practice, clinical care has been based on long term face-to-face contact, establishing trusting relationships through continuity of care, and using knowledge of patients’ personal circumstances and social context to provide holistic support. Now, these fundamental principles are challenged.
Matt Hancock (UK Health Secretary) has welcomed rapid changes towards digitalised clinical practice as an overdue development, stating that wherever possible, all future consultations should be conducted remotely. But is the pandemic ‘crisis’ simply being used to introduce unscrutinised change? The WHO recently considered the opportunities and challenges of digitalising healthcare systems to address global healthcare workforce shortages and support delivery of universal healthcare, interprofessional working and patient engagement. The report also highlighted potential challenges to equality and social justice posed by private companies keen to exploit the healthcare “market”.
Accessing healthcare through digital services initially seems cheap and even democratizing – what could be easier than emailing your GP? But the reality can be very different. It potentially undermines core primary care principles: the importance of patient interaction; treatment of the whole patient; and situated use of evidence to individualise care, for example negotiating competing priorities in the context of multimorbidity. Worse, it widens health inequality: the healthy, the wealthy and those requiring simple transactional interactions benefit; whilst those with complex health problems struggle to get the care they need.
Remote digital consultations work well for simple transactions, for example, where a straightforward problem leads to a clear-cut disease diagnosis and treatment. But the main users of primary care are young children, the elderly, and those with multiple problems associated with long-term health and social conditions. Telephone and video provide less rich information than face-to-face consultations, making management of these complex situations difficult. The move towards remote consultations is a shift towards less personal and more transactional healthcare and away from an individualised, whole-person approach built on a patient-doctor relationship. Using an online form or telephone consultation means problems risk becoming over-simplified, over-investigated, medicalised and stripped of context and nuance. There is less opportunity for in-depth exploration of patients’ concerns and health beliefs, or for shared decision-making.
Studies in different countries have consistently shown that patients choosing remote consultations are predominantly young adults who are healthier, more educated and more affluent than average. These are the opposite of the characteristics associated with health need. Older, less educated patients and those with chronic illness are motivated to access digital healthcare, but face more difficulties in doing so because of lack of access to technology, the confidence and skills to use it, or physical or cognitive limitations. This should be no surprise to those looking at the “digital divide” in other sectors. For example, over 1 million Lloyds Bank customers (16%) required help to access internet and digital services; moving universal credit on-line increased claimants’ use of Citizens Advice; and, it is the over-75s who comprise most internet non-users.
Digitalised access to healthcare does not therefore equate to equitable access, nor does it necessarily reduce professional workload. Digital access can increase demand, as a ‘quick and convenient’ patient option and can increase the need for follow-up.
These changes impact how primary care is perceived. For patients, those with simple health needs may appreciate the convenience of remote consulting but those with important personal issues to discuss may resent barriers to seeing a doctor in person. For GPs, it can undermine their sense of purpose and identity: many doctors choose to work in primary care because they want to offer high-quality, holistic care to a patient they know. If a large proportion of their day is spent emailing or telephoning unfamiliar patients, it degrades both the quality of care and satisfaction in their work. Doubtless it will influence career choices of future doctors.
Short-term, we need to make patient care during the pandemic safe. This requires dynamic and personalised risk-assessments with patients to ensure that face-to-face contact is only used when clinically needed, and in the patients’ overall best interests. While more remote consultations are needed, teams can maximise collaborative learning about how best to conduct and utilise digital patient interactions. However, we should resist normalising remote-first healthcare in the longer-term. Remote consultations offer advantages in specific situations. ‘Digital First’ interactions remain, however, problematic for many patient groups and long-term strategies need to retain agile, flexible and human-centred services, enabling patient choice about access and quality of care.
This article was first published by the NIHR School for Primary Care Research.