Modern primary care
Primary care witnessed a dramatic and substantial shift in the way GPs work and deliver services during the COVID-19 pandemic. From seeing the majority of patients face-to-face following an approach made by the individual, usually via telephone, GPs shifted to a mix of consultation modes. An initial focus on remote consultations has shifted more recently to a melange of face-to-face, telephone, video, and web or digitally based consultations, sometimes preceded by online triage or by initial approaches for health care involving administrative staff.
These changes around consultations reflect a wider move, actively promoted by the UK Government, towards promoting digital and online routes of access into NHS care.1 For many people such a move has been welcome, bypassing the ‘8am rush’ to secure appointments, potentially obviating the need to take time away from work or social responsibilities to attend for care in person, and handing elements of control back to the potential user of NHS services.
But not all may welcome these moves. The risk of exacerbating pre-existing inequalities in the availability and uptake of healthcare services is high, especially for individuals who may find use of new digital and online platforms challenging. Evidence has demonstrated that there are groups of patients who are more likely to access services digitally or to have difficulty in doing so. These groups include some older people,2,3 migrants, those experiencing homelessness, those whose first language is not English,4 and individuals facing the challenges of living with learning disabilities or with severe mental health conditions.5,6 National policies for introducing digital and online routes of access are introduced at the population level, ignoring the variation that exists in whether people can effectively engage with such services.
In addition, the large-scale roll-out of existing and newly emerging innovative health technologies may present its own challenges — especially in a resource-constrained public-service environment. The roll-out of new and potentially useful health-tech innovation across the NHS and primary care services has historically been slow and faced challenges of poor coordination and limited resources. Financial resources in health care are tight. The UK spends around 11.3% (£193.8 billion) of GDP on health care, significantly below the US (16.6%), Germany (12.7%), and France (11.9%).7 Just 8% (£14.9 billion) of UK healthcare spend is on primary care, despite this sector shouldering the vast majority of patient interactions.7 GPs are coordinators of care, ideally providing continuity as individuals and across their teams. GPs act as the first point of access to NHS services and deliver clinical services to the whole population. They absorb and manage the majority of patient requests for health care without recourse to additional external services beyond primary care.
Digital facilitation
Effectively delivering technological services requires know-how, investment, coordination, and vision. The NHS faces challenges of multiple IT systems that do not effectively communicate with each other across and within healthcare provision, for example, between practices within primary care networks and care systems; between primary and secondary care; and, of increasing importance, between primary and social care.
To enable patients’ use of NHS digital health care we have recently suggested that efforts at ‘digital facilitation’ are necessary. We have defined such efforts as encompassing that range of processes, procedures, and personnel that seek to support NHS patients in their uptake and use of online services. This incorporates the day-to-day work required by general practices in supporting patients to use services. Our research highlights many challenges for planners, users, and healthcare staff in ensuring the effective delivery of a functional, patient-facing, digital-based system of primary health care.8
At present, there is no shortage of guidance available on how to deliver online services, and this is in patchwork form: for example, guidance from NHS England for general practices and patients on what they need to know about the NHS App; guidance from NHS England for patients on how to use online services (though they must identify the service from a list of those available including the NHS App); guidance from technology suppliers on how to use specific online triage tools within the NHS App; and guidance from technology suppliers on how to use their individual platforms. What is missing is the support for general practices and patients to work together to turn this guidance into action.
We found that in the rush to embrace new technologies, the planned provision of such support had been overlooked and was often ad hoc. At the sharp-end, is it now the role of practice administrative staff to support patients in accessing and obtaining their repeat prescriptions, in accessing their medical record and investigations, and in booking their online or face-to-face appointments? Do these staff now need training in helping to support patients in registering for NHS online and digital services, and in promoting their ongoing use of such services? And what about the digitally disadvantaged — do such individuals need concerted efforts to ensure they are not victims of already widening healthcare inequality in the UK?
When it comes to being digitally competent, digital inclusion has been tackled by the charitable sector, with organisations such as the Good Things Foundation (https://www.goodthingsfoundation.org) and Healthwatch9 identifying who is excluded and creating strategies to address the problem. The NHS framework for digital inclusion signposts to evidence, tools, and resources, placing the onus for action on commissioners and practices.10
Conclusion
Investment in adequate support for patients and for practices to facilitate their use of online NHS services has the potential to deliver dividends in terms of efficiencies in healthcare delivery and better access to care, but who should fund this support and where the support should come from remain unanswered questions.
Focused efforts to support patients in the new digital world of health care in 2024 are essential. Success in such efforts is likely to offer many benefits across the UK population. But strategic investment, careful coordination, and socially intelligent breadth of vision are essential if that prize is to be grasped.
Notes
Provenance
Freely submitted; not externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2024
References
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(2021) Healthwatch. Community Insights on digital inclusion,
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