Gaps in care provision are widening, and take-up of GP Online Services (GPOS) is increasing, but there is still a long way to go, as shown by a recent GP survey1 that highlights low usage of the service despite increasing sign-up. GPOS (the generic term for the multitude of platforms for medical record access) was envisioned as the gateway to primary health care, dually granting citizens increased control of their health and reducing practices’ workloads. However, there are still millions of patients who are not signed up, and, if those who are do not use the service to an optimal extent, it is fair to say that GPOS will not meet expectations nationally. In the current market, where online GP consultations are increasingly being sold to patients through private providers, comes the launch of the new NHS app (now in a gradual rollout phase). But what factors are responsible for the slow progress in widescale adoption and substantive variation in the percentage of the population signed up to GPOS? And how does the app overcome them? Will building on existing GPOS by simplifying the sign-up process (for practices as well as patients), introducing additional features, and overall improvement of accessibility make it competitive enough? So far, expectations and reality have not aligned, but could the NHS app be the solution waiting on the horizon?
BACKGROUND
There are widening gaps in care provision, as forecast in the Five Year Forward View :2
‘The health and wellbeing gap: If the nation fails to get serious about prevention then recent progress in healthy life expectancies will stall, health inequalities will widen, and our ability to fund beneficial new treatments will be crowded out by the need to spend billions of pounds on wholly avoidable illness.’
Recent figures show that these predictions are coming true. Box 1 shows the current evidence for the growing health and wellbeing gap in England.3,4
Current evidence for the growing health and wellbeing gap in England
The promise of GPOS and more generally technology-enabled care services (TECS) in the NHS is that we will be able to do more with less: reducing demand by providing access to routine services (and beyond) and increasing productivity by freeing up practice staff and clinicians’ time. As reported in the recent Topol Review — Interim Report,5 Health Education England (HEE) forecasts that a failure to reduce demand and increase productivity will result in a shortfall of 118 000 staff by 2027. If services such as GPOS are not taken up and/or do not meet users’ expectations, the likelihood is that the gaps in access to care will continue to widen, and scant resources will be spread even more thinly.
FACTORS AFFECTING TAKE-UP
Digital literacy
Going digital, using GPOS as the spearhead, was a key message for the future of primary care, set out in the GP Forward View.6 But there are perennial complaints from practices about the lack of interest in digital modes of delivery of care from certain sectors of the population, in particular older people. This is a concern when these groups are also the people who may benefit the most from digital access. But do the complaints bear scrutiny? Data relating to internet access and usage of online transactional services7 are relevant comparators as a guide — the former is required for GPOS and the latter what most patients use GPOS for, that is, reordering prescriptions and booking/cancelling appointments. The data show that households with only one person aged ≥65 years had the lowest proportion of internet access. However, these households also had the fastest rate of growth in internet access (Box 2).7
UK internet access figures7
National proportion of households with internet access | 90% |
Proportion of households with internet access with one person aged >65 years | 59% |
Households with fastest growth rate in internet access | >65-year-olds (up 23% since 2012) |
Similarly, internet usage figures describe a digital literacy age-gap: only 48% of the >65-year-olds used the internet to shop online, but they had the fastest growth in internet shopping too (Box 3).7
Online shopping figures by age group7
16–24-year-olds | 95% |
>65-year-olds | 48% |
Fastest growth rate by age group | >65-year-olds (up 32% since 2018) |
So, although these data do support the claim of a digital literacy age-gap in the UK, they show it is narrowing faster than ever and numbers of those who do not have internet access and/or do not use the internet for transactions are dwindling. Thus (answering the complaints), it should only get easier to promote GPOS if present growth rates persist.
Of course, there are many other factors involved in the digital literacy question for both the ageing population and other social groups affected. While recognising that older people and those who are disadvantaged are increasingly using GPOS, more needs to done to make them as easy to use as other commercial apps and the affordability and/or connectivity of internet-linked equipment should be considered. The solutions require concerted efforts on multiple fronts. For instance, a general practice nurse action learning programme in Staffordshire is creating digital nurse champions who receive training and support to use health technologies and then share their knowledge and enthusiasm for TECS with their practices and patients.8 Even those nurses who (by their own admission) were not digitally savvy learnt how to use different modes of TECS such as GPOS, Facebook, apps, telehealth, and video-consultations, depending on their clinical focus. This type of frontline clinical champions approach is just what is required to help accelerate the digital revolution.
Variation of services
Patient sign-up to GPOS in Staffordshire ranges from 3% to 51% of patients in individual practices (as of November 2018). The variation in ways practices operate GPOS is considerable and may account for limited sign-up and usage, causing consumer dissatisfaction and loss of interest. Currently, patients who request access to GPOS via their practice are offered a few options for third-party solutions to enable them to view their own records online. Patients are given a code and password that can be used for recommended apps/portals provided by the practice, or they can search the App Store or Google Play Store for another option they may prefer. Functionality can differ between these products, but ultimately they should all present levels of record access requested/permitted by practices. Generally, this is access to appointments, prescriptions, and list of allergies. There is no right or wrong app to use but, as with all products, if the one chosen does not work well patients are unlikely to return and use it again, which may impact on usage of GPOS across primary care.
IS THE NHS APP THE SOLUTION?
Although the present transactional offer of GPOS may not feel transformative, it opens the door to faster and more personalised patient access to other facets of health and social care in the future. The NHS app allows citizens to identify themselves using the national Citizen Identity tool. This should potentially help by overcoming the annoyance for patients being required to attend their GP reception in person to validate their identity with supportive documents. This is a requirement that seems counterproductive in the modern world. Therefore, providing an option whereby patients can verify their identity online rather than going to their GP surgery removes another barrier.9 The new NHS app aims to address market competition on two fronts: with trusted branding and extra functionality. First, as market competition steadily rises, the importance of being the reliable provider increases. Second, the NHS app is intended to launch the additional facility of a symptom checker and access to donor information, that is, opt-out status. Although these are useful additions, some providers are now enabling access to GP consultations via mobile phone. A major shift in the landscape is taking place and, without further investment, the NHS app risks falling behind the competition. Increasingly, patients who prefer convenience and are prepared/able to pay for it are turning away from their usual general practice provider to an online private provider, raising another conundrum for traditional general practice altogether, as the richer and generally healthier patients are creamed off the NHS budget, and this in turn means risking financial deficits in traditional general practices with proportionately more complex and frail patients. Despite concerns raised over patient safety in 43%10 of online providers (for inappropriate antibiotic prescribing and failure to gather necessary patient information from GPs), this new style of healthcare access is increasingly popular and widening health inequalities further. Therefore, to help bridge the gap the NHS app needs to go much further than currently planned (requiring substantive government funding and support) to enable GP practices to provide similar e-consultation facilities, like some commercial companies are, meaning that patients do not have to de-register from their usual general practice. Paraphrasing Professor Helen Stokes-Lampard’s address at the recent RCGP annual conference, online general practice services should work for patients, make GPs’ lives easier, and ‘… not line the pockets of private investors at the expense of the NHS’.11
As demand for services continues to rise, digital delivery may provide an essential part of the solution to the necessary changes in healthcare provision, making the NHS fit for the 21st century. The more power patients are given to manage their health with online services, the more NHS resources can meet the needs of its population. Encouraging figures show that age-related digital literacy is improving and therefore demand will grow for online services as the population ages. Moreover, with further initiatives that champion digital services from the ground up, engagement is likely to be more meaningful. Improvements to GPOS are coming in the shape of the NHS app, which could be not only a better version of GPOS but also provide a platform for the latest digital health services. However, an eye must be kept on market developments for, without proper investment and vision, the danger is that expectations and reality may never meet.
Notes
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2019
This article is Open Access: CC BY-NC 4.0 licence.