Hands up who is finding life tough in General Practice at the moment? Certainly me for one, and if our straw poll from the Hot Topics webinar last Saturday is anything to go by, I am not alone (thank you to everyone who joined us on such a lovely day!). 96% of you said you were struggling with the current demands and ways of working. There will obviously be a multitude of reasons for this, but the current upsurge in demand on the back of an exhausting year and major changes to the way we have had to work will be key factors. But I had a very supportive appraisal last week which helped, and I am always grateful for my yearly ‘check-in’, but really appreciated the less demanding written requirements this year!
So not all change over the past year has been a bad thing, but one of the things we discussed in my appraisal was how the move to remote consultation has impacted me and my patients, and my concern that this has negatively impacted continuity and patient care. This change was absolutely necessary at the beginning of the pandemic, and I’m sure we would all agree that there have been many benefits and positive legacies. However, a year down the line it is time to take stock and reassess what is working and what isn’t working.
The effects of remote consulting was the subject of an excellent study published in the BJGP last month (BJGP 2021; 71 (704): e166-e177). It was a mixed-methods longitudinal study assessing both quantitative and qualitative data on consulting practices in primary care between April-July 2019 and April-July 2020, thus covering the changes and impact over the first period of the pandemic. It covered 21 practices in the west of England and over 350,000 patients, representing a very good sample size.
The quantitative data confirmed that GP consultation rates dropped in the early part of the pandemic from 218 consultations/1000 patients in April 2019 to 180/1000 patients in April 2020 (although consulting rates for the elderly were steady and actually increased for those with mental health problems and those shielding). By June/July 2020 consultation rates were back to pre-pandemic levels (and this doesn’t include the nurse/paramedic consultations!). The data also confirmed the massive shift to remote consultations - in April 2019 67% of GP consultations were face to face (F2F), by April 2020 only 9% were F2F, but by July 2020 this had risen only marginally to 14% F2F. Video consultations had a very brief initial surge but this waned quickly and video consultations had limited impact due to many issues including connectivity and IT, in contrast to the massive increase in SMS contacts.
But for me, the most insightful information was in the qualitative data. Initially, there was ‘universal consensus’ on the need for remote consulting with staff feeling ‘a strong sense of achievement in having worked so effectively….to implement the necessary change’. However, as time went by practices reported increasing challenges with remote consultations - ‘many telephone consultations required more careful questioning than pre-COVID (because even complex problems were now routinely managed by phone)’ and ‘fatigue from holding increased levels of clinical risk, partly because of remote consulting and partly because of the backlog in secondary care’. This was neatly summarised ‘as consultation rates returned to normal from July 2020 and patients began to consult with more complex problems, GPs found remote management can be more time-consuming, clinically challenging and less satisfying.’
So here we stand, almost 10 months on with a bit of a ‘curate’s egg’ situation. Yes, there have been many positives to come out of the changes during COVID - I’m sure we would all agree (as was highlighted in this study) that many problems we deal with in General Practice can be dealt with remotely, that SMS messaging is both convenient and a great ‘safety net’, that being able to work from home with flexible start times can help with family life, and that we don’t want to go back to waiting rooms stacked with patients getting frustrated that Dr Walker is running late again. But this data highlights important issues around the ongoing delivery of this level of remote consulting - it carries greater clinical risk, it is difficult (and slower) to address complex issues over the phone, risks widening health inequalities for those with poor IT access or skills, and some people just hate it and very much see it as the telephone ‘consolation’ that one of my ex-colleagues termed them. So I would very much agree with the conclusions of this study that ‘promotion of it (remote consulting) as a preferred consultation process is premature’, that the model will need to evolve and that post-pandemic the proportion of F2F consultations should increase.