Researchers warn online GP consultations need careful implementation
22 January 2019
The new NHS 10-year plan launched earlier this month [7 January] states all patients in England will have access to a "digital first primary care offer", such as GP online consultations, by 2022/23. Online consultations have the potential to improve patient access and reduce face-to-face contacts, freeing up GP time. But research led by NIHR CLAHRC West and the Centre for Academic Primary Care at the University of Bristol found that unless these systems are carefully implemented, they won’t yield the benefits policymakers are hoping for.
The researchers, in collaboration with the One Care Consortium, conducted the largest UK study of online consultations to date. The study examined the effectiveness, acceptability and impact of implementing a GP online consultation system (eConsult) in 36 GP practices in Bristol, South Gloucestershire and North Somerset.
Patients access the eConsult system via their GP practice website. Patients who want help for a specific condition are given options to access self-help information, learn about pharmacy treatments or contact NHS 111. Patients can also submit their symptoms via an online form, creating an 'e-consultation'. For any urgent symptoms identified during the eConsult process, patients are signposted to their practice, emergency services or NHS 111.
The research found:
- Patient satisfaction with the online consultations was high and they improved access for some patients, but staff at GP practices didn’t think they created efficiencies
- 70 per cent of online consultation resulted in a face-to-face or a telephone consultation with a GP
- Online consultations risk increasing workload in GP practices unless they are carefully implemented and effectively marketed
- Online consultations may have value for some patients, such as test results or advice for ongoing conditions, but they can't replace face-to-face consultations in more complex situations
- Patients need guidance on when to use self-help, when to consult online, and when to book a face-to-face appointment
- Evaluating the implementation of online consultation systems is essential to monitor patient experience, risk and workload
Dr Jeremy Horwood, of NIHR CLAHRC West and the Centre for Academic Primary Care at the University of Bristol, said: "Online consultations may have value for some patients, such as straightforward medical enquiries, but they cannot replace face-to-face consultations in situations which are more complex. There is a central government drive to move to these systems, which is a key part of the NHS 10-year plan. But our research shows they need to be carefully implemented and effectively marketed to yield the benefits that politicians are hoping for."
Over half of all patients using the system were aged 25–44 years. The oldest patient using the system was 90 years old. Most online consultations were completed during GP practice opening hours.
More than a fifth of all online consultations were for 'administrative reasons' such as fit notes, repeat prescriptions or test results. The next most common reason related to infections followed by musculoskeletal issues such as back or knee pain. In almost a third of cases, the patient had consulted about the same issue within the previous six months. Most patients (66 per cent) received a response within two days.
The staff cost of dealing with an online consultation was higher compared to a standard GP face-to-face consultation. The cost was driven mainly by the time needed for a GP to triage the e-consultations and that 70 per cent of online consultations resulted in a face-to-face (38 per cent) or telephone (32 per cent) consultation with a GP, which could duplicate workloads. A face-to-face consultation was more likely for patients presenting a new condition.
Staff felt that online consultations worked well for straightforward queries such as prescriptions, fit notes and follow-up from previous consultations. These enquiries didn’t need direct contact between the patient and the GP.
GPs often needed to see or speak to the patient when patients had multiple symptoms, had conditions which were new and complex, or GPs weren’t able to interpret patients’ symptoms from the written information provided.
Patients satisfaction with the system was high with most (81 per cent) likely to recommend the system to others, while 76 per cent said they would use the service again instead of booking a face-to-face appointment.
Patients were usually dissatisfied with the system because of:
- lack of interaction with a GP
- missed communications
- thinking that their query could be answered remotely, and then being asked to book an appointment
- delay in receiving a response from their online consultation
While some patients used the system to try and save time for themselves and their GPs, some used online consultations when they couldn’t get a timely face-to-face appointment.
Improving the use of online consultations
Online consultations need careful marketing. Online consultations cannot replace face-to-face consultations when diagnosing new or complex symptoms. Practices should consider marketing their system to encourage patients to use online consultations for routine enquiries or follow-up advice and discourage use for more complex enquiries where a face-to-face appointment will probably be needed.
Online consultation systems need to be carefully implemented. GPs who are familiar with the patient and their condition may be better placed to respond to an online consultation, as they might be more aware of the patient’s care needs and ensure continuity of care. Also, when an online consultation was followed up with a face-to-face appointment, if the GP who initially read the online consultation sees the patient, the consultation could be quicker and more focussed. Practices should, where possible, consider which GPs undertake online and follow-up face-to-face consultations.
Make sure the patient knows what's happening. Whilst most patients were satisfied with their online consultation, 14 per cent said that after a week, they still hadn't heard back from the practice about their online consultation. Communication channels need to be robust, to make sure that all patients know what’s happening in a timely way following their online consultation.
If a GP practice is using an online consultation system, it could be improved by:
- Using signposting to encourage patients to use online consultations for simple conditions or questions, and encourage patients to directly book a telephone or face-to-face appointment for new, complex or multiple symptoms
- Triaging patient queries to direct them to the most appropriate service, such as a pharmacy for hay fever
- Allocating online consultations to GPs who already know the patient
- If a patient needs a follow-on phone or face-to-face appointment following an online consultation, allocate this to the GP who processed their online consultation if possible
- Ensuring that there is a robust system to communicate back to patients the results of their online consultation in a timely way.
'Use of a primary care online consultation system, by whom, when and why: evaluation of a pilot observational study in 36 general practices in South West England' by Hannah Edwards, Elsa Marques, Will Hollingsworth, Jeremy Horwood, Michelle Farr, Elly Bernard, Chris Salisbury, Kate Northstone in BMJ Open
'Implementing online consultations in primary care: A mixed method evaluation extending normalisation process theory through service co-production' by Michelle Farr, John Banks, Hannah Edwards, Kate Northstone, Elly Bernard, Chris Salisbury, Jeremy Horwood in BMJOpen
'The use of electronic consultation in primary care: views and experiences from general practice' by John Banks, Michelle Farr, Kate Northstone, Elly Bernard, Chris Salisbury, Hannah Edwards, Jeremy Horwood in British Journal of General Practice
PolicyBristol Policy briefing: 'Online GP consultation systems need further development and careful implementation to realise benefits'
CLAHRC BITE (pdf) (research summary produced by NIHR CLAHRC West)