New models of primary care in the UK

Rodger Charlton

HK Pract 2019;41: 117-119

Summary

Heraclitus the Philosopher describes the only constant in life is change. So it is with primary care in the UK where there is considerable transformation and rapid change of the consultation arising as a result from the different models of primary care. These changes have been catalysed by a GP workforce which has been reducing through poor recruitment and retention as well as fuelled by increasing patient demand and expectation for instant access. In London, the e-consultation has now taken off exponentially with a new organisation called ‘GP at Hand’ working with the digital health provider, Babylon, to provide video consultations on smart phones. This has global implications as Babylon seeks to expand.

Advances in Technology allow not only rapid improvements in diagnostic techniques, e.g. through new enhanced imaging but also evolving treatments, not least in cancer care. Similarly, the way doctors consult is changing through information technology and smart phone devices. This has implications for the doctorpatient consultation, not just in the UK, but globally. In this short paper the term General Practitioner (GP), Family Physician and Primary Care will be used interchangeably for a global audience.

摘要

哲學家赫拉克利特說，“世上唯一不變的是永遠在變”。 英國的基層醫療也是如此，由於基層醫療的模式不同而導致了診療的巨大的變革和快速變化。人才聘用和保留機制 不佳導致的全科醫生數量減少，以及患者不斷增長的需求 和對立刻得到服務的期望，更是加劇了這些變革。電子診療在倫敦飛速發展，新機構“指尖全科醫生”(GP at Hand) 與數字醫療供應商“巴比倫”(Babylon) 合作，通過智慧手 機提供視頻問診。“巴比倫”公司正在尋求擴大發展，因此這將對全球產生影響。

技術進步不僅讓診斷技術得到快速完善（如新的強化影像），而且也使治療得到改進，特別是癌症治療。同樣，利用資訊技術和智慧手機設備，醫生診療患者的方式也在 改變。這些都對英國、乃至全球的醫患關係產生了影響。 為方便全球讀者，全科醫生(GP)、家庭醫生和基層醫療在本文中具有同等含義。

The consultation model is changing

Consultation models are the frameworks in which doctors and patients meet and interact and may involve lists of questions in an organised way. They are useful in teaching consultation skills. Until very recently the basic tenet of the consultation has been that the doctor and patient would meet in a consulting room (GP or hospital clinic) or at the bedside in the patient’s home or hospital. Where this patient-doctor interaction involving verbal and non-verbal communication and a physical examination were not possible, a limited consultation may take place via telephone, including telephone triage, often to be followed later by a face-to-face meeting.

Sir James Spence Professor of paediatrics, Newcastle upon-Tyne in 1960 said, “The essential unit of medical practice is the occasion when, in the intimacy of the consulting room or sick room, a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation and all else in the practice of medicine derives from it.”¹

Now the availability of e-consultations through smart phone devices takes this to a different and challenging level.

Evolving clinical environments

In the UK and other countries more complex care is taking place in the community and less in hospitals with the advancing diagnostic and treatment potential available to GPs. Patients present earlier on in an illness or attend for screening and preventive care. Thus, proactive rather than reactive care is happening. Patients’ expectations are higher including not having to wait to be seen by a doctor and access to doctors 24 hours a day. This requires new innovative models of care to meet these needs. This is occurring with an underlying background of recruitment and retention difficulties in the medical and other health care professions. It all results in a reduced workforce and an increased demand for health care.

In the UK, this has led to the observation by some of a crisis with the public wanting instant access to health care. This has resulted in hospital emergency departments being flooded with patients, many of whom would be better treated in the primary care setting. In rural and remote practices, telemedicine has been used e.g. for the diagnosis of rashes and skin lesions. However this has often resulted in a request by doctors to see the patient with a rash for greater clarity. Smart phone devices with an ever higher camera quality and video facilities are overcoming the need for this and henceforth resulting in the redundancy of face-to-face clinic appointments.

Patient needs and ideals

In the UK the average patient consults 5 times per year with up to 3 problems in each consultation. The duration of consultations is currently 10 minutes and patients and doctors now believe this to be too short. There are increasing frail elderly patients with complex multi-morbidities who need considerable time spent with them to stay healthy and independent in the community. Although GPs and their teams now see just over 90% of patients it can be argued that resources to take over work from hospitals is not increasing in real time. The NHS (National Health Service) has celebrated its 70th birthday and is the largest employer in the UK with a huge expenditure and a workforce undergoing change fatigue as politicians increasingly introduce new strategies which can be at odds with the views of health care professionals themselves. The King’s Fund who regularly evaluate change in the NHS has defined 5 key attributes that underpin General Practice which are: that it is patient-centred, has good access, is well coordinated, provides continuity of care and is community focused. ² These attributes should be borne in mind particularly in relation to e-consultations.

The 5 year forward view

In 2014, the UK government funded an initiative which encouraged smaller GP practices to join together as a consortia, alliances or partnerships with registered patient populations of up to 50,000 patients or more.This enabled practices to extend opening hours and so access from 8am to 8pm, 7 days a week with central hubs for urgent problems and financial inducement for these practices also to provide out-of-hours cover. This could not be done by the small individual practices. The resultant implications are that patients may need to travel further to be seen and there may be a reduction in the continuity of care provided by a personal trusted doctor. Therefore for many patients the ‘Big is Beautiful’ of small practices coalescing to form large GP practice units would not necessarily be of their choosing. A target of the 5-year-plan is also to provide a definite cancer diagnosis 28 days following GP referral, a maximum of a 4-hour wait in hospital Emergency Departments, increasing availability of psychological therapies with a transformation in child, adolescent and adult mental health services and integrated health & social services care.

New innovative models of care

The traditional model of General Practice in England is changing. New regional and locality models of care has arisen through considerable Government funding. This has resulted in new initiatives referred to as National Health Service (NHS) Vanguards which are regional groups viewed as leading new developments with new regional services involving major redevelopments and often franchising with the private sector. Similarly locality Sustainability & Transformation Programmes (STPs) are in place to plan for the long-term needs of local communities. The terminology is confusing and changing again with the now new NHS Long Term Plan. Traditionally GPs have been independent contractors subcontracting their services to the NHS but many newly qualifying GPs prefer to be salaried and work in large groups including the NHS Vanguards and STPs which may or may not integrate with the traditional partnership model of a GP practice. Another new model which may become more widespread in Central England is the Royal Wolverhampton NHS Hospital Trust which has taken over GP practices and employed GPs to work in the community. In July 2018 it was reported that the hospital has taken over its 9th GP practice with a total of 70,000 registered patients and employing 43 GPs. A further new model within some existing GP practices, but at a smaller local scale in order to stay viable, has looked at ways of reducing workload and this in the past has been via the employment of ‘expert patients’ to work with patients. Now the concept of group consultations as a sustainable alternative to current one-to-one primary care consultations has reported some success for patients with long-term conditions such as diabetes. ³

Digital consulting

Until the advent of the smart phone, digital consulting happened occasionally by email or Skype. A further new model of the e-consultation has now taken off exponentially with a new organisation called ‘GP at Hand’ starting in Hammersmith, London, in 2017. They have chosen to work with Babylon, which is said to be UK’s leading digital health provider. 200 GPs are working for Babylon with 40,000 NHS patients in London being registered with this group. They aspire to expand to other parts of the UK. It is available 24 hours a day on a smart phone or in person at 5 clinics in London and offers Skype-like video consultations. Babylon’s mission is to put an accessible and affordable health service in the hands of every person on earth. Currently it is in the UK and Rwanda and has plans in progress with major providers in China including Hong Kong, the USA and the Middle East. Their offer is to see a GP from wherever a person is, access them through an app on a smart phone and to be able to replay the appointment.

There are some issues that are being raised even though it has been inspected by the Care Quality Commission. Does it meet the King’s Fund 5 key attributes that underpin General Practice? How safe is the interactive symptoms checker which has been reported to have a high rate of false positives? Will it impact on traditional General Practice as this model is ideal for the fit and well of the population? Could this cause a diversion of funding which could destabilise existing GP practices providing more resource intensive care for frail elderly and vulnerable patients? What of the doctors who works for it – will there be analogy with Uber taxi drivers as one can clock on and off as available and so what of continuity of care? It does, however, provide instant access and the support of Government with their pledge that every patient should be able to Skype their GP in five years’ time via an app and as part of the New NHS Long Term Plan, 1 in 3 hospital clinic appointments are to be replaced by Skype appointments. Similarly in Hong Kong, there are potential implications for primary and secondary care.

Future role of the GP and the consultation?

A new digital world is evolving rapidly and influencing and potentially replacing the once face-to-face consultation and personal trusted relationship with one Family Physician. It is a challenge for patients and doctors alike and what remains of the face-to-face consultation. In terms of training, it will become a consultation model in its own right and developing skills in digital consulting will be necessary as has happened with telephone triaging, where the patient is not present with you in a consulting room. In order to aid this process, for all of us working in health care, there is a challenge to ensure effective information-sharing of the patients’ records. Patients can themselves, if needed, be able to share information digitally during and out-of hours and in all clinical settings. This would require a shared software where the patient owns the record and decides who has access to it.

This changing UK model will have a global impact and other countries need to be prepared and embrace it to ensure the key attributes of accessible, good, personal and patient-centred care in the community.

Editor’s note: Charlton R. Paper summarises the above lecture given to the Hong Kong College of Family Physicians on Wednesday 9th January 2019 at 2:30pm via video link at the Lecture Theatre, 8/F, Ambulatory Care Block, Tseung Kwan O Hospital, Hong Kong.