In our Digital First Primary Care feature we speak with TPP and X-on to hear how the organisations are respectively driving digital primary care.
We explore the past few months, some of the recent challenges, and what’s next for the providers.
We speak with Paul Bensley, CEO of primary care communications specialists X-on, and Matt Stickland, Director of Strategy & Communications at TPP.
We ask both Paul and Matt about the technology projects they have focused on in supporting healthcare over the past 12 months and also during the Covid-19 pandemic.
Paul starts our feature, explaining how X-on’s cloud-based digital telephony system Surgery Connect has been evolving and how it has been able to quickly adapt in the past few months.
Following close collaboration with GPs, X-on has also developed the GP@Home service, which allows doctors to provide patients with the same level of phone and video care from their own home as they would from their surgery. The technology provider has also developed Video Connect, which enables GPs to switch from phone to video consultation in a single click. These two services are fully integrated into Surgery Connect.
What technology has X-on implemented in primary care?
We’ve been developing and delivering a digital telephone system for primary care over a number of years now and this has proved itself adaptable to a sudden change in situation during the pandemic.
We’ve switched from a culture within primary care with patients queuing at 8am on a Monday morning to get an appointment, to new ways of working remotely. This has been achieved almost within a couple of weeks. That’s something that couldn’t be accomplished with the legacy phone technology that’s still around. Our Surgery Connect system has enabled GPs to work in different environments, work from home, work in hubs, call patients back, not be limited by line capacity, integrate with video and also measure the response. We’ve demonstrated digital acceleration can actually work in practice.
I’ve tried to define it in three phases; the first phase, pre-Covid-19 within primary care, was characterised by patients calling in, getting an appointment and moving on – a standard approach. We then switched to a second phase, where we are currently – a telephone/video triage service with the telephone being the primary method.
There’s been an increase now in online consultation and chat, a sort of broadening of the routes but still fairly discrete mechanisms for delivering care. So, video for example tends to be a standalone system that has been purchased in a hurry where online is still catching up with different providers offering different types of service.
The third phase, after Covid, is knitting the aforementioned together. In other industries where you have an ‘omnichannel’ (within healthcare, effectively meaning that a patient’s way of getting care is not limited to one particular mechanism), users could be shouting at Alexa, going online or using an app on public transport. They are going through to a broader more responsive contact centre style solution but still at a local level – still primary care rather than a national 111 service, still getting a localised service for their care but something more bespoke and more extended across different types of media.
As previously mentioned, ‘omnichannel’ has been in common use in other industries for some years. For omnichannel to work, there needs to be two prerequisites: the technology needs to join up, so a patient request online, on the phone, on WhatsApp and so on, can be prioritised and triaged uniformly regardless of the access preference. Also, the GP front line needs to be of sufficient scale to handle the queue of requests. A small practice with 7,500 patients cannot make a GP available to service omnichannel requests, even if the technology is in place.
Omnichannel drives efficiency at a level above the current phase of ‘triage’. On our service desk, urgent requests come in by phone and are distributed to available experts who are also dealing with those that arrive through the web forms.
Some types of requests are dealt with by signposting to appropriate online resources, others are diverted automatically to other points of help in the company and some are processed during the inbound call and closed there and then. Given the prerequisites stated earlier, the same can be the case in primary care. Efficiency happens by removing layers of multi-touch, except in the case when that is needed.
What challenges have you faced recently?
One of the challenges that we’ve got is the increase in volume of outbound practice calls as opposed to inbound calls, which is a commercial change; it is something we are currently addressing. From March, telephone triage has suddenly become the norm, with a small proportion using the ‘free’ video option they have been given by providers. The patient goes online (web or app) or calls the receptionist and the GP calls them back. Demand and supply have been kept in check, though much of this is owing to the reduced demand from patients not wishing to bother the NHS with minor complaints.
Most legacy phone systems collapsed at the start of Covid-19 because there were insufficient lines to make the outbound consultation calls. This ceased though to be a problem when patients gave up calling their surgeries, believing that there were no appointments.
The new technology deployed suggests an explosion in digital adoption, however the approach has been necessarily piecemeal with some tools being adopted as personal favourites and many working in isolation. This phase could be characterised as ‘enforced triage’. Whether it will handle the return to full demand, or worse still full demand plus a second wave, is unknown.
I think there will be challenges in terms of the integration between multiple vendors because some very quick decisions have been made, particularly in relation to online and video that were rolled out in a hurry with huge budgets. Presumably those budgets are going to be more challenged in the future, but the work to be done is the more difficult bit, such as the integration and drawing of things together into a national framework where the data can be consolidated. That is going to be the future issue that will keep everybody scratching their heads.
What are you most proud of and what does the future hold?
I think it is the GP@Home package; the concept that a GP can work with all patient communication within a single package. This has been delivered to our existing customer base and also new customers, in fact an entire STP corner of London has committed to GP@Home as being their go-to patient communication mechanism for emergency use for the crisis and beyond.
We are certainly proud of how rapidly this package has been delivered. There is technology available now that can deliver the benefits of digital-first primary care, for both patients and practices. Today’s VOIP telephones can provide easy ways for patients to amend appointments, reducing ‘did not attends’. They can support more collaborative working, with video and teleconferencing.
We need to see telephony as one of several communication types integrated into clinical practice, so that GP surgeries offer a mix of face-to-face, telephone, video or online consultations, as required by the PCN contract guidance. Let’s get those basics right, and then we can be confident that digital-first primary care works for all.
We spoke with Matt Stickland, Director of Strategy & Communications at TPP:
Can you tell me about the past few months for TPP?
One of our first conversations was with Public Health England at the end of January. Very early on we were aware of a significant change that was likely to take place in healthcare.
To try and summarise what’s happened at TPP in the last few months, we can broadly put it into three categories. Firstly, engagement with end users. Obviously we haven’t been able to get out and about to speak to customers in person, but webinars and video conferencing have meant that we have still been able to talk with a lot of customers. We have probably been working as directly with end users as we ever have been, to work out their needs, explore what’s possible with the system, support their new ways of working, and look at any new developments required. It was clear in primary care that there were going to a pretty seismic change to the way healthcare professionals delivered care to patients. For example, we’ve been helping GPs move to use SystmOne remotely, over the internet, enabling them to have secure access to patient records with video and phone consultations from their own home.
As the Covid response has moved forward, the user needs have changed at both local and national levels. Sometimes the best solution has been for us to quickly get existing pieces of functionality into new care settings. For example, we made the national electronic prescribing (EPS) system available in non-GP settings, working with NHS Digital and NHSX. This has made a big difference for community prescribing and is now expanding into outpatient clinics. The original central assurance piece for community EPS was going to take up to 12 months but, with the drivers aligned, the functionality was live in a handful of days.
Secondly, we have been working closely with NHS England and NHS Digital on programmes specific to the Covid response. For example, we rapidly developed software to add and update lists of shielded patients into the GP system. We supported the NHS 111 Covid triage system with some new interoperability work, flagging suspected Covid patients to their registered GP. We’ve also completed the upload of “Additional Information” Summary Care Records for every patient on our system and pushed through a new Covid component of the GP Connect FHIR messages. In fact, this period has highlighted how much progress has been made in interoperability in primary over the past year. There’s still a long way to go – for example, with hospital settings – but the Covid response has benefited from the interoperability groundwork that’s been put in.
Thirdly, we’ve been supporting research and analytics projects since the start of the outbreak. We’ve worked with PHE to monitor childhood vaccination rates, have helped develop the new OpenSAFELY platform work with Ben Goldacre at the University of Oxford, have worked with the team supporting the national PRINCIPLE clinical trial, have produced two emergency primary care extracts for UK Biobank, and have helped CCGs with regional dashboards and reports.
These have been our three main strands of work. Alongside these, the biggest news for us in terms of products, has been the early release of our new patient-facing smartphone app, Airmid. Initially we anticipated releasing this towards the end of the year but we quickly realised we should push it through as quickly as possible. We knew it had functionality that would be extremely useful to patients and healthcare professionals during Covid-19. This included booking and performing video consultations, requesting repeat medication, barcodes for collecting prescriptions, viewing records, and the opportunity for digital first, patient-led consultations.
What’s coming up over the next 12 months?
I think the shift towards a larger percentage of remote consultations will remain; We’ve seen about a 950% increase in video consultations, where the numbers have gone from around 7,000 over a 2-month period in 2019, to about 75,000 in the same 2-month period in 2020. We have also seen telephone consultations ramp up, they’ve doubled from 3 million to 6 million over the same period.
There’s been a lot of excitement about video consultations, certainly in the media. However, the telephone has remained the most popular remote consultation method by far. There are all sorts of reasons for this – it was already an establishing working practice for many GPs, it reduces the digital divide for groups of people who may not have access to the internet and smart devices, and often a video is simply not required. However, for certain specialities, dermatology, for example, video consultations are used more frequently as the visual aspect is so important. There’s also no hard boundaries; a phone call can transition to a video call, which in turn can lead to a face-to-face appointment.
We have now moved into a different phase in the pandemic, and we are transitioning from a nationwide approach to lockdown to a more localised response. We have been talking to our users about building tools into the system to support this. This includes analytic reports and dashboards to give local areas insight as to what is going on in a region. The applications are broad. This can involve monitoring for local trends for Covid-related symptoms, as well as identifying Covid “aftershocks” and managing people with existing or new long-term conditions, who may not have received the routine care they need during this crisis.
What challenges has TPP faced?
Of course we have faced the same challenges that everyone around the world has – fear, worry and concern for family and loved ones. For everyone in digital health it has also been an exceptionally busy time. Whilst we are not on the frontline, we have a really strong sense of obligation to do everything we can to support frontline staff. I do think the health tech sector has stood up very well as part of the response.
We made a decision early on to ensure we could support our end users in the best way possible by running a complete service, but turning the focus directly onto Covid. Likewise, we made a decision not charge for any new work related to the pandemic but to provide solutions for free, for as long as they are needed. For example, we’ve installed 45 instances of SystmOne in the Covid-19 service hub that have been rapidly established across the country
Is there anything that you’re particularly proud of?
We were certainly pleased to have pushed Airmid out early and know that this was the right decision. The thing that makes us the most proud, however, is when you hear that some of the work we have done is making a difference to staff on the frontline. A word of praise from a doctor or nurse provides more motivation for us than anything we can do internally. It is fair to say that we really did come together as a whole team to make the decision to keep working as hard as possible to support the NHS. When you see how useful some of the developments have been to frontline staff – for example, the detailed Summary Care Record now being available to clinicians in urgent care settings – that’s the type of thing that makes us most proud.
There have been some important lessons for everyone working in digital health and we need to work hard to make these part of a new normal. They include streamlining assurance, improving governance, encouraging data flow, and promoting open national standards. We’ve also seen numerous projects going quickly from initial deployment to national roll-out, whereas previously they would have stayed in pilot phase for a long time. Suppliers can keep up this pace of working, if we remain focused on user outcomes, keep drivers aligned, and don’t let some of the historical blockers creep back in. There has been a responsibility on suppliers to be as responsive as possible during this pandemic. There are many great examples of this across health tech. It just needs to continue.