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Video: Dr Minal Bakhai keynote talk from HTN Digital Primary Care

Dr Minal Bakhai, the Clinical Director for Digital First Primary Care at NHS England and NHS Improvement, delivered one of the two keynote speeches at HTN Digital Primary Care 2021.

Focusing her talk on a ‘digital first primary care’, Dr Bakhai began by asking the audience to “take a step back for a second” and think about the digital landscape pre-COVID, and also how – during the pandemic – digital tools have been rapidly adopted out of necessity.

Explaining that there has been a “doubling” in the use of online consultation systems, she said that “we’re now seeing 600,000 requests made through an online consultation system per week” and noted there has also been a “quadrupling” in the use of one-to-one SMS – from around 500,000 to over 2 million per week.

The availability of online and video consultations, she added, has also increased – with video rocketing from just three per cent of GP practices offering the format to around 99 per cent currently, while online appointments have jumped from 30 per cent of practices being able to offer the service to over 95 per cent.

This, she said, was “extraordinary” and a “substantial change” – probably one of the fastest at-scale changes that the NHS has “ever seen”, due to the agility and adaptability of general practice in the face of a global pandemic.

“This is about looking at system models, service redesign”

Moving away from the COVID-19 pandemic context, however, Dr Bakhai steered the conversation towards thinking about what ‘digital first primary care’  actually means. “Have we connected digital transformation with the purpose and values of many practice teams?” she questioned.

“Why is ‘digital first’ an important part of NHS policy going forwards?” she considered. “Actually, for me, this is about looking at system models, service redesign – what is the model that we are looking towards, and therefore, how can digital be an enabler to help improve and augment that model?”

Citing some of the pressures in general practice management: high demand for services, staff exhaustion, the juggling of the vaccination programme – which general practice has delivered 75 per cent of – Dr Bakhai acknowledged that patient expectations were changing but that there seemed to be limited ways to enhance GP capacity, quickly.

“Some of these are the same problems we were facing pre-COVID, but they’ve just been exacerbated during the pandemic,” she said. “There is a lot that we can learn from each other to help shape what a good service redesign of the general practice model needs to look like.”

“Deep-diving” into different types of demand on services, Dr Bakhai revealed that around 30 to 50 per cent of appointments are seen as “movable” and that about 20 per cent of GP time is spent on around five per cent of patients – “those that contact us three or four times a week”. She add that this tends to be a majority of younger patients who are struggling with “complex social needs” – with primary care stepping in to act as a “sticking plaster solution” because “there’s a gap in our services for these people.”

“Digital first is not wanting to just digitise the patient interaction”

To inadvertently avoid shutting out others, and particularly those that are vulnerable, Dr Bakhai returned the conversation to the part that ‘digital first’ could play.

“Digital first is not wanting to just digitise the patient interaction – it’s about wanting to better match urgency and need to clinical capacity. We don’t want to force patients to go online but what we do want to do is be able to see our demand more clearly,” she explained.

“We want to be able to allocate our resource better and we want to enable patients to interact in ways that suit them better, whether that’s from home – in their own environment, where they feel there’s a better power balance – or if it’s talking about difficult subjects or supporting self-care.”

“We’re on a journey to each of these,” explained the practicing GP, “[we’re] thinking about what we’ve learnt from the pandemic; the importance of signposting and triage, being able to move away from a model that is ‘first come, first served’, to a more equitable model which prioritises care based on need and matches people’s need to the best person or service.”

“It’s about having a choice of consultation models, moving away from a one-size-fits-all,” stated Dr Bakhai, “it’s about integration…having well-designed user experiences that can take people to the right service without having to repeat their story. And it’s about optimising the use of our skills and expertise, because we don’t have enough GPs. How can we better use our social prescribers, community pharmacists, PCN pharmacists, physiotherapists etc.”

“Fundamentally, it’s about service redesign underpinned by three principles – inclusive access, equity and personalisation,” she said. “The aim is, can we meet patient need through the most appropriate person with the minimum number of hand-offs? Can we then help practices better meet patient demand within their existing capacity, by using the skill mix of the wider team, not just the GP?”

Independent research, Dr Bakhai added, showed that by ensuring the service model is designed well, practices could take back control of the situation. This could mean they then have the ability to organise their working day, sort requests and prioritise based on need, have greater flexibility and be able to spend more time on those with complex needs, make it easier to have team meetings and huddles to foster relationships, and enable staff to work more flexibly, too.

Dr Bakhai then shared a case study of patient who successfully used an online consultation to get help quickly and receive a swift diagnosis, to outline how online systems and digital tools can help those that may be in full-time work or have caring responsibilities, as well as people with disabilities or impairments, or those who may feel uncomfortable discussing a problem face-to-face.

“It’s important to keep that mind when we’re thinking about how we design our systems, and the digital tools that we want to use to enable access,” she said.

“We as general practice need to celebrate what we’ve achieved”

Dr Bakhai also went on to praise the ‘simple’ success of telephone triage and consultations – and how this has flown under the radar – before stating that “we as general practice need to celebrate what we’ve achieved, because it’s no small feat”.

Returning to service design, she pointed out that “amazing is the new norm” thanks to global search and video platforms, and free call and messaging capabilities. The London-based GP then went on to highlight positive examples of NHS digital user experience, as well as examples that would illustrated that there is need for further improvement, to show that there is currently a “huge variation in the online consultation platforms and journeys”.

“However,” she said, “it’s important to stress that great user experience does take time and energy and effort,” highlighting the need for “deep collaboration” with practices, patients and system suppliers to design a better service.

Explaining that there is currently a national programme – a rolling piece of user research – to identify needs and pain points and help shape better standards, Dr Bakhai spoke of planned improvements to data quality and piloting work around national communications.

Speaking of the new procurement framework – the DFOCVC [Digital First Online Consultation and Video Consultation] framework, which was launched in April, she added that it: “streamlines frameworks….so that there is one place to find the suppliers, it increases requirements and standards on suppliers – so it brings all the standards together, it increases clarity about the capabilities of different products – there’s a buyer’s catalogue. I would urge you to have a look at that and please give us feedback.”

On the NHS’s work around integration, she added: “We’re currently testing integration of online consultations with the GP IT clinical systems, with the next step being able to pass structured, coded data from the online consultation into our GP clinical systems to reduce manual burden.”

To conclude, after discussing other current bodies of work and future aims for service redesign, Dr Bakhai gave the audience a “sneak preview” of some of the user design work – a one-click button to send an online consultation to pharmacy, when it falls into a practice workflow. “This is the key”, she summed up, “how can we use digital as an enabler to make the journey really seamless – both from a patient perspective and from a practice and pharmacy perspective? That is really the focus from the service redesign that I’d like to see going forwards with digital first.”

To find conversations around this topic and more, follow the hashtag #DPC2021 on Twitter.

Watch Dr Bakhai’s full presentation, or view the audience Q&A, via the video the link below: