Dr Minal Bakhai, Clinical Director for General Practice Transformation and Digital First Primary Care at NHS England and NHS Improvement, delivered one of the two keynote speeches at HTN Digital Primary Care 2022.
Focusing her talk on ‘transforming the model of general practice’, Dr Bakhai discussed the changes in access to general practice. She highlighted the ways patients are now accessing general practice and shared some initial findings from user research, before covering the impact and opportunity of digitally supported models in general practice.
“We know that not everyone is digitally enabled”
Like all GPs, Dr Bakhai has seen profound changes in the last two years: “I’ve been trying to do my best in the midst of increasing demand from the COVID backlog, ongoing workforce pressures and a rising complexity that we’re seeing in health needs from our patients,” she explained.
In response to these challenges and wider trends, the way general practice is accessed is changing – a theme Dr Bakhai introduced in her previous HTN keynote. A flexible, “more digitally supported triage model” is vital, she said. “That could be online, it could be telephone, it could be in person. And it’s really important that all three are available, because we know that not everyone is digitally enabled.”
“It has been accelerated during COVID”
Moving away from a first-come-first-served approach to a consistent model of triage and care navigation is crucial, said Dr Bakhai. “Then we’re able to better prioritise care based on need, utilise the wider range of skills that we have within our team, including our PCN ARRS roles, to be able to use our workforce more effectively, and distribute work to the right person or the right services.”
Practice staff can then choose the best way to respond to patients, based on their clinical and communication needs, and regardless of the way patients first got in touch with the practice.
Dr Bakhai acknowledged that some of these changes began before the pandemic. “It’s not a brand-new model,” she said. “But it has been accelerated during COVID.” Her practice is in a deprived area of Northwest London, with relatively high levels of patient need, and it can be challenging to recruit staff. “This model has really helped us adapt quickly to the demands of the pandemic,” she said. “It’s actually helped us deliver benefits, particularly in equitable access, and in timely identification of the urgent and serious need, as well as the efficiencies in how we use our staff time.”
“Every system is designed to get the results it gets”
“Every system is designed to get the results it gets” is a famous quote attributed to the engineer W Edwards Deming. For Dr Bakhai, it’s a crucial point when we consider online consultation tools, which are hugely diverse in function and design, as well as the way they’re implemented.
“It’s not surprising,” she said, “that we’re seeing variable impacts of these types of systems within different practice and patient contexts. And that we’re hearing they work for some practices, and they’re not working for others, or that they’re working for some patients but not working for others.”
The Improvement Analytics Unit (IAU) has looked at quantitative data showing the impact of online access and different implementation models. The study considered one form-based online consultation system across 146 UK practices, taking into account different practice sizes and levels of deprivation. In total, 7.5 million patient-initiated requests across all access routes were analysed.
Demand has increased by “almost a quarter”
Patient-initiated demand has increased by “almost a quarter” since the pandemic began, noted Dr Bakhai. “But there was no evidence in the analysis that this was driven by the online system making access easier or from supply-induced demand. Rather, this was growth due to pent-up demand, a backlog of the pandemic, an increase in use of services and an increase in requests about new problems.”
The analysis showed a shift to online from phone and in-person and showed that the way patients contacted their practice depended on their context. For instance, once patients had used the online channel once, they were more likely to do so again. Patients getting in touch about an existing medical problem were also more likely to go online than those with new problems.
The contact channel chosen did not affect the consultation modality that followed. “Face-to-face consultations,” explained Dr Bakhai, “were more likely to be used for new problems, new patients, the very old, the very young, and those more likely to need a physical examination. Remote consultations are more likely to be used for those with existing medical problems and well known to their practice.”
Crucially, despite concerns about the digital gap, while older patients were the least likely to use online in these practices, said Dr Bakhai, “they still accounted for the greatest increase in contacts during the pandemic”. Another positive sign was the response time, which was “usually within five working hours”. Dr Bakhai also noted that “only a minority of patients at these practices requested face-to-face care”. Pre-pandemic, this figure was around 30%, at the height of the pandemic it was under 4%, and by September 2021 it was at around 10%.
“The findings suggest that some of the key concerns about encouraging greater use of online access to general practice can effectively be addressed in a hybrid model that combines the digital and non-digital,” said Dr Bakhai. The fact that patient preferences are more nuanced than simply preferring a single mode of access, meanwhile, shows a “complex interplay of multiple determinants of good access,” she continued. We need to “take a holistic approach to the quality of access and avoid a focus on any single aspect, or targets”.
“We have a bit of catching up to do in healthcare”
The study focused on a single online consultation system, but different systems and models will have different effects. We need to prioritise user centred design. And it’s clear as an increasingly utilised starting point for many patient journeys, some websites do not offer the best user experience. Between 2019 and 2021, the proportion of people trying to use GP surgery websites to access services and information rose from around 38% to almost 53%. Such users may expect the intuitive design of services such as Google and Whatsapp. “We have a bit of catching up to do in healthcare,” acknowledged Dr Bakhai, “because we don’t necessarily mirror some of that great user centred design in the NHS. Some websites might not offer the warmest welcome for patients.”
Dr Bakhai’s team tested seven GP website templates, representing 80% of the market. The 63 testers struggled to complete basic tasks (such as getting test results) around a third of the time. To find an online consultation form took them up to six minutes, with around a third not finding the form at all.
Key terms were another source of difficulty. While routine and urgent appointments were widely understood, “there was confusion around what emergency appointments meant, particularly in a general practice setting,” said Dr Bakhai. Language such as “triage”, “online consultation” and “clinician” caused further problems. More testing will follow, and Dr Bakhai underlined that “we need to think of more precise and well understood terminology to help patients”.
“We need to design for equity of access”
Dr Bakhai has “continuous improvement” in her sights. She underlined that user-centred design and better terminology can make a real difference to digital inequality. “We’re working with suppliers to improve the usability and accessibility of products and strengthen standards,” she said. That means collecting data to understand the online journey – and the points where users drop out of it.
“As the research demonstrated, we need to design for equity of access, and equality of outcomes,” she said. “This is an adaptive change. And it’s not easy, and the energy and the effort and the investment required should not be underestimated.” Practices must be supported in the adaptive change with a “robust support infrastructure” and provision of a “differentiated support offer” that “recognises that everyone’s context is different and there is no one size fits all”.
Digital should be an integral part of equality impact assessments. Dr Bakhai suggested assessments should be brought to life by considering “different patient personas, how they might be able to traverse our models of care and how they access our services. They can then inform an approach in which you’re always thinking about individuals, communities and how a model of general practice in primary care can support them.”
“I think the future is really exciting”
The Fuller Stocktake is currently live, which will also examine how primary care can operate within an Integrated Care Systems (ICS). Claire Fuller of Surrey Heartlands ICS is leading the Stocktake, which will begin by assessing the priorities for a more integrated and effective NHS. “I would encourage everybody,” Dr Bakhai said, “to contribute to the stocktake and have your voice heard about what you think the future should look like. It provides us with some real opportunities to drive forward the collaboration, integration and the innovation we’ve seen happen over the last two years.”
Dr Bakhai noted examples of this work such as the outreach approach demonstrated by the vaccine programme in general practice, and work led by her team on virtual hubs and ongoing development, design and integration of online systems with community pharmacy services. “How do we build on that,” she asked. “What are the key digital transformation priorities we need to focus on to make more of that a reality? A lot of that will be centred on interoperability, record sharing, data continuity and data architecture, but also how we better improve the design of our tech, = tools and services to support us and our patients.”
Dr Bakhai ended by underlining the opportunities that Integrated Care Systems bring to successful digital transformation beyond making services more sustainable and better at meeting patient and staff needs, but also contributing to digital upskilling in the community. “I think the future is really exciting,” she concluded. “There is lots of opportunity for digital transformation in this space, and hopefully I can share more with you next time.”
Watch Dr Bakhai’s full presentation via the video the link below: