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“Fundamentally, pathways need to be really clear” Dr Ishani Patel and Dr Shanker Vijayadeva on building digital access hubs

At HTN: Digital ICS, we were joined by Dr Shanker Vijayadeva (GP and clinical lead for NHS England – London region) and Dr Ishani Patel (GP and clinical co-founder of Lantum) for a discussion on building digital access hubs to increase patient access across primary care.

How do digital access hubs support GP practices?

Ishani: A few years ago, back in 2018, there were a couple of primary care networks (PCNs) in North West London who wanted to drive online consultations, but we recognised that not every practice across the two PCNs had the workforce to power it. We built what was called an e-hub at the time, but is now known as a digital access hub, and we developed a workforce team that was multi-professional, that would triage and process online consultations for the practices. That really prepared the PCNs for the arrival of the pandemic, when access needs and demand shot through the roof. That hasn’t died down, it’s forever increasing.

It provided a really good infrastructure for the practices to maintain and improve access, because the team had already been put together and nurtured, and quality standards had already been set. Since then, in North West London, we’ve seen seven or eight digital access hubs follow a similar model. They can help provide some stability and resilience for PCNs, especially when you’ve got surges and falls in workforce and things like winter pressures.

Shanker: I think a key point is the fact that there are lots of different angles we can take with digital access hubs; there are different dimensions, different approaches. Access is a key theme, and one of the biggest goals, but it’s not the only area that these hubs can support.

GP access recovery plan: how can digital access hubs support the goals?

Ishani: The three things that really stood struck me were tackling that 8am rush, the real drive towards working more collaboratively with our community pharmacies, and the plans for the NHS App.

For the 8am rush, from a digital access perspective, PCNs wanting to start their own hub could set up and use their additional roles to help manage that first two-to-three hour surge in demand at practice level. They could encourage patients with appropriate levels of digital literacy to submit an online consultation that can be rapidly triaged, which means a suitable action can then be taken according to the needs of the patient.

On the push for collaboration with community pharmacies, online consultations actually do fit into that very well. It obviously requires pathway working and potentially some training for the community pharmacy colleagues.

Finally, looking at all the fun stuff that is coming with the NHS App, I think there’s a key area of work in terms of how we can optimise the utilisation of the app to improve patient messaging and improve responsiveness to patients.

Shanker: I would echo what Ishani has said, but I’d add that if we look at the vision of the plan, there’s also a focus on making sure that patients get what they need on their first call. To achieve that, we need to route to the right team member, which is where you get the hub working – you can bring all of those different roles into the hub to try and deliver that.

There’s also the two week timeframe that we are trying to meet in terms of general practice. To deliver those timeframes, we need more at-scale working, and I think the hubs can bring real benefit there.

There’s the human element with regards to wellbeing as well; the new GP contract emphasises the importance of looking after our staff. If we are all really struggling with the pressures of our traditional ways of working, sometimes the access hubs could improve our staff wellbeing. We can implement ways to cope with the pressure better as a team. There could be interesting learnings around improvements in working relationships, from staff perspective, through digital access hubs.

What is required from a workforce perspective to make sure digital access hubs are a success?

Ishani: Fundamentally, whether it’s administrators, GP assistants, clinical pharmacists, paramedics, first contact physios, GPs – whoever is in the digital access hub workforce ecosystem – pathways need to be really clear. That is key in order to minimise harm and reduce significant events, and brings more clarity around patient expectations.

Supervision and support play an important role; where you’ve got co-location of a team, you need to have someone in place for staff to call if they are not sure. Online consultations are a good way in, but there are a lot of nuances. You’ve got access to the patient record so you know whether someone is a high priority, whether there are complexities, whether they are a carer, for example, and all of these factors affect the pathway that a clinician may choose. But where there is doubt, having someone there in real-time, on the phone or in person, is so helpful. That creates group learning for the team and gives them some confidence as well. A lot of clinicians do work in silo and feeling that you have someone to rely on for support is really important for setting up a workforce team for success in access hubs.

Shanker: I think we need to bring more understanding and flexibility into the workforce. I’m a great believer that whenever you put a change in, it always makes things worse at the beginning. You could plan for 10 years but as soon as you go live, a question will arise. There will be bumps with your digital access hubs – your IT might go down, for example. We have got to work together, learn together and share learning to improve.

When we present our hubs, we always present information on how well it’s doing – we’ve got to be open about what doesn’t go so well, and re-iterate that those bumps are normal. The important thing is that we are open, we learn, we’re flexible, and we work as a team. Then we’ll get there.

Learnings and challenges so far

Ishani: The learnings that really stick out are around practice expectations and their understanding of what the service can do for them, and understanding the individual cultures within each practice. I agree in standardising some things and having a uniform way of approaching certain tasks, but some practices have internal protocols that are quite different to the modelling you want to use for your digital access hub. Speaking to each of your membership practices and understanding what their expectations are is really important to minimise those bumps that Shanker mentioned. That then helps you understand patient expectations, because of what they experience in their own practice. Collecting that learning will then reduce the number of complaints and improve patient confidence.

It’s not something you can know from the beginning – you will learn by gathering feedback from practices and patients. It’s about having an open forum for practices about what’s going well, what they like, what patients like, and the flip side of that – what can we do differently, how can we try to accommodate as much of the asks from practices as possible? It’s not easy, especially with the variety in PCNs, you have to try and find some middle ground.

Shanker: Buy-in can be a challenge. The fact that primary care can be so tailored is both a plus and a weakness. There’s a journey to undertake to ensure that the team believes in the vision of the digital access hub. Then there’s work around communicating what the hub is doing, and everyone can perceive that differently – a patient might feel that they’re just being dumped onto the hub rather than seeing it as a positive, for example, rather than thinking that they are getting the right care in the right manner.

Lots of the bumps can happen around IT, which can be for a variety of reasons. It could be that staff haven’t been trained well enough on the different features of the hub, or the host IT platforms could lack functionality for what you need to do. Or you might have the functionality, but lack the capacity, or the financial resources to buy equipment.

The isolated nature can be a challenge, too – how do you get a new team bonded with remote working, how do you keep them engaged?

Practical steps for ICSs to make digital access hubs a success

Ishani: It comes back to targets; whilst an ICB does sit across commissioning and providing, the ICB is also accountable to NHS England.

ICBs can support digital access hubs with the technology, with the hardware, with providing contacts with other digital-first leads in other parts of the country to share learnings.

Lantum is working with ICBs where the ICB is partnering with us to provide the staff banks, so that’s a cost that a PCN doesn’t have to worry about. The ICB can set up a digital staff bank and then give access to its membership PCNs, and they can use that to help staff their digital access hub. Allowing them access to the full workforce pool across an ICB could be really helpful, especially for people who are hybrid working.

Shanker: Flexibility is key again. When we created our hub, we almost had an open book approach – from the start, how can we be open about the challenges, the finances, the flexibility of the model?

We’ve touched on workforce recruitment; that’s an issue in the NHS and it’s no different in the hubs. You might have a particular role you wanted for the hub, but the staff don’t want to engage or you can’t recruit them. You might have to change the model.

There’s no correct approach to how you start off or how you evolve, but I think because of these challenges, ICBs shouldn’t be rigid about it. It could just mean that the hub doesn’t evolve into what it needs to become.

Looking two years into the future, what would good look like?

Ishani: I would love digital access hubs to use technology platforms that also support the long-term conditions piece more. Historically, access hubs have been more for on-the-day demand; then enhanced access came out and there was a bit of a pivot to include more of that QOF (Quality and Outcomes Framework) element. It would be great to use access hubs as a way to bolt on things like proactive hypertension modelling, heart failure, COPD. It wouldn’t just be about digital consultations, it would be about using a number of digital modalities to help support the local population.

Shanker: When we think about access hubs, we tend to place a lot of the focus on their role in same-day access and routing patients away from urgent care centres. I think we’ve got that emphasis slightly wrong. The capacity is exactly the same as in a practice, the staff dealing with long-term conditions or chronic diseases are the same staff dealing with those same-day problems.

I think organically, primary care is facing an ever-increasing workload. If an access hub evolved naturally to meet the needs of primary care and becomes more sustainable because people see the value of it, it will benefit whatever form of access you want to measure. If we manage a diabetic patient more efficiently in terms of how they access their annual review, that could free up appointments for patients with a same-day need. Also, that patient who is potentially facing a lifetime of the same annual challenge around their diabetic review; they get a huge benefit from an improved access process.

How an ICS ensure that patients know about these resources?

Shanker: It’s all about communication and we’re not always good at that within the NHS.

Wouldn’t a sign of a good access hub mean that the patient experience is such that they don’t even necessarily realise that they’re in an access hub? To me, ‘good’ would be if your processes were built so well and the communication was so good that the patient, entering the hub, doesn’t even realise. There’s no need for queries because the communication would be in real-time about what is happening to them.

At top level, you obviously need to communicate on things like practice websites, you could do mailshots to the patients to explain things, but I think that can still land as jargon until you actually experience it. Until you use it, you don’t really understand it. How does a patient interpret what you mean by ‘hub’? There’s a risk of miscommunication, so I think the focus should land on getting the communication right whilst they are actually having the experience.

Ishani: I would say, historically patient feedback wasn’t a big thing for the early versions of the access hubs, which we would probably think is a no-brainer. As different contracts have come in, I think we need to be surveying our patients a lot more to understand how they experienced the hub. The danger of that, as Shanker was saying, is that they may not have realised that they were being looked after by an extended member of the practice, so from an information governance perspective that is really important. The patients need to understand where their data is going, and the communication can then start once the online consultation has been acknowledged.

Many thanks to them both for taking the time to join us.