Join us as we take a deep dive into digital primary care, exploring examples of best practice, challenges and how they could be tackled, and industry viewpoints on what ‘good’ looks like.
We’ll take a look at some of the latest announcements in primary care, including GP practice IT funding and contract changes; as well as a case study from Iatro, and our readers’ views.
At HTN, we’ve written fairly extensively on the impact of digital on primary care, through our news channel and dedicated feature long reads. We have also held regular online events covering the topic and have the next planned event set to take place 2 August!
Back in August 2022, we spoke with Dr Minal Bakhai, national director for primary care transformation at NHS England, along with Dominic Vallely, user experience lead at Digital First Primary Care Unit, NHS England. Minal and Dominic discussed ways to improve patient’s digital journeys through enhancing usability and accessibility of online experiences, with advice including prioritising key tasks for patients and making these key tasks easily visible and accessible through GP websites.
Minal joined us again in February, to talk about how technology could help to improve sustainability in primary care. Here, Minal emphasised the role of technology in meeting demands and lessening pressures on practices, outlining a new model for modern general practice.
Minal highlighted how the model would include long-term condition management and proactive care as part of population health management. It would encourage self-referral and self-service for admin tasks to reduce the admin burden and expand non-GP services, supported by digital integration. Hubs would be used to provide additional capacity, longer hours or out-of-hospital specialities; multi-disciplinary teams and additional roles would also increase capacity. The model also encourages remote and flexible working for clinicians to increase capacity and retention, enhanced triage and navigation to route patients to the right place first time, and choice of patient contact routes and consultation modality including online, phone and face-to-face.
Access and empowering patients, are key factors in what good looks like; in May we looked at the role of digital in the new GP access recovery plan, considering how the new guidance would help practices to develop their online presence and improve accessibility for patients. In the plan, NHS England highlights the role of digital in helping practices manage demand through means such as bookable online appointments, remote consultations and automated reminders, as well as the ways in which digital can support self-management.
We also covered the launch of NHS England’s primary care digital and transformation lead development programme, through which PCN digital and transformational leads will be supported to develop core skills to lead transformational change. The programme will run for 12 months and will see these roles supported in quality improvement, data and digital, managing transformation. They will also be provided with a peer community to share learnings.
Earlier in the year we shared the updates to the GP contract which emphasised that practices should move across to cloud-based telephony, and noted projects that have supported developments in digital primary care, such as our coverage of a tracking dashboard which helps to build a profile on access and provides data on primary care network performance.
To support transformation, NHS England’s Additional Roles Reimbursement Scheme provides funding including a new digital and transformation lead role. For the tech itself, the new Tech Innovation Framework for primary care IT opened in 2022. The framework aims to support the provision of electronic patient record systems and associated solutions for primary care, in line with a new set of standards and capability requirements. Its mission is to “encourage innovation” and “news ways of working” to support the future of a digital primary care. The framework also aims to encourage new entrants into the market, with an aim of a “more competitive, solution-orientated marketplace”. More recently, in June 2023, NHS England shared plans of a £975 million tech framework called Digital Services For Integrated Care Suite of Frameworks.
We reached out to our audience for comment on what good looks like in digital primary care, and received some insightful responses from a wide range of NHS staff, commentators and stakeholders.
David Harding, practice manager at Swineshead Medical Group, said that improvements needed in digital primary care included delivering better data. David noted that looking only at GP appointments data is “seriously floored” because GPs “do not always record on the appointment system consultations they have with patients when they speak about blood tests or tasks sent by staff. This needs to be addressed in a way that we are all doing the same thing, so NHSE are comparing apples with apples rather than apples with pears.”
David also spoke of the need to overcome the challenges related to interoperability, stating that suppliers should be “held to account” to ensure that they are “contractually obliged to improve their system”.
Professor James P Kingsland, OBE, chair of the Digital Clinical Excellence Forum, commented that aspects of online consultations need careful consideration, due to the challenges with “translating complex interactions into a new format”. He said that one of the key issues to overcome with digital primary care is “normalising into everyday service and enabling currently digitally excluded to be able to utilise, and improve digital literacy”.
To James, good in digital primary care looks like “efficient access with easily navigable appointments and timely response – almost immediate connection with remote diagnostics access and monitoring facilities, akin to virtual wards.”
Bex Cottey, business manager at Conisbrough Group Practice, said that achieving good in primary care means starting with the basics. She pointed to a need for “one system for all primary care patient communication” and the need to remove communication costs associated with printing and postage.
Belinda Kristiansen, digital transformation lead at Quayside Medical Practice, highlighted the need for standardised computer systems for sharing knowledge and skills. She said that good would look like provision of the correct tools for the constant changes, awareness of the reliance on the internet, understanding of the immediate need to fix IT issues to prevent downtime, and provision of more training for new systems “so they are used more effectively and efficiently as they are designed for.”
Finally, we heard from Krishna Vakharia, clinical director-patient at EMIS Health. Krishna talked about how improvements in video platforms for virtual NHS consultations, and the use of virtual wards to support community care, would reduce the admin burden and improve patient safety “by seamless integration of EHRs from primary, community and secondary care services”. Krishna also noted the importance of maintaining the human element of patient care, and said good would look like patients being able to see the clinician they need at the right time, and that clinician having “everything at their fingertips to have an informed, holistic and safe consultation”.
Last summer, we gathered more thoughts from the healthcare industry on what digital primary care will look like in 2, 5, and 10 years. Comments included the need to shift away from a one-size-fits-all appointment model, and the need to promote free-flowing data, as well as the urgent requirement to achieve better interoperability.
We asked our LinkedIn followers the question of ‘what should be the biggest priority for digital primary care in 2023?’. At the time, 43 percent chose interoperability; 24 percent selected citizen service; another 24 percent thought that the priority should be upgrading and improving core systems; and 9 percent supported the development of back office and coordination tools.
Another poll, we asked a question regarding their thoughts on the future of primary care: “Two years from now, how many GP clinical system suppliers [core EHR] will there be?“.
We received 104 votes in total from a range of professionals including chief digital information officer, chief clinical information officer and head of clinical systems.
The most popular answer – with 64 percent of the vote – indicated that there will be one to three GP clinical system suppliers available in two years, with roles such as doctor, ICT operations manager, digital director and service improvement manager selecting this option.
The second most popular option suggested that there will be more than seven GP clinical system suppliers by 2025, with 19 percent of the vote and voters including EPR consultant, associate director of quality and patient safety, business change manager and deputy chief nurse.
Finally, with 16 percent of the vote, was the middle-ground option of four to six suppliers. Here, voters included GP, technical architect, consultant, head of communications and digital, and PCN manager.
To gain a different perspective, we chatted with Thomas Porteus, founder and CEO at digital primary care specialists iatro. Thomas discussed the accessibility and usability of GP websites and what good looks like in this area.
Thomas began by stressing the importance of practices considering website accessibility in the same way that they consider physical accessibility. “A practice wouldn’t have three flights of stairs outside the door, so if you consider the website and the digital services the ‘digital front door’, then that’s really important.”
Thomas discussed how GP website accessibility is key to ensure that patients are able to easily locate and use available services: “If patients can’t find and use all of these digital services that are being paid for, or that practices are funding themselves, then it’s a complete waste of money. There’s no point having e-consultations if patients can’t find and access them.”
He went on to provide detail around his team’s experience in working with the new guidance from NHS England, as raised by Minal earlier in this piece.
“Most practices tend to think, ‘if it’s important, put a pop-up box on the website and make sure that it’s the first thing they see, that will definitely work’,” Thomas said. “Actually, as we know, when we’re browsing the rest of the internet, when a pop-up box comes up the first thing you do is close it and move on. You’re missing the message.”
Thomas referenced a statistic indicating that only 17 percent of patients could get past this kind of pop-up box displayed on GP websites, meaning that it was preventing them from actually accessing anything beyond it. “So what do they do? They call. They don’t try the website again.”
On the relevance of the new guidance, Thomas said it “has been a long time coming. It’s the first time practices have had something concrete to look at, to work through, and to maybe challenge suppliers on, to say, ‘actually this isn’t good enough’.”
Navigating usability and accessibility with suppliers
Thomas noted that he and his team see the issue of accessibility from both sides of the table, witnessing how a change designed by NHS England is put into place on the ground. Iatro. has both Practice365, a primary care website platform, and OneContact, an e-consult platform, which both run on the NHS’s frameworks.
He added that there is “no obligation in those frameworks for suppliers to not use pop-ups, or to make sure that they are meeting accessibility requirements – the accessibility is self-certified, so when you’re signing up on the framework you’re saying it’s accessible but no-one is checking. We spent lots of money and time checking we were meeting the standards, but there’s no guarantee that all of the suppliers have.”
Whilst the new guidelines are a step in the right direction, Thomas believes that there is a long way to go, especially to ensure that suppliers are on the same page.
When it comes to taking responsibility for ensuring accessibility and usability, Thomas said that Iatro. think of themselves as a “primary care technology business, in that order. We only care about primary care, and technology’s how we can help”. He added that when suppliers are from a different industry, and are perhaps primarily design-focused but working in primary care, that’s where the issues can arise.
Iatro.’s work with practices
We asked Thomas whether there were any projects that he and his team had worked on that they were particularly proud of, that demonstrate what good looks like.
“We work largely with individual GP practices, but we do work with ICBs and regions,” he said. “One project that we are probably most proud of is in Sunderland. We’ve been working with them for just over a year and have moved all of their sites over to our platform; and now we’re working with the individual practices to move everything over and upgrade the content. That’s been a really good collaborative experience, I think, for us and Sunderland.”
Another project highlighted by Thomas involved moving all 290 GP practices in West Yorkshire over to the Iatro. platform, which he described as “a massive change. You had a lot of practices who were suddenly having to use online routes, which they hadn’t necessarily thought about before. Being able to manage that for them was really useful.” Making this switch over to Iatro.’s platform meant maintaining consistency across the board, he said, especially in instances where the ICB would send out a request for all practices to add something to their websites, which Thomas and his team could then take care of for them.
“With Practice365, it’s about making sure that practices are getting, at a really reasonable price point, the level of service that they expect from their supplier,” he said. “We don’t talk about the tech with them, that’s not important; we talk about the outcome. The tech is for us to solve.”
When it comes to solving the issues surrounding tech, Thomas and his team are confident in the abilities of their solutions to integrate easily with practices and to ease common burdens for primary care services.
“OneContact is an e-consultation platform, but it’s also a long-term condition platform and it’s a QOF platform. Often we can help practices to digitise work they’re already doing. For example, if a practice already has an asthma form, it’s not about us designing a better version, it’s about allowing them to get this out to their patients easily; so for us it’s about understanding what the practice is doing and supporting them in doing that.”
Whilst Iatro. has their own clinical team, Thomas said, they recognise that practices also have fantastic clinical teams, so there’s “no ego there” when it comes to ensuring that the best forms are in use for the practice. For Iatro., it’s about supporting the practice to be able to do things the way they want to do them, and helping them to shape the demand that they’re experiencing.
We spoke with Steve Black, a freelance data scientist and commentator working in healthcare. Having worked in the NHS for many years actively participating in driving change, as well as for a company providing tools for GPs, Steve offered insight from both sides.
For Steve, good would look like improving data quality in primary care. He commented that in his view, at present the NHS “does not have a very good handle on what the level of activity in primary care actually is”. From a data standpoint, Steve questioned whether the recorded number of appointments conducted at practice-level every month was a reliable number, due to the duplications and irregularities that exist within the published data.
“The reason for that is because the definition of the level of activity in a GP has been treated for a long time as people who have appointments in the diary. There are several problems with that,” he said. “For example, if you’re producing a lot of remote activity, such as on the phone or online; that doesn’t correspond to any particular appointment in the diary. So practices with a lot of online activity don’t currently show that within the national dataset.”
It’s not only the data which has to change, Steve suggested, but also the mindset of GP practices and the ways in which they approach digital contacts with patients. He noted that there is still a tendency to think of face-to-face appointments as the first port of call, which Steve referred to as “old thinking”.
Improving data quality, then, would not only help to better inform strategies surrounding primary care; it would also offer the kind of insight that may be required to make more transformational changes in thinking and approach amongst those on the frontline.
“I don’t think everybody in the system, thinking about strategy, has fully appreciated what the problems are in primary care. If you look at where GPs are in the country, they’re not evenly scattered, and there’s a huge problem relating to the distribution. Somewhere like Cornwall, a typical practice probably has 1900 patients per GP; if you’re somewhere like Bedfordshire, that’s probably closer to 3000. That’s a huge problem, we’re not getting GPs to work in the right parts of the country.”
We spoke with Yorkshire & Humber Academic Health Science Network (Yorkshire & Humber AHSN), to hear about some of the primary care projects they have been involved in over the last few months. We chatted with members of their team including project leaders and those on the ground in practices across the region to learn more about what the AHSN has been doing to drive innovation at scale and pace in primary care.
Firstly, we heard from Ellen Barnes, YHAHSN & HNY Digital First Primary Care Innovation Hub Lead. Ellen called digital “a key enabler” for transformation and improvement. She described the work of the AHSN’s enterprise and innovation team in meeting with innovators and conducting horizon scans of innovations from around the world, hosting innovation workshops to identify unmet needs and showcasing digital innovations. Ellen also spoke of ongoing collaboration and the importance of sharing good practice. She hopes that the HNY Digital Primary Care Innovation Hub will be the “front door for digital enabled innovation and improvement for primary care, including pharmacy, optometry and dentistry specialties”.
Ellen commented on the “huge enthusiasm” that exists within primary care teams to utilise available digital solutions for improvement and transformation, and also noted that the pandemic has led an acknowledgement of the importance of digital in all areas of healthcare.
Ellen said in her opinion, what good looks like in digital primary care is the ability to use digital innovation to work smarter, not harder, especially given the workforce shortages and increasing demand for primary care services. Identifying and evidencing the need for change is critical and forms the baseline for measuring impact and success of digital innovation projects, she noted, and clinical transformation must be clinically-led, with patient co-design, digital inclusion considerations and the acknowledgement that not all patients are able to or want to transition to digital services. Ellen suggested that more work is needed to ensure digital literacy, capabilities and patient choice are understood and recorded, highlighting the work of a GP practice in HNY who have developed a platform to do just that. Equally important, she added, is the need to up-skill, train and support the healthcare workforce.
Next, we were joined by Sophie Bates, Yorkshire & Humber AHSN’s workstream lead. Sophie has been involved in primary care projects such as rolling out AI triage and online consultations solutions across a large PCN in York, which aimed to improve patient flow through efficient triaging and prioritisation. On what good looks like to her, Sophie said that she felt the wider use of technologies allowing for remote monitoring and at-home testing would be beneficial in alleviating some of the pressures on primary care practices, and also in reducing patient stress. Sophie noted some of the good work being done at present relating to faster diagnostics, including tools which help to identify risk levels for diseases like cancer. Good, in this case, would mean a wider uptake of these types of solution to enhance patient outcomes and help primary care services to meet the challenges in demand.
We were also joined by Harriet Smith, workstream lead at the AHSN. We heard about Harriet’s experiences helping to implement digital solutions in primary care; for example, she has been involved in projects transforming asthma pathways, improving asthma literature, and improving access to asthma services for underserved communities. For Harriet, good looks like working to improve IT infrastructure to support data analysis and sharing at a local, regional and national level. Looking at implementing digital interventions, Harriet added that good looks like working with manufacturers to build-in costs for ongoing maintenance of tech solutions, and utilising data to ensure that this tech is distributed to areas which need it most.
Next, we heard from Dr Emma Broughton, GP at Priory Medical Group. Emma spoke with us about the challenges in finding the right products when it came to digital interventions for primary care, and her own experiences trialling available solutions. A shortcoming Emma identified in some of the solutions she had tried was the lack of capability for many of them to deal with the complexities of common problems. She noted how cases of the menopause, due to their high variation of symptoms, “almost broke the tool”.
Emma talked about the need for a solution to help signpost patients to the correct type of appointment or provider. A tool would need to be easy for patients to use, she said, and would enable them to provide enough information to be triaged effectively, making the most of capacity and allowing for efficient workforce planning. The ability to capture data is another integral feature which would help to identify and quantify demand for specific services, “based on clinical need rather than patient demand.”
Getting the right kind of data from a digital solution, Emma highlighted, not only helps to overcome health inequalities by pointing to underserved areas or populations; but can also enable practices to harness the right “skill mix” when it comes to staffing levels, which is again something that can enhance practice efficiency across the board.
On her vision of good in primary care and how to achieve it, Emma said that there are some flaws in the current system for measuring data, including difficulties in reconciling the data collected with actual demand levels, and issues with comparing practices which are working on different systems. Emma commented on the issues that this can pose for building a realistic picture of primary care at local, regional or national levels: “the current system shows what a practice is delivering, and not what the demand is”.
Good, to Emma, could look like having a single space where “all your data sits and all your patient need sits, so that you can then create the right skill mix and manage patient demand.” Good would also look like “a tool which allows me to know why the patient needs to be seen, so that I can prioritise their care. It would collect useful data to help me with their consultation, so if they require investigation, I can arrange this before I see them. That way, when they do come in, we have the results and can work on the follow-up.”
Emma also pointed to the need for consistency and enhanced interoperability, with solutions that work with existing systems and don’t require “five different log-ins.”
In an article published last year, titled “Digital technologies in primary care: Implications for patient care and future research“, authors Neves and Burgers consider the outlook for digital in primary care, taking into account trends from across Europe.
The authors highlight how the COVID-19 pandemic drove uptake and implementation of digital health technologies, and note digital health’s “potential for the delivery of higher quality, safer, and more equitable care”, with particular focus on primary care. They share five wishes for the future of digital care in general practice – their vision for what good looks like. These wishes are for more involvement of primary care professionals and patients in the design and maintenance of digital solutions; for infrastructure, support and training to be improved; development of clear regulations and best practice standards; more focus on patient safety and privacy; and working towards more equitable digital solutions “that leave no one behind.”
The study points to the opportunities for the use of “novel data mining techniques and increased computational power” in order to utilise non-identified health data for broader purposes, including achieving a better understanding of patient profiles, service needs, care priorities and geographical differences.
“Big data in healthcare is also a powerful resource for research purposes. In the evaluation of drug effectiveness, for instance, primary care has heavily relied on randomised trials performed in inpatient and secondary care settings,” the authors state. “Those often included particular and non-diverse groups of patients that do not represent the typical patient presenting in general practice. Using electronic health records for these purposes opens new avenues to explore real-life data to inform clinical decisions on diagnosis, management, and follow-up in the primary care setting, in addition to the evidence from randomised controlled trials.”
The article goes on to examine “the growing need to evaluate [digital solutions’] impact on primary care, including risks and benefits, and to inform health policies that are both patient-centred and evidence-based. As research on digital care covers the whole of medicine, including clinical and contextual issues, defining the focus of research is essential for addressing the most important issues faced by patients and society.” The authors call for a research agenda “independent from commercial interests and preferences of funding agencies” that could help “focus on issues that matter most.” All relevant stakeholders in primary care, they specify, “should be able to contribute in defining and selecting research questions to reduce any bias. Public and patient involvement is needed to capture diversity and ethical issues.” They point to the Dutch general practice research agenda as an example of what good looks like in this area.
What does good look like for digital primary care in other European countries?
Leading on from this, we took a closer look at Denmark’s healthcare system.
In 2019, King’s College Hospital NHS Foundation Trust’s transformation programme manager Des Carter took part in an exchange programme to learn more about the Danish healthcare system. He shared a blog on his experiences in which he notes that Denmark’s electronic health record (EHR) is “much more mature than in the NHS”, with a personal identification number (Civil Personal Registration number, or CPR) for all citizens that is used across government services. Denmark has used the CPR in many of their digital solutions, Des observed; this includes integrating the EHR for use across primary, secondary and tertiary care, and allowing patients to digitally check in for appointments.
Sharing a snapshot of what ‘good’ looks like from the Danish angle, Des commented: “The result is a very high degree of effective information sharing using IT systems at both a regional and national level. The CPR number enables Denmark to benefit from excellent data that can be used to inform service improvements. It’s something that we’re working towards in the NHS and having seen the benefits of this in Denmark, is something we should continue to collectively strive for.”
Elsewhere, in Estonia, where 99 percent of public services are said to be digitised, ‘good’ looks like a focus on innovations to support medical professionals and improve efficiency. The e-Estonia website shares an example in the form of a clinical decision support system implemented in May 2020, which “brings patient-based recommendations to their desktops and makes decisions faster and better. The clinical decision support system is the first tool of its kind in Estonia and the first in the world to be implemented nation-wide. It collects and analyses human data, such as diagnoses, medications, and tests from the last five years, blood pressure readings, and lifestyle indicators.”
In terms of what this means for primary care, the system has the ability to analyse patient history alongside new information inputted by a GP, displaying treatment options and even suggesting drugs and dosages. This is helped by Estonia’s e-Health Information System, which stores all health data of every individual in Estonia, as well as by the standardisation of information across different healthcare institutions.
Many thanks to everyone who shared their comments, experiences and insights with us.