The world is changing. The days of popping down to Toys ‘R’ Us for a present for the kids are over. Last week Toys ‘R’ Us announced it was closing all of its stores. According to toy industry analyst Jim Silver, “They lost online and they didn’t adapt.”
It is not just the toy industry that is changing. It is everywhere. Earlier this month Countrywide estate agents reported significant ongoing financial difficulties. In a statement they acknowledged they had not yet learned how to deal with the challenge from digital property services (such as Purple Bricks).
General practice is not immune to these changes. Lillie Road Medical Centre practice in Fulham, which last year started to offer the GP at Hand video consultation service to anyone outside its area living or working in London, has seen startling growth. Taking up the service requires patients to leave their existing practice and register as an out of area patient. The list size of the practice has grown from 5,000 to almost 25,000 in 4 months, and 85% of registrations have been patients aged 20-39.
The GP at Hand experience means the digital threat to general practice has just become real. The capitated payment system of reimbursement for general practice means losing the younger, healthier patients on the list, and being left with patients who are older with more complex health needs; and could result in income not matching costs. It could well be the final straw for many practices already experiencing financial pressure.
Should these changes be resisted? Are video consultations a “good thing”? In a paper published in the Journal of the Royal Society of Medicine, the team from the Department of Primary Care and Public Health at Imperial College London said that while there is evidence that video consulting is acceptable to patients and offers many potential benefits, at least to those of younger age, its safety and efficacy in primary care currently remains largely untested. It raises concerns that while online consultations may help practices manage demand more easily, it may conversely increase pressure through supply-induced demand, or defensive practices.
In our new society, video consultations are more about allowing patients to access services in the way they want to, and less about reducing workload for GPs. Increasingly, it is patients who are going to set the pace for changes like this. The early results from GP at Hand demonstrate for some there is an impatience to see these changes now. Our recent technology panel ultimately felt the profession would not be able to keep control of the use of technology, and it would be driven by patients, if not now then certainly at some point in the future.
We are only at the start of the “digital journey” in general practice. Technology is evolving all the time. Jim Forrer on the technology panel talked about an app currently in development that can monitor blood pressure, pulse rate, oxygen saturations and respiratory rate through the camera function on a smartphone. Technology will change the doctor patient interaction and the way patients manage their own health. Google and Amazon are entering the health space, using global cloud-based health platforms and data, and this is going to have an impact on general practice.
We may think in a tax funded system based on needs not wants that market forces won’t apply. But the reality (as demonstrated by GP at Hand) is they will, because people will not accept what they perceive to be a second class service when it comes to their health, and will demand that health services evolve in the same way as every other aspect of the world. Resisting the implementation of technology will, at best, be a short term strategy. The risk of that approach is that others will move in to fill the void and the opportunity to respond positively may be lost.
If we can’t stop the march of technology, and given the significant potential financial impact, can general practice survive the changes that are coming? Well, established players in other industries (unlike Toys ‘R’ Us and Countrywide) have. Take the experience of the supermarkets. Online grocery shopping is the fastest growing area in the sector, but it is the major supermarkets who understood the change was coming and set up their own services. While new entrants have come into the market, Sainsbury’s, Asda, Morrison’s and Tesco are the major players. Morrison’s are now building partnerships with those with better distribution networks such as Amazon and Ocado to further cement their place.
The world is changing. GP at Hand is simply the indicator that general practice is not immune to these changes. Right now the onus is on general practice to respond, to respond quickly and to respond positively. Part of the opportunity of the move to scale in general practice is precisely for this, as it enables practices to invest in technology or partner with technology firms, to test and develop its usage and to evolve the model of care. By working together, practices can meet this challenge. The other option, to resist the changes, to pass motions that “more needs to be done” by commissioners and policy makers to preserve the status quo has the whiff of King Canute on the beach, and may leave current GP practice businesses in a position like Countrywide or Toys ‘R’ Us, rather than evolving with the changes like the supermarkets.
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Whether GP at Hand works well or not, the technology isn’t going to be stopped by opposition from existing GPs. And, if they hope that future trials will prove it doesn’t work well and will stop its progress in its tracks, they will be disappointed.
Patients don’t choose the service because it has had an RCT proving it does a good job, they choose it because it (very obviously) does a few things better than the model most GPs currently operate for handling their patients: patient calls GP, GP offers some face-to-face slot in a couple of weeks time…
GPs can and should combat the challenge by changing the way they work to match the parts of GP At Hand that patients find attractive. They don’t have to go the way of Toys’R’Us.
The key feature seems to be much better responsiveness to demand coupled with a much more convenient way to communicate the demand to the GP practice. And there are several tools any existing GP can deploy to offer a similar service (though all require some changes in how the GP responds to demand to be effective). And the issue is not improving the ease of booking f-to-f appointments: practices need to rethink the mix of ways they support patients to get advice that helps them. The assumption that help can only be provided with a 10min f-to-f is both inflexible and ineffective.
Tools such as askmyGP or e-consult can be deployed to support existing GPs to accept demand online (full disclosure: I provide askmyGP with analytics of their activity and have helped their software design). Other tools are available.
We don’t yet know which tool does the best job (as the total penetration in practices and patients is still low) and their philosophies differ: some try to replace part of the GP’s role by collecting enough diagnostic history to do preliminary diagnosis and offer some routing or signposting of demand. Others (like askmyGP) stick with the simpler task of providing a better way to communicate the requests from patients to the GP practice and don’t deploy any clever diagnostic or routing algorithms. Not every patient will find this the best way to talk to their practice, but many askmyGP practices have moved 30-50% of all their demand to the online tool. Practices who adapt their working practices seem to be able to virtually guarantee same-day responses (including same-day f-to-f appointments for all who need them).
This is what many patients want. And, though some patients won’t prefer online communication, there are a surprising number who find it superior to phone calls and long waits for appointments. GPs like it because it supports them to be more effective and efficient in how they handle the demand.
In short, the tools to enable existing GPs to compete with GP At Hand already exist. But GPs can’t get the benefit unless they are also prepared to adapt how they work. Those practices that don’t want to change will increasingly find their patients abandoning them for others who do (and services like GP At Hand will win even if they don’t do a good job for all patients).