In 2015, The Kings Fund underlined the growing understanding that innovation is key to the future of general practice, adding that to meet rising demand, new technology needs to be embraced and the doctor-patient relationship has to evolve.
At the time, the think tank acknowledged that it was setting out a daunting challenge, saying that ‘much will hinge on the ability of healthcare leaders at all levels to embrace uncertainty, unpredictability and experimentation’, but reiterating that such innovations ‘have the power to truly transform care’.
Since then, despite some barriers to the development and adoption of innovation in general practice there is a growing number of digital products and services in development, supported by the increasing sophistication, flexibility and usage of new technologies in the wider communities, with patients of all ages becoming familiar with the use of smart technology in their everyday lives. Many innovative providers have already harnessed the power of everyday technologies to improve access to primary care.
The GP’s surgery
In the UK, GPs and their teams see 1.3 million people a day, and do more than 370 million consultations annually – 60 million more than five years ago, according to the Royal College of General Practitioners. A recent report by Deloitte (Connected Health: How Digital Technology is Transforming Health and Social Care) states that more than a quarter of the UK population have long-term conditions, and it is these patients who use half of GP appointments, while GPs carry out 90 per cent of all activity for less than 10 per cent of the health budget.
Some GP practices are further down the modernisation path than others. The Digital Health London 2016/17 Digital Pioneer Awards scheme attracted applicants from across the NHS, of which several were projects designed by, and for general practice.
Anshumen Bhagat is the Founder and Chief Medical Officer at GPDQ, the team behind the UK’s first on-demand app for GP visits, and a 2016 Digital Health London Digital Pioneer for Innovation.
GPDQ was founded in 2015 to provide affordable, high quality healthcare through the use of technology, connecting patients with available GPs in their area for a consultation at their home, hotel or office within an average of 90 minutes. It books and tracks GPs via Smartphone, allows for 25-minute consultations and includes a 2-hour prescription delivery service. It is currently available in and around Central London and Birmingham, with plans to launch in six new cities in the first quarter of 2017.
“Data has emerged showing more people are choosing to pay for a GP appointment at a
private clinic as an increasing number of patients are being told they have to wait as long as 2 weeks for an appointment on the NHS,” Bhagat explains, “People want an affordable, prompt and clinically sound service that connects them to a doctor at their time of choosing.”
Nazmul Akunjee is a GP at West Green Surgery, in East Haringey. He appears twice in the list of Digital Health London’s 2016 Digital Pioneers list, once in the Innovation category and also as a Pioneer for Sustainability through Digital, having led work in reducing inappropriate antibiotic screening as well as creating a series of digital chronic disease care plans to help improve patient understanding and reduce avoidable A&E or hospital admissions.
Excessive use of antibiotics is leading to increased bacterial drug resistance. Akunjee’s team set out to reduce antibiotic prescribing, educating patients and doctors, through leaflets, clinical templates and short videos. The three-pronged approach includes using discrete popup alerts informing clinicians of how many times a patient has been issued with an antibiotic over the past year, and using clinical templates based upon NICE guidelines. Personalised antibiotic prescribing leaflets are translated into numerous languages to help improve understanding.
“We felt that a softer approach of identifying patients within the consultation would be better and would aid the clinician in making the decision as to the appropriateness of antibiotics. We also felt that showing patients short videos of red flag symptoms would aid them in understanding whether antibiotics were necessary.” Akunjee explains, “By digitalising the whole process we reduced the time spent hand writing care plans and saving them into the clinical records.”
Akunjee’s second innovation is underpinned by a recommendation from the National Service Framework for older people, that a shift from reactive hospital admissions for unscheduled care, towards an anticipatory approach, would ensure higher quality and better experience in meeting the needs of the growing older population.
In response, the team developed 7 digital chronic disease care plans with clinical templates to help improve patient understanding regarding their health and reduce avoidable AE attendances or hospital admissions.
The plans aim to improve concordance of medication and healthy lifestyle, explain the potential complications of long-term conditions and inform the patient as to what to do in an emergency. All clinical information (including problems, allergies, blood test results, smoking status and so on) recorded via the plans, can be easily shared electronically with other local community services as well as with the patients themselves.
“There is strong evidence that self-management and patient education creates resilience within patients and reduces unnecessary healthcare-seeking behaviour,” says Akunjee, “Chronic disease education for patients improves concordance with medication usage and reduces wastage.”
Another GP-based 2016 Digital Pioneer with two significant projects is Kartik Modha. Modha is a GP at Friern Barnet Medical Centre, is Co-founder and CEO of myHealthSpecialist.com, and the founder of Tiko’s GP Group (TGG). Both his innovations are focused on using technology to facilitate relationships and communication within the clinical community.
www.myHealthSpecialist.com is an online resource to help GPs and patients find peer-recommended specialists. It aggregates clinical recommendations into a single search interface. To date, it has aggregated over 6500 clinical recommendations across the UK and received 3 million specialist profile views to date. It supports the Royal Medical Benevolent Fund and hosts regular education and networking events to build community ties between primary and secondary care clinicians.
“There was no centralised way for patients to know who doctors recommended outside of a consultation or for GPs to quickly know who their colleagues recommended,” Mocha explains, “ It wasted a lot of time, increased message traffic and, where this information wasn’t available, led to patients having insufficient information to make an informed healthcare decision. Paper lists, diaries and word documents in GP practices become outdated rapidly, and storing recommendations in a centralised online database, with relevant information simplified into specialist profiles which can be freely searched by GPs and patients, is a solution.”
Modha’s second innovation uses Facebook to help GPs communicate asynchronously with each other.
“The aim behind TGG was to remedy the isolation of practicing as a qualified GP
and to spark innovation within UK primary care,” explains Modha, “For the group to feel safe it needed to be closed from the public and yet it needed to convey a friendly atmosphere to engage newcomers in conversations. Most of my colleagues were already on Facebook and it had robust administrator options to manage new member requests and group posts.”
The value of interaction
As these digital pioneers develop their innovations, the importance of interaction and feedback between clinicians and patients has become evident.
GPDQ was originally launched purely as an app-based service. However, the team quickly realised that as an unfamiliar company, patients needed more reassurance that the service was trustworthy. They were offered the option to call and book appointments over the phone, and a web booking tool allowed them to request an appointment via the GPDQ website and get a phone call to confirm, before receiving an email with details of their GPDQ account so they could book future appointments.
At West Green, Haringey, early challenges included how to integrate the templates and alerts within the GP computer system, and making the search for a patient’s antibiotic record discreet and simple. It was also important to encourage clinicians to use the care plans.
“Whilst initially it appeared challenging, we found that as patients embraced them, the clinicians were encouraged to use them more,” adds Akunjee.
In implementing the 7 care plans, the West Green team had to engage Haringey CCG and remotely access their systems to facilitate installation across all 20 practices. They held meetings with GPs and practice managers to encourage them to offer the plans to patients, illustrating the benefits and time-saving potential, and worked with a developer to redesign and structure the innovation for use with several platforms used across the CCG.
As Kartik Modha found, the myHealthSpecialist resource needed to have sufficient scale, and quickly, in order to be useful, so the team had to seek current and valuable recommendations to build specialist profiles, and correspondingly increase usage, while the challenges faced by the Facebook Group were ones of acceptance, resourcing, managing group culture and sustainability.
“Initially the medical establishment were wary of GPs having discussions online (albeit in a closed environment), but as time passed, the value of the discussions became apparent and integral to understanding the challenges faced by the GP frontline.” he adds.
These and other innovations currently under development across the NHS, many of them utilising already available technology, and using patient/clinician interaction to spread their usefulness, are already having a significant impact.
“We’ve already seen positive results in the GPDQ practice.” says Anshumen Bhagat, “35% of our patients surveyed said they would have either waited to see their own NHS GP or attended an NHS walk-in clinic if they hadn’t found GPDQ. Another 20% said they would have gone to an A&E department. Over 20% of our patients have used us again within that time, and some have used us five or six times already.”
Early analysis of Nazmul Akunjee’s diabetic care-plan showed that after detailed patient consultation, and an agreement of shared outcomes, a significant improvement in their stats was recorded, and patients felt that they better understood their condition, as well as being more likely to take their medication.
The care plan system spread from Akunjee’s single practice of 10000 patients, to 20 practices in the most deprived part of Haringey benefiting up to 13700 patients, and has now been installed across all 47 practices in Haringey, benefitting up to 300,000 patients, and targeting all patients, rather than the specific over-75 age group.
Khartik Modha believes that the clinical conversations and shared learning are already impacting positively on the millions of patients served by the GPs in the group.
“TGG has fostered 1000s of GP conversations since its inception in 2011,” he says, “It’s hard to quantify exact clinical outcomes, however its growth to 4500 NHS GPs with
2000 requests to join demonstrates its immense popularity and the value the
members derive from one another. Allowing real time shared learning leads to a reduction in missed diagnoses and inappropriate referrals, and improves patient safety and GP productivity and morale. The more clinically effective primary care is the more money is saved in the NHS and the better the experience and outcome for patients.”
With any significant innovation, introduction needs to be a managed, and collaborative process, with careful and informed input from innovators, stakeholders and users. The very people designed to benefit most from technological innovation in general practice, the increasing numbers of patients in the older age brackets, may face challenges in understanding and accepting the introduction of new systems and processes.
Older patients may fear being fobbed off with generic advice and a lack of face-to-face contact with their own doctor. They might mistrust technology and be reluctant to track their own vital signs. Many patients with dementia, and their carers, lead isolated lives and might worry that technology will mean less human contact.
With the introduction of digital innovations within the doctor-patient relationship, ensuring patient confidentiality is a continued concern amongst the patient community and an ongoing priority throughout the NHS.
However, research by patient and clinician groups, as well as the experience of innovators such as the Digital Health London Digital pioneers, shows that significant numbers of patients, say they would be prepared to monitor basic vital data, such as blood pressure, heart rate and weight, at home. And as people grow better at using technology to manage long-term conditions, or adopt healthier measures to reduce chances of developing lifestyle-related conditions such as diabetes or heart disease, this could cut GP appointments and reduce acute attendance at A& E.
A Digital Future for General Practice
Health experts are hoping the digital revolution will free up resources and allow people to monitor their own health rather than relying on professionals. It is estimated that going digital will save the NHS up to £5 billion over the next decade. NHS patients with long term illnesses could soon be able to monitor their conditions remotely through high-tech clothing and wearable gadgets which will link directly to their medical records,Wearable technology like Jawbone, Fitbit, Misfit, the Pebble and Apple smartwatches are already able to monitor heart rate, sleeping patterns, steps taken, diet, alcohol intake and running speed.
However companies are also developing health gadgets which can check blood pressure, monitor insulin levels and even pick up neurological conditions by videoing eye movement or depressive symptoms through language used on Twitter feeds. Apps which remind patients to take their medication are also in development.
People suffering from chronic conditions like asthma, diabetes, heart disease or high blood pressure could be constantly monitored remotely through wearable skins sensors or smartphone apps with data uploaded directly to health records so that problems can be spotted immediately.
Within five years patients across the country are likely to be able to go online and speak to their GP via videolink, order prescriptions or see their entire health record as part of widespread digital revolution of healthcare in Britain.
In its document General Practice Forward View, published last April, NHS England re-iterates that GPs are are the heart of our communities, but are experiencing unprecedented pressure. The Government has committed to an extra £2.4 billion a year to support general practice services by 2020-21, a 14 per cent rise in real terms. Investment will be supplemented by a £500 million “turnaround” package to support GP practices. As well as pledging to find 5,000 more full-time GPs in the next five years, the plan backs greater use of technology, including apps connecting patients to their practice and systems to manage appointments online. It also aims to share records more successfully across teams.
As Digital Health London’s GP-focussed digital pioneers are already discovering, the combination of face-to-face interaction with patients, integration with healthcare providers at all levels, and optimised communication with each other, together with the wealth of technology and social media innovation in development and already available, are changing the face of General Practice.
Author: Victoria Barry