Online GP services: The way forward or caveat emptor?

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Dr Ray Walley in the Medical Independent, 5th April 2018.

mHealth Insights

“We live in a world of rapid advancements in technology but with all the benefits, there are some dangers, as we have seen in relation to the current controversy on the harvesting of personal data.”

The thing I find incredible about hearing this from Doctors is that most Irish Doctors and HSE are already facilitating this. Despite probably the ‘biggest success’ of their €800M eHealth Ireland project (that I’ve been critical of since it’s inception as it was clearly building on obsolete tech) being the HealthMail.ie service they’re still not using email properly (regularly sending emails with all recipients listed) and routinely sending out highly sensitive and confidential Patient information to medics who use email services like Google, Yahoo and Hotmail (which collect and sell on information contained within these “strictly confidential” emails).

“The delivery and provision of healthcare has changed apace with technology, bringing many benefits to patients, and doctors have embraced such advances. Advances in technology can assist with GP learning and enable patients, but we must be careful in ensuring that all the technology does not undermine or damage patient care or health outcomes. In an unregulated environment, there can be real dangers.  The recent proliferation of online GP services is not just a matter of concern to doctors but also, as the evidence is gathered, to health regulators. We must learn from the mistakes that are happening in other jurisdictions and not rush to adopt models that may, in the longer term, be damaging to patients and undermine population health”

I don’t think online GP services do operate in an unregulated environment. Perhaps regulations aren’t being enforced but that’s not the same thing.

“The UK Care Quality Commission recently reviewed online prescribing by such companies and medical practitioners working for them. Such concern has it caused that leading news outlets in the UK reported on their findings.  Some of their comments included: “Safety is where we found the greatest concerns… In February 2018, we found that 43 per cent of the providers were not providing safe care according to the relevant regulations. Their specific concerns included:   Inappropriate prescribing of antibiotics and prescribing high volumes of opioid-based medicines without talking to the patient’s registered GP.   Unsatisfactory approaches to safeguarding children and those who may not have the mental capacity to understand or consent to a consultation.   Not collecting patient information or sharing information.   Inappropriate prescribing of medicines for long-term conditions”

As many critical articles about “Online GP services” do this one also didn’t take long to start mixing them up with “Online Prescription services”.  These are very different things and this would be a great place for regulators to act. In the meantime GPs shouldn’t be using confusion to cast stones at colleagues who have had the courage to move beyond the 2000 year old office visit only model of care.

I think the simple short answer is to only let people who are actual online GPs call themselves online GPs.

One really odd thing I notice about the CQC is that GPs are forever quoting it’s reviews to make their arguments despite the fact the organisations abilities to conduct reviewS have been widely deemed useless (and dangerous) by GPs in the UK.

“Another UK study found that online-based systems were contributing to inappropriate referrals to emergency departments. A recent study in regard to electronic alternatives to face-to-face consultations with GPs published in the British Journal of General Practice showed that such access did not help to alleviate workload pressures of GPs, nor did it improve access for patients. The Royal College of General Practitioners followed up this study with cautionary advice for its members, indicating that if practices chose to provide online and telephone consultations, then it should be only as part of the practice service and that GPs should continue to provide face-to-face consultations, patient safety being paramount in any clinical consultation”

I’ve covered the reasons for this finding extensively on this blog over the years. The NHS has worked hard to undermine GPs with the +£100M pa they keep pumping into their success failed triage services (branded NHS ReDirect, NHS 111, etc). The simple fact is online based communications should avail of clinically validated tools so that Patients Primary Care needs can be handled by their GPs because triaging isn’t the easy bit where you can cut corners it should be done by the most experienced Clinicians and their time used efficiently by letting Patients help and supporting them with the provision of Patient History Taking tools.

“These findings should not be ignored in Ireland and health regulators need to take notice. The bedrock of patient care in general practice is continuity and that is something that must be protected at all costs. All the medical evidence points to the positive link between continuity of care with a GP and better health outcomes for patients. There is a proven link between the provision of a personal GP and reduced hospital admissions, better mortality rates and more equitable delivery of healthcare across socio-economic groups”

I agree with this but it’s 2018 and a general practice clinic like Dr Ray Walley’s that has no website and is closed most of the time isn’t providing what most citizens of Ireland would consider to be continuity of care. What are people supposed to do to get continuity of care? Send a tweet to their GP?

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“The GP is at the centre of healthcare provision: Of the 25 million patient consultations in general practice, 90 per cent are dealt with by the GP without the need to refer to another service. This deeply personal relationship is reflected in a high level of patient satisfaction. The value that patients put on their GP, accompanied by a low rate of referral, is only possible where the GP has a long-standing relationship with the patient, access to a patient’s previous records, including attendance at the practice and out-of-hours service, referrals to secondary care, medication, a complete history of that patient and all the factors driving healthcare needs”

The GP was at the centre of healthcare provision but convenience is now a quality measure and Patients and Carers in Ireland are nearly all now carrying around supercomputers through which they’re able to Google their symptoms, Google their medications, Google their Doctors, read about their treatments, watch free videos about their conditions, etc.

Oh and because the world’s biggest corporation is betting the farm on it very soon they’ll be able to download their electronic medical records to their mobile…

“Sláintecare and the Health Service Capacity Review both cite the importance of general practice and the need to deliver more services through general practice. However, in the absence of any support or resources by the State, the potential for better patient outcomes is in danger. As Ireland grapples with the appropriate funding and provision of general practice, there is a race to the bottom to replace the existing GP model with alternative models that, although dressed-up as general practice to distract from their lack of long-term detailed analysis, are not general practice”

I think the simple short answer is to only let people who are actual online GPs call themselves online GPs.

“What we are now seeing is a commercially-driven shift from patients having a relationship with their GP, being partners with their GP in managing their health and wellbeing, to accessing healthcare on a pay-as-you-go basis. While there is of course a benefit in GPs using video consultations with their own patients in certain circumstances, this is not what the models being promoted are offering. In fact, it is the exact opposite. Healthcare in Ireland is fast becoming a commodity that is being driven by market forces, not by medical evidence or in the pursuit of quality patient care”

I think this has already pretty much happened in the USA where 100s of millions of VC debt have driven the growth of phone call services that have undermined the last few GPs.

I’m sure there is no political will in Ireland to stop major tech companies like Google undermining GPs by offering their Patients free video chats 24×7 so it’s really key that Irish GPs take the initiative and start providing online services to their Patients and we’re working with a few GP practices in Ireland now to bring in a successful service that’s already been deployed at scale in the NHS:

It’s interesting that Dr Ray Walley now states “While there is of course a benefit in GPs using video consultations with their own patients in certain circumstances” because in his own practice it seems he doesn’t even have a website and no means for Patients to discover whether they have the ‘certain circumstances’ for which a video consultation would be helpful.

“The ‘Uber-like’ apps that offer a so-called GP service emphasise access and speed, but there is no continuity of care and it is not a GP service. It is a service of convenience and from evidence to date, we can now see it has the potential to lead to inappropriate prescribing and safety issues. The doctors providing the system may be trained GPs, will likely make more money and have a less stressful career, but what they will provide will not be general practice”

Sounds like a simple trade description issue. If you’re not an actual online GP you’re not allowed to call yourself one. Call on the ICGP and NAGP to suspend any GPs contravening this for dishonest conduct. Nothing stops Dr Walley reporting them himself.

“Government must take action and ensure that a meaningful and evidence-based general practice service is provided to patients, with the required support and investment from the State. General practitioners are not Luddites by any measure and technology has a place, as long as it enhances patient care, not undermines it. The advice has to be caveat emptor”

Sadly the government has little no interest in properly supporting GPs, there’s an abundance of evidence that the office visit only consult model can be very dangerous (and we know that self-harm is the largest killer among 15 to 24-year-olds in Ireland), so buyer beware doesn’t apply because if you provide a service in 2018 and have no website and offer no means for a Patient to engage with you electronically they’re going to go somewhere else for advice.

*** UPDATE 15 April 2018 ***

Classic example of how an organisation like the RCGP is unaware that it is helping peddle misuse of the term ‘online GP’ by sharing news articles that use the term inappropriately:

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