The idea of telehealth is a simple one: healthcare delivered at a distance, most likely through a video call to your smartphone or PC. The idea has been around for almost as long as broadband internet, but it has taken a new wave of startups to really light a fire under the idea.
Telehealth promises to solve the problem of long waits to see a GP, offering an answer to current complaints about doctors' appointments that are increasingly only available to emergency cases on the same day, and to everyone else with less urgent problems several weeks later.
For a fee, telehealth providers offer users the chance to skip the queue, and get to talk to an NHS-trained doctor at a time that's convenient, without even having to leave the house. Thousands have decided that the £30-or-so cost of a ten-minute appointment is money well spent.
Among the best known providers are Push Doctor, founded in 2013, with the appealing strapline: 'See an online doctor in minutes and get prescriptions, referrals and sick notes instantly', and its competitor Babylon Health, which also offers real-time GP consultations via a video or phone call.
Dale Peters, research director at tech analyst TechMarketView, credits the rise of online GPs to both changes in consumer behaviour, and to the desire by the NHS to use IT to generate greater efficiencies.
"It's a combination of the fact that the technology is in the right place now, and largely because everyone had access to a smartphone and is used to using it for almost everything else," Peters says. The NHS is keen as well because it can potentially trim demand for in-person GP appointments, which are a desperately limited commodity.
Having used one of the telehealth providers, in one ten-minute appointment, all the flaws and advantages of the new system became clear.
I did get to choose an appointment at a time I wanted, but I still had to wait over half an hour before the doctor became free. I got to talk to a GP the same day, but she couldn't prescribe the medication I needed without checking my blood pressure – and that wasn't something that she could do over a video link.
As I couldn't provide a blood pressure reading there and then, the doctor suggested I go and get one and ring back. Where could I get one? Gyms have blood pressure machines, she said, but I'm not a member. "What about your local GP practice?", she offered without irony, before pointing out we were about to run out of time and that tacking on another 10-minute consultation would cost me another £30. And then there's a further charge for the prescription (if you get that far). Any drugs privately prescribed are likely to cost far more than the £8.90 the NHS charges for a script.
These sorts of online consultations are clearly better suited for some types of healthcare needs than others. Follow-ups for some conditions can be done quickly and remotely: re-prescribing drugs that don't need monitoring, for example.
But anything more involved – simply looking in someone's ears or feeling the texture of a rash – and the online-only system clearly can't deliver. Communication skills are now heavily stressed in doctors' training, but medicine goes beyond talking alone – oftentimes a doctor needs to be in the same room to get the true measure of the patient's illness.
However, there are questions over how much of the overall healthcare market will move to digital GPs. "There is some evidence that these new entries have had some success," says Andrew Thompson, director of therapy research and analysis, medical devices, at researcher GlobalData. Thompson points out that the Care Quality Commission (CQC) currently lists 39 providers of 'digital doctor' services, which are hoping to win business from insurance companies by providing a cheaper service compared to the conventional private medical sector.
"But clearly, the CQC does not believe that these digital services currently offer a comparable service, in terms of safety. This, and the long-term decline in self-pay, would indicate that these companies will not win significant share of the UK private GP market. I remain of the view that the heaviest users of the NHS GP service, the elderly and chronically ill, are less likely to use these pay-for services, and are unlikely to benefit from them through employment health insurance," he says.
The safety of some of these apps has been a concern in the past; the CQC found nearly half of non-NHS online GPs wanting when it comes to patient safety in a 2018 report: "Safety is where CQC found the greatest concerns, but also where CQC has seen the greatest improvement," the watchdog said. Some of those concerns arise because of the lack of face-to-face meetings between patients and the GP, said Thompson, when it comes to prescribing.
The telehealth providers are aware of all this, and in some cases have opened physical surgeries for things like blood tests. But for those outside its catchment areas, and for providers that don't have bricks-and-mortar clinics, if there's any doubt, doctors will often send their patients to the NHS' 111 service or direct them to A&E – the same place those patients would have ended up if they'd gone to their family GP in the first place.
While some of those A&E visits will have been necessary, others could have been avoided with face-to-face consultations – which risks pushing more cost onto the NHS's overstretched emergency departments.
However, for all these limitations, the momentum is with virtual GPs. And as well as the private service where patients pay to see a doctor, these services are also gradually being incorporated within the NHS, too. Babylon Health has partnered with a primary care organisation in London to provide NHS services through its app and a local clinic. The service, called GP at Hand, uses Babylon Health's platform and is offered by a London GP with four partners. Push Doctor has a similar arrangement in Birmingham, where it provides telehealth appointments for 13 practices with nearly 90,000 patients, around one-third of whom have signed up for virtual GP appointments.
Such services should help take some of the strain off the NHS, so the thinking goes. What's more, such services often operate outside normal office hours, meaning patients can potentially be seen sooner. Such flexibility may also attract doctors back into the profession: parents with young children can work after the kids have gone to bed, for example. More available doctors and more appointments should ultimately help patients get seen sooner, either within the NHS or outside of it.
It's not always so simple, however. For every patient registered at a GP practice, the government hands over a sum to help fund their care – paying for necessaries like rent and dispensing. Last year, it was an average of £152 per patient. Although the per-patient fee is adjusted by age and gender, it's only with a mix of fit and healthy patients and those with more complex needs that a GP can hopefully balance the books – spare budget saved from the healthy can be spent on the ill.
Typically, the patients that use apps tend to be at the younger and healthier end of the spectrum, meaning they have a relatively low care overhead and thus can afford to be seen by remote GPs.
Those who use the GP at Hand service have had to de-register from their local GP, which first means the £152 is redirected away from the bricks-and-mortar GP service. But those traditional GPs may end up keeping the most complex cases on their books, while newer virtual services siphon off the least costly. With the relatively fit and healthy removed, NHS GPs' budgets risk becoming unbalanced.
The Fulham and Hammersmith CCG (a clinical commissioning group is a body that oversees primary medical care in a given area) where GP at Hand is based recently announced it was facing extra financial pressure and cash flow issues due to the amount of patients signing up with GP at Hand. While the CCG is expected to fund patient care in its local area, many more patients are signing up for the service from across London. The CCG recently said it had expected the costs for such out-of-area patients to be mitigated by NHS England, but it now believes this is unlikely to happen.
The GP at Hand practice now has 40,000 patients, and has been granted permission to expand beyond London, with a rollout planned for Birmingham. Such cross-CCG healthcare provision is likely to prove a challenge for the NHS, at least in the short term.
"Shifting money around is the big issue – the system needs to be in place to allow that. You'll need to have budgets that are flowing around much more freely than they currently do," TechMarketView's Peters says.
In the future, IoT networks and connected medical devices will also make it easier for medical professionals to review changes in a patient's health without having to physically bring them in for a consultation. And clearly there is an appetite for services that fit more around patients' lifestyles.
As a result, the NHS at large is responding to changes in the market and patient preference, and will offer digital "telephone and video consultations" to everyone over the next five years,"usually from their own practice or, if they prefer, from one of the new digital GP providers", the NHS' recently published Long Term Plan says.
According to health think tank the Nuffield Trust, there's no doubt that the rise of the online GP services will bring with it changes to the NHS we know today – but whether those changes will be positive or negative is less obvious.
"The GP at Hand model is, without doubt, disruptive. Used at scale, it necessitates changes to funding and contractual arrangements, as well as service planning. Not only this, it transforms the nature of interactions between patients and professionals," it says.
"But it isn't clear – at least yet – that it's destabilising general practice. We don't know how the service and uptake will evolve. Rather than view it as a threat to traditional general practice, perhaps it should be viewed as an opportunity (or a challenge from the market) to offer a new service that – for many – is preferable to how it's always been."
That's perhaps an uncomfortable truth. For the NHS, the current way of doing things, dishing out GP appointments by who can get through to the surgery on the phone first in the morning, is one way of rationing but one that's far from ideal. Virtual GPs may be disrupting the traditional way of NHS working, but it's an alternative that patients are growing to like.
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