Online GP consultation systems may not be the silver bullet for reducing GP workload and patient waiting times that government policymakers are hoping for, NIHR-funded research from the University of Bristol has found. These systems offer the potential to revolutionise use of primary care, but only with careful implementation and effective marketing, the researchers concluded.
NHS England is offering a £45 million fund to support GP practices to adopt online consultation systems. However, the evidence on the use and effectiveness of online consultations is limited.
The research, published in BMJ Open and BJGP, evaluated eConsult, an online consultation system where patients can submit their symptoms to a GP electronically through their practice website, creating an 'e-consultation'.
The system was piloted in 36 GP practices in Bristol, North Somerset and South Gloucestershire. The team looked at website usage data, how patients using the system went on to use other care and patient surveys and practice staff interview data.
They found that patient use of the system was low. Across the participating practices, there was an average of two e-consultations a month for every 1,000 patients.
Usage was lowest outside standard practice opening hours, especially at weekends. Nearly 60 per cent of all e-consultations took place Monday to Wednesday, with use declining towards the end of the week: only a little more than 12 per cent of e-consultations were completed at the weekend. Users were more likely to be female and aged 25-44 years.
The most common reason for an e-consultation was for administrative reasons such as requesting fit notes or repeat prescriptions, followed by infections and musculoskeletal issues such as back or knee pain. Most patients said they valued the eConsult system. Clinicians reported eConsult worked best for simple and routine enquiries that they could respond to without the need for a face-to-face or telephone follow up.
Practices were often motivated to use the system because it offered the potential to reduce face-to-face contacts and free up GP time, as well as improving access for patients. However, GPs highlighted the challenges of remote consultations which lack the facility for real time interactions with patients.
Thirty-eight per cent of e-consultations resulted in a face-to-face consultation. A further 32 per cent resulted in a telephone call from a GP, for more information to reach a clinical decision. A face-to-face consultation was more likely for patients presenting a new condition than a pre-existing condition.
When symptoms were complex or new, clinicians felt it was best to arrange a face-to-face consultation. Practice staff felt these cases were using more GP time than if there had just been a usual face-to-face appointment. The eConsult platform's lack of integration with existing IT systems also created challenges which could duplicate staff workload.
Online consultations were not an immediate solution for efficiency savings, but could improve access for some patients, the researchers found. Some of the issues they found were due to limitations of the eConsult system itself, which has potential for improvement. Other issues were associated with the way practices advertise and implement these types of systems.
Dr Jeremy Horwood, of NIHR CLAHRC West and University of Bristol's Centre for Academic Primary Care, said: "While our study focused on a particular system in a regional GP consortium, there are lessons here for any GP practice considering moving to an electronic consultation system. There is a central government drive to move to these systems. However, our research shows that they need to be carefully implemented and effectively marketed to yield the benefits that politicians are hoping for.
"Online consultations may have value for some patients, such as straightforward medical enquiries, but they cannot replace face-to-face consultations in situations which are more complex."
Dr John Heather, Chair, One Care (BNSSG) Ltd, said: "Online consultations are one of a number of innovative ways to address the sustainability of general practice, and understanding more about the environment and conditions in which they function well allows us to offer best-value to practices and patients. The findings from this research can influence implementation guidelines for garnering the opportunity presented by e-consultations to enable general practice to survive and thrive."
Murray Ellender, Chief Executive of eConsult, said: "Online consultations may not be a silver bullet, although our experience shows they could be a significant part of the solution, and have evolved a long way since this study was carried out. It is encouraging to note from the evaluation that more than six in 10 online consultations did not require a face-to-face consultation, and quantifiable feedback from patients indicates they value having this option.
"eConsult now supports more than 350 practices and we are gaining expertise and knowledge all the time, and using this to improve our offer. We welcome studies such as this, from which we learn and evolve."
'Use of an electronic consultation system in primary care: a qualitative interview study' Jon Banks, Michelle Farr, Chris Salisbury, Elly Bernard, Kate Northstone, Hannah Edwards and Jeremy Horwood. Published in BJGP
'Use of a primary care online consultation system, by whom, when and why: evaluation of a pilot observational study in 36 general practices in South West England' Hannah B Edwards, Elsa Marques, William Hollingworth, Jeremy Horwood, Michelle Farr, Elly Bernard, Chris Salisbury, Kate Northstone. Published in BMJ Open