Primary Care is Broken
With an easing of the lockdown hopefully only weeks away, should the front line of healthcare go back to the old way of working? I say absolutely NOT. Primary Care in the UK is not fit for purpose. Public satisfaction with our primary care has been sliding for a decade. Ask any UK resident juggling work and family life about their experiences of GP visits and they will complain of long waits, inconvenient visiting hours (only 30% of people in England have access to a GP outside of working hours), too much paperwork, no integrated health records, waiting rooms full of sick people, then a quick check up from a generalist doctor — at which they are either told to self-help, receive a prescription or get a referral to see a specialist. Lonely, retired people wanting a chat might appreciate this, but there are better ways to support the elderly, which don’t involve highly paid doctors. For busy tax payers and parents, the system is not remotely fit for purpose. Luckily, there is a better way, and the necessity of the coronavirus lockdown has given us all a glimpse of how that might look.
The Current NHS Plan Doesn’t Fix It
Before writing this article, I wanted to check that I wasn’t proposing something that the NHS was going to do anyway. So I read NHS England’s ‘Five Year Forward’ Plan. It reads like a plan for rearranging the deckchairs on the Titanic. There is virtually no mention of doing things differently.
Some background stats for you. There are 300m primary care consultations in England per year, costing £10B annually. This equates to £33 per consultation. You can add to that at least £20 per visit, to allow for 2–3 hours of wasted time per patient. For simplicity, let’s say that the cost per consultation — to the economy — is £50 per consultation. So the true cost to the economy is more like £15B.
NHS England’s proposal is to increase the number of GPs by 5,000 and increase primary care spending by £1B per year, or 10%. More doctors is not the answer. There is no imagination in the plan. Surely — like all other industries — the plan should include minimising face-to-face consultations, through using automated self-help as much as possible? Self help is free for the NHS and often the most convenient solution for the patient. Doctors should only be used when self-help and other cheaper options can’t work.
Proposal: Make Triage Remote
Triage, or prioritisation, of patients’ conditions and treatment, doesn’t require doctors in most cases. Imagine if we could close all GP surgeries and design the process from scratch— how would we do it? I suggest something like the following:
- Digital Self Assessment. Patients self diagnose, using interactive mobile apps, enhanced with clever tech, such as image recognition for rashes/ marks. The app can 1) calm you down if there is nothing to worry about, 2) recommend over-the-counter drugs to buy if appropriate, or 3) recommend home testing kits.
- Home Testing. If blood/ urine/ stool/ blood pressure tests are required, NHS-approved home testing kits could be made available through Amazon/ Boots/ Tesco. These should be price controlled to take advantage of NHS purchasing power. They could even be free (e.g. for children and pensioners) on submitting your National Insurance number.
- Video Call. If the digital assessment and/ or home testing kit indicates that a doctor is required, then the patient schedules a remote (video) call with a doctor/ nurse. These people could be anywhere, and likely working from home, and should be available 24/7 (would be easy with some staff in, say, Australia). The outcome of this call could be self-help, receiving a prescription or a referral to specialist.
- Specialist Meeting. Only after going through the appropriate steps above would you be allowed to book an actual physical face-to-face meeting. And it wouldn’t need to be with a GP, but directly with a specialist — for an expert opinion or access to advanced testing.
Possible Risks
I have discussed this idea with people in the industry, and they came up with two possible challenges, both of which should be manageable.
- Holistic Care. Supposedly, one of the benefits of having a GP is that they join the dots with helping patients to get the best integrated care. Yet in reality they are terrible at this, due to overwork, paper record keeping in multiple locations, and poor communication within the NHS. A decent mobile app, with all patient data in it, including blood type, innoculations, past operations, test results, doctors’ notes etc would do a much better job. It could also be used to track viruses, integrate with Fitbits and heart monitors, plus track trends like weight, blood pressure and heart health over time.
- Managing Costs. Another supposed benefit of the current system is managing budgets. However, given the enormous waste in the NHS, that can hardly be deemed a success. It should be possible to have automated ‘flags’ to go off whenever individuals are suspected of fraud or being a hypochondriac. These individuals could have services paused while a (human) investigation is conducted. This is clearly a complex issue, so a lot more more work would be needed to flesh this out.
Redirect £7B Savings to Improve Health
If you analyze the reasons for the 300m annual GP visits per year, my guess is you could reduce face-to-face GP consultations by over 70% (it is hard to find a decent study of this subject — suggestions please). You would also save a fortune on rent and administration costs for the 5,000 buildings. If true, the total saving for NHS England would be up to £7B per year. What could we spend the money on? Personally, I would focus on some of the following:
- Offering proactive screening to catch conditions (e.g. cancer) earlier, saving yet more money and improving lives.
- Increasing support for mental health issues.
- Proactively tackling obesity, diabetes, heart disease and associated cancer issues.
- Move the money out of healthcare into other societal investments to drive healthier lifestyles, such as cycle paths, school sports and pedestrianising city centres.
- Ensuring preparedness for when the next pandemic hits.
This is Possible Now
The above is not hard to imagine, as 1) all of the technology is available now, and 2) this is how many GP surgeries have been running since coronavirus hit. And with old people likely to be on lockdown for many more months, remote service will have to continue for them for some time.
Just like we don’t need bank branches in a cashless society, we don’t need physical GP surgeries when everyone has a smartphone. They are a relic of the pre-smartphone era.
Ben Legg is the Founder and CEO of Digital People International, which works with startups to reinvent healthcare, education and society for the better. An engineer and serial technology CEO, he has lived in nine countries and used a wide variety of healthcare systems. His experiences of health services have included the births and inevitable medical issues of his four children (one of whom was diagnosed with a brain tumour aged five) plus various operations and tropical diseases, some of which could have been avoided (tip — don’t eat the giant snail in Nigeria).
