Online patient access and triage, can it help to improve health equity?
Blog post by Dr Esme Lawy (Trailblazer GP 2019/20)
I work in a large two-site inner-city practice serving an extremely diverse population of patients many of whom live with deprivation, many of whom are migrants to Sheffield, many very recent arrivals. It is a population of patients who are not necessarily brilliantly served by the wider health service. We have adapted to some of the challenges we face in terms of sheer workload by moving in the past year to entirely clinician first triage with patients greatly encouraged to use our online consultation system AskmyGP. The (sometimes enormous) list of patient contacts and queries is then shared around the available clinicians with a great emphasis being placed on continuity, if it can go to the doc who knows that patient then it will. We then decide whether to engage with the patient online using the messaging system, phone them, bring them straight down for a face-to-face appointment or triage it elsewhere eg. Straight to a physio assessment or another service. They can send photos easily as long as they have a smartphone with a camera (I have found through asking my patients that most but clearly not all do have one in the household).
I have been at this surgery for a year and throughout this time we have been adapting and getting used to the system and, more to the point so have our patients. Some are instant converts. One 80 yr old woman who chuckled when I asked if she had a smartphone and said ‘yeah, but I can only use messenger’ was pretty impressed when I explained that it was pretty much the same thing but she could speak to her doctor, within a few hours, without having to be on hold on the phone at all.
There are drawbacks, I have had questions in my mind throughout the process along the lines of does this make things better for our patients? Does it makes things better for our staff? Does it make things better in terms of reducing health inequity? I don’t think the answers here are simple. The first thing to say is that we have always actively been intending to improve and not to create a barrier to access, people can still also reach us in exactly the same way as they always did before, via the phone line from 8:30-10am and they will be prioritised in exactly the same way (ie clinically), reception just create an AskmyGP query on their behalf.
There have been some serious questions raised and discussed in our meetings about how this system impacts our patient’s who have low literacy or little English. Our feeling is that the requirement for English is no greater than that required to speak to a receptionist and ask for an appointment. If anything I have probably found many patients are happier this way. They can use Google translate, they can ask a family member who can create the query for them as a proxy, and they always have the option to just fall back on the old system and phone to speak to reception or pitch up at the desk (well, in simpler, pre-COVID-19 times they could anyway). The literacy side of things is interesting, since learning recently that the average reading age of adults in the UK is somewhere in the region of an 11 yr old I have adapted the way I use the system. It’s the same old com-skills that we all know and use automatically but you just have to remember them as an absolute priority. Keep it simple, don’t use jargon, keep it brief and wait for confirmation that you have been understood. If we don’t get that indication using the online messaging we would almost always phone them or bring them down to ensure things have been understood and their issues fully tackled. And one strength with online communication is that the information is there for them to go back to later, with a phone call or face to face appointment it is gone unless you also gave them some written information or they had the where with all to take notes.
A big concern is the use of the system by perpetrators of coercive control to further distance their victims from a professional who might be able to spot something amiss and offer help. Other concerns would be for those who don’t speak or write English or possibly vulnerable older people who might find that some of their communication with their doctor is taken over by a very ‘helpful’ partner or family member or friend who is more fluent in English or more computer literate. Again there is something about the system that has the potential to distance the individual from their clinician. I answer to this I can only vouch for the fact that everyone I work with has their radar switched on when it comes to spotting these problems. I’m not saying it is perfect but I do think that used judiciously and by highly trained clinicians who are not out to turn a blind eye to these scenarios I think it can work. At least as well a telephone based doctor first system. And the idea really is to free up time, if you have been able to deal with a simple UTI in a 23 yr old with a quick back and forth message you have time and, more importantly the thinking and emotional capacity to take something potentially bigger on and ask the uncomfortable question, use a professional interpreter instead of a family member even though it will take much longer, ask to see the patient alone, start to build a bridge.
And then I come finally to the current situation we find ourselves in. I do worry immensely about the disproportionate effect of the current COVID-19 crisis on patients like ours whose lives and health are not always as secure as they would like. I am alarmed by the emerging figures showing the disproportionate number of deaths amongst health professionals from a BAME background. Ten of the first eleven doctors who have died from COVID-19 in the UK were of a BAME background. It would appear that this virus does discriminate in the same way that so much ill health does. Even the experience of self-isolation/lockdown/being shielded clearly is very different for those who live in inadequate or overcrowded housing or those who live with serious long term mental illnesses. This has all been spoken about very informatively by Tom Ratcliffe in his recent blog entry below.
Very understandably coronavirus has our patient’s stressed and scared. So suddenly there is a different feel to all these online and telephone triage conversations, people are very onboard with anything that avoids them coming down to the surgery, we are now having to negotiate with people who really do need to be seen to get them in. Clearly this a frightening time for all but do think that out of this could come some positive behaviour change. More of our patients are using the online system, many many more are happy to engage with online consulting using messaging, photos or video. And we as doctors are suddenly more motivated to use it to its full potential and iron out any glitches which might have been holding us back slightly. Most of this move to online and telephone consulting is entirely appropriate. There will be non-coronavirus related fall-out from this crisis; worsening of people’s mental health, delays in diagnosis of serious disease and increased risk to those living in precarious or abusive situations. But I think used judiciously and by those who have already developed skills around it I think our system is a force for good through this time. A piece in this months edition of The Doctor cautions against a rushed move to the use of online systems. And I think there is a crucial distinction to be drawn between systems like ours and those that are designed, perhaps with AI capabilities to divert patients away. I feel fortunate to work in a practice where using this technology is an embedded part of how we work. I think that out of this appalling crisis will come a further positive shift in how we and our patients use and value the system. I think that together we are using it to build better and closer relationships.