Riverside Medical Centre

“We are opening another channel for patients and making it easier for them and easier for us at the same time.”
Online consulting is better for GPs and better for patients too, says London GP Dr Ross Dyer-Smith

Although, like many GPs, Ross Dyer-Smith was sceptical about online consulting, he now believes it improves his patients’ experience – not just by broadening their options but also by easing the demands on his time, which helps him provide a better level of care. This is true for all patients, he says, not just those for whom online consulting is the preferred method of contact.

Among the objections that GPs raise when thinking about online consulting are concerns that it could exclude vulnerable groups such as the elderly and those who may not have online access. Yet it is precisely by offering all patients a faster, easier way to consult with their GP that online consulting also helps those with issues around access and those with complicated health conditions.

“By reducing the number of face-to-face consultations I carry out, I have more time for the people who need in-depth interaction and a higher level of care”

says Ross, who joined the Riverside Medical Centre in Vauxhall, south west London, in 2010.

Riverside Medical Centre has around 11,000 patients, most of whom are in the 25-40 age-group. Burgeoning patient numbers, a savvy and demanding demographic and a commitment to ensuring the best possible patient experience persuaded Ross and his colleagues to look into online consulting more than three years ago. “I have to admit I was unconvinced at first,” he says. “I thought an eConsult was just another questionnaire and that most patients would still have to come into the surgery anyway, so what was the point?”

Ross built his confidence in online consulting by referring to his initial experience with telephone consultation. “Usually in general practice, it’s all about face-to-face, so consulting by telephone for the first time as a trainee feels very strange, even risky. But you learn to manage the risk and ask the right questions. Your first telephone calls often last half an hour, but with experience now they shorten to last 5 or 10 minutes. And it’s the same with eConsults. I started off calling everyone in anyway, nervous of the perceived risk, but over time I became comfortable with online consulting and now I can go through an eConsult in a couple of minutes. It’s easy because the system tells you where to look for the vital information, and you can make your decision very quickly.”

“It’s easy because the system tells you where to look for the vital information, and you can make your decision very quickly.”

Channel shift

The Riverside team saw electronic consulting as a natural progression in the drive to meet patient needs. “In general practice we have to find smarter ways of helping more and more patients. I can’t help thinking of Einstein’s definition of insanity – doing the same thing over and over again and expecting different results. The world has moved on, but we have been using the same method of consulting since the invention of the telephone. You go and see your doctor, sit in front of them and discuss your symptoms, and the doctor makes a decision on treatment there and then. But we’ve got to the stage where things have started to tip, and there has to be a new way of doing things that is better for patients and more effective for GPs. So my view about online consulting was that there was no harm in trying.”

He believes that a holistic approach is crucial to success when the system is introduced: “It’s very tempting when you get a new piece of tech to think that you press a switch and it will solve all your problems overnight. But you have to get the implementation right, and that includes getting the patients to use it. Luckily our patients are very tech-literate, but we shouldn’t be discriminatory and assume certain groups won’t access it – I think the oldest patient using eConsult with us is 93. The key is letting people know about the system and making it easy for them to use.”

At Riverside, visitors to the practice website are directed towards an online consultation in the first instance. Patients who do phone into the surgery also hear a message about e-consultation before they speak to a receptionist. Posters in the surgery and occasional direct marketing campaigns also help raise awareness. “Once people realise how easy it is, they’re usually on board,” says Ross.

“Once people realise how easy it is, they’re usually on board”

“We did a survey to ask if patients would access more services online. One of them said he wouldn’t as he was consulting a doctor and it wasn’t as simple as ordering a pizza – the irony is that in some ways, it is! We are moving towards online models for so many everyday services – so why should GP services be any different? Now I can deal with a patient’s health problem from end to end, even if they are miles away. I can process an eConsult and send a prescription anywhere for them to collect.
“I say it’s all about ‘channel shift’, from face-to-face or telephone consultation to consulting online. You’re still consulting with your own GP. And because your GP has the opportunity to read and digest your eConsult form before responding to you, he or she can really think about your symptoms and come up with the very best solution.”

Ross believes asynchronous consultation is a lot less stressful for both the patient and the GP. “In a face-to-face consultation, somebody is talking to you and you are taking in data and formulating the next question to ask. It is intense. The eConsult takes away that need to be thinking rapidly on your feet, in ‘real time’. Most of the history is already there for you on the electronic form, so when you call the patient, you already know the two key questions you want to ask, rather than asking them 15 or 20 from scratch to get to that point.”

Time to care

Like many GPs, Ross starts his day with an 8am consultation and goes on for three or four hours. “I’m making decisions all day long. It can be very emotional for the patient and hugely stressful for the GP. But when I do my eConsults it is like a breather. It gives me a chance to think and focus. You are still helping the patient and dealing with problems, but it is a different kind of interaction – even when you do talk to the patient. You can actually spend more time addressing the issues that come out of the consultation, making it more targeted, more therapeutic.”

Ross’s term ‘channel shift’ is highly appropriate for electronic consulting. “People ask about consulting via Skype, but that’s still face-to-face, it’s still thinking on your feet and it doesn’t create efficiency,” he says. “You still take ten minutes of your time, and ten minutes of the patient’s. With eConsults you can give the problem the time it deserves, at a time that’s right for everyone.”

“People ask about consulting via Skype, but that’s still face-to-face, it’s still thinking on your feet and it doesn’t create efficiency,”

And with GPs’ time being so short, the fact that Ross can do two or three eConsults in the time it takes him to do one face-to-face consultation is key. Not only does eConsult treble Ross’s efficiency, it also helps his team. “Receptionists take the brunt of patients’ frustration when they’re trying to get an appointment,” he says. “Now there’s an alternative way to consult with their GP, which results in fewer phone calls.”

He estimates that around 8 to 10 per cent of his consultations are now online: “We also have to remember that a lot of patients are using the self-help option, which obviates the need for a GP consultation at all.” And by reducing the number of consultations he carries out, Ross has more time for the people who need more in-depth interaction and a higher level of care.

Jewel in the crown

Asked which way the wind is blowing for general practice, Ross accepts that some GPs may remain resistant to change but, he says, “Online consulting is the direction of travel. You only have to look at the explosion of apps in the private sector, with the likes of Babylon and Push Doctor. This is what patients deserve. It’s what they want, and the NHS is a little bit behind the curve. There are more and more patients and not enough doctors. Demand is rising and the current model can’t be sustained.

“It’s been said that primary care is the jewel in the crown of the NHS. Well the jewel in primary care is GPs’ ability to change rapidly. We are small businesses and we have to be agile. People in general practice are already doing amazing stuff. It wouldn’t surprise me if someone didn’t pick up online consulting and take it even further. GPs are brilliant at getting things moving. And the advantage of general practice is that if something doesn’t work you can change it. So really there is no reason not to give it a go.”

Fears that a new channel will create even more demand, and that groups like the elderly will be excluded, are quickly allayed once a practice embraces online consulting. “This is not replacing general practice,” concludes Ross. “We are opening another channel for patients and making it easier for them and easier for us at the same time.”

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