by Dr Aravinth Balachandran

The future is digital

South View surgery in Bromley has 13,000 patients, many of whom commute into London every weekday. Keen to keep up with digital trends, the practice’s five partners wanted to offer patients a better way to get the healthcare they need, which led them to implement eConsult earlier this year.

Like many GP practices, South View was finding it difficult to meet patient demand. The wait time for a routine appointment could be up to three weeks, and consequently the duty phone list after morning surgery was ever expanding. “It was often exhausting to come out of a morning surgery and plunge straight into the duty phone list, in a race to get through it before the afternoon surgery started,” explains one of the doctors, who has worked at the practice as a salaried GP for two years.

Not only was this a strain for the practice, it wasn’t meeting patient needs either. “Many of our patients work full time, and it isn’t always convenient for them to wait for a call from their GP sometime in the middle of the day. They had to fit around us. Now they can complete an eConsult form online and they know we’ll get back to them by the end of the next working day – and often on the same day. Because it’s an online communication, they can read it in their own time. It’s much more patient-centred.”

Patients who wanted to be seen sooner than the standard wait time would often try to book an ‘on-the-day’ appointment, calling the surgery at 8am, even when their concern was not urgent. “It meant that reception was gridlocked from 8am every day, which wasn’t great for patients or receptionists”.

“Reception was gridlocked from 8am every day, which wasn’t great for patients or receptionists”

The practice’s partners have always been open to new ideas, and online consultation seemed like a solution to some of these issues, as assistant practice manager Nina Jenkins explains: “Everyone has smart phones these days, and many of our patients are very good at going onto Google to find out anything they want to know. We thought they would take to online consultation in the same way. We saw this as another way of triaging calls, and the best way to give patients more choice because we could never keep up with the demand for appointments.”

Preparing for success

To prepare for the new system, Nina and her colleagues revisited the way they planned each clinic. “Implementing eConsult didn’t take a lot of preparation at all,” says Nina. “It was mostly about getting it right our end – for example, how we were going to incorporate it into the GPs’ day.

“We introduced a new template so that each GP carried out a certain number of face-to-face appointments and then we removed two ten-minute sessions at the end of each clinic and allocated the time to two e-Consults and two urgent calls. The admin team monitors the eConsults as they come in, and allocates them to a doctor’s clinic task list as appropriate. Our GPs can process up to two eConsults in the time it takes to see one patient. So now, our GPs have completed their workload when they walk out of their surgery, and we’ve done away with the duty calls list for most patients, with only under-18s and those who are unable to access eConsult still being allocated urgent call slots.”

The clinical and reception teams pulled together to become familiar with eConsult so that they could introduce it to patients. “We worked quite hard to get to grips with it ourselves, so that we understood it,” continues Nina. “This included submitting our own eConsults to see how it worked. That definitely made it easier to explain about it to patients when the time came.”

The practice took a robust approach to marketing, advertising eConsult on its website with a link to the home page, and placing posters, flyers and even balloons in reception to help get patients’ attention in the first weeks. “We also printed prescription-sized slips advertising eConsult and put them in with paper prescriptions, as well as handing out slips to everyone queuing outside the surgery at 8am for an appointment, telling them about this alternative option.

“Our reception team spoke to everyone who asked to go on the duty phone list and explained that they could consider going onto eConsult instead. But perhaps the most effective thing has been the message on our phone system. Everyone who rings in will hear a message advising them about eConsult and asking them if they need a face-to-face appointment or whether their issue could be dealt with online via eConsult. That seems to work very well.”

Managing expectations

From a GP’s point of view, eConsult has made a huge difference to the on-call part of their day. “Since introducing eConsult a few months ago, we have seen a 38% reduction in the size of the duty phone list. Those patients are now using eConsult instead. This hasn’t made us less busy, but has made us much less exhausted. When you’ve been talking to a different person every ten minutes all morning, it is lovely to be able to work through an eConsult with a cup of coffee and a clear head.”

The GPs also feel that they are able to be more effective with eConsult, as well as more efficient: “Knowing more about someone’s problem before I respond to them lets me think, and gives me time to compose a considered reply. I find I can be more concise and provide a better quality response than in a phone consultation, where we may be talking about a simple problem but it can take some time to get to the point.

“The brilliant thing is how smart eConsult is at getting to the exact problem.”

“The brilliant thing is how smart eConsult is at getting to the exact problem. Unlike an email or generic questionnaire, the software identifies the presenting complaint or query and tailors the questions it asks the patient accordingly. This gives us a much more focused history, which includes key red flags for presenting complaints, and also health promotion questions. I worry as a GP that in the bustle of a busy list of phone calls after an energetic morning surgery, I might forget to ask an important question, but by honing in on the questions relevant to the patient’s particular presenting complaint, I feel eConsult has my back, which is good for patient safety and my own peace of mind. It also acts as a triage tool for us, because it helps specify and delineate the problems at a glance, which highlights patients we might need to talk to urgently. Another real plus is where people need to have investigations like blood tests or X-rays before we see them. I get that done first, so they don’t need two appointments.”

When it comes to self help, the GPs found that people’s reactions vary. “If patients want advice for something like earache, I can point them to NHS Choices. But just telling them in an email to ‘go here’ and providing a link sometimes isn’t enough. People can be a bit suspicious of quick replies without the personal interaction. I find it’s better for me to make the effort to personalise the reply, and patients respond better.”

Routine requests for referrals, sick notes and other admin issues are now easily dealt with via the eConsult ‘I want administrative help’ option, creating an audit trail within the patient’s records, as well as reducing the number of emails required to deal with these standard requests.

Another unexpected bonus has been managing patients’ expectations. “We say that people can expect a reply to an eConsult by the end of the next working day. So patients are very impressed when they get a response on the same day. Sometimes on the phone if people are told we will get back to them that day, they expect to be called back immediately, and that can lead to disappointment when it doesn’t happen. Using eConsult helps us manage people’s perceptions and expectations, which means they’re generally happier with the service they’re getting from us.”

Positive indicators

Although it’s still early days, the team at South View are pleased with the way patients have responded to eConsult. They conclude: “Initially I wondered how different eConsult would be to having patients simply emailing in, but I hadn’t realised just how smart it was in extracting the key clinical information from the patient’s query. We did wonder if people were going to use it just like email, creating yet another channel into the practice, but that hasn’t been the case. It is unlimited, so we could have a deluge of minor queries, but that has not happened. Rather than simply having the option of booked appointments or phone calls, eConsult gives people a more flexible way to contact us, and it is working very well.”

“eConsult gives people a more flexible way to contact us, and it is working very well.”

Nina agrees: “We’ve had a lot of good feedback from patients – the system has been surprisingly well embraced. Commuters are particularly happy with it because it means they don’t have to fit around us to such a large extent. They can submit an eConsult and they know they can expect a response the next day (and often on the same day) that they can read in their own time. And we have drastically reduced our duty calls list, which is great for morale, productivity and patient satisfaction.”