Agenda item

General practice continues to evolve in response to increasing patient demand, workforce shortages, and the need for more efficient care pathways. Automation tools, such as Rapid Health Smart Triage, are being introduced to help practices manage demand, improve access, and ensure patients are directed to the right care at the right time.

This report sets out:

·           The challenges general practice faces and the need for change

·           Why practices have moved from eConsult to Rapid Health Smart Triage to support their access transformation

·           How automation to support access is being adopted and embedded in Surrey Heath and Farnham practices

·           Early experiences from Surrey Heath and Farnham, including successes and areas for ongoing improvement.

Automation is an enabler in the transformation to establish more sustainable general practice models. Its role is to reduce unnecessary manual processes, improve triage, and ensure patients receive care in the most appropriate setting while preserving personal interactions where needed.

Meeting resumed at 11.44am

Witnesses:

• Mark Nuti, Cabinet Member for Health, Wellbeing and Public Health
• Gurpreet Mangat, Associate Director of Digital Primary Care (Frimley ICB)
• Karl Bennett, GP and Clinical Lead for Primary Care Digital Transformation, Frimley ICB
• Dr Mark Pugsley, Clinical Lead- Surrey Heath Place (Frimley ICB) and GP Partner
• Nina Crump, Primary Care Digital Programme Manager (Surrey Heartlands ICS)
• Samantha Botsford, Contract Manager (Healthwatch Surrey)

Prior to the discussion, witnesses provided a presentation on the report to the committee.

Key points raised during the discussion:

1. The GP and Clinical Lead for Primary Care Transformationnoted that GPs were under increasing pressure, not solely due to patient demand but also resulted from issues that resulted from the impacts of COVID-19. There was a focus on hospitals to reduce waiting lists and welcomed the shift to primary care, with more work undertaken outside of hospital, the resources would need to be available to align with that. It was noted that the controversy around online consultations similar to the controversy around telephone appointments with some success and convenience was there, and a recognition there had been improvements for access with some groups and that more could be done in terms of improving the access, for certain other groups. Primary care needed to be clever with demand management and achieve consistency of access. The distinction between a patient needs and wants meant that there was a perception the service was failing by not meeting the patient expectations. There was work to do in the way GPs handled online consultations, and they would continue to do so.

2. The Associate Director of Digital Primary Carehighlighted the efforts of the practice to try to find ways to meet the need and think about how to use the workforce differently whilst maintaining a consistency of offer. The online consultation market was evolving which allowed practitioners to ensure the right tools were in pace to support their model and support them in managing capacity to best support patients. Differentiating patient need and preference was challenging but was aligned with equity so that no matter where you went, you would have the same story and were supported by the new digital capabilities coming in. In Frimley, whilst everything cannot be standardised due to population differences, what could be managed was to ensure that the consistency was in place and could be ensured. GPs were able to use the best tools to support them in this in order to take patients on the journey so that it was understood.

3. The Associate Director of Digital Primary Care added that every practice had a cycle of communication and engagement, using various methods. Some Frimley practices held face-to-face sessions for those that could not use digital engagement which helped to relieve their concerns. Positive feedback was received from one practice which had showed that fifty percent of patients who used one of the tools found them easy to use, which would help in creating capacity by freeing up phone lines.

4. The Chairman referred to the issues concerning the GP industrial action that had resulted in services becoming rationed and of the impacts of the reduced interaction with patients. He hoped the new GP contract and extra funding would make a difference and referred to a situation that had been generated where patients had felt dissatisfied such as by using the E-Consult service noting that it was only open for half-an-hour a day, which caused issues. The GP and Clinical Lead for Primary Care Transformation clarified that his practice was involved in collective action, and made the distinction that it was not involved in industrial action. The GP and Clinical Lead for Primary Care Transformation clarified that in relation to managing demand, he had a dashboard categorised by severity, those patients that needed prioritising. Continuity of care and access to care was very important for patients with complexities and with multiple conditions. Language needed to change from “see your GP” to “contact your surgery”, to help adjust and manage the patient expectation on who would respond to enquiries.

5. The Clinical Lead for Surrey Heath Place and GP Partner referred to E-Consult and the comment that it was not always switched on in the surgery, and referred to the Rapid Health model which could be left on throughout the core hours of service and many surgeries had opened it ahead of the 8am appointment start window, which had allowed people to go online to access appointments and had proved positive in that respect.

6. The Chairman noted that it was a key message to get out to patients that this service exists and is in place as an option.

7. The Associate Director of Digital Primary Care highlighted that every GP practice was on a different transformation journey, with models taking time to achieve and to explain that messaging to patients so that it was consistently explained, and patients did not feel it was something different every time. Rapid Health in Surrey Heath was a good example of trying to bring patients on the longer-term journey.

8. The Chairman highlighted the issue of unequal access and the challenges faced by people with technology, language, and literacy issues, who often presented complex health issues. He noted that the patient ‘front door’ experiences varied across Surrey for residents and considered that a large culture change was needed internally to provide a seamless experience with the best outcomes. The Primary Care Digital Programme Manager explained the importance of getting the channel agnostic access correct which was a focus for Surrey Heartlands ICS. In the last two years, as part of the transformation work with GP surgeries, was to provide face-to-face workshops to engage with GP practices and to get them working together as peers to understand those challenges. Patient communication was a key area of challenge highlighted in the first workshops, and they were keen to receive support on. Following that work Surrey Heartlands ICS had produced communication material that the practices could use which they hosted on a central platform that GPs could download and share on social media. Surrey Heartlands ICS was procuring social media support to produce materials, that picked up new roles, opportunities, and benefits for patients, which also enabled a continuity of support for those patients with complex needs. The tools allowed flexibility and management in different way.

9. A Member asked how digitally excluded populations could be helped to access support and drive seamless access. The Clinical Lead for Surrey Heath Place and GP Partner explained that a lot of work occurred around health inequalities. There was a lot of data around patients, so they could be contacted in different ways. They used proactive approaches as well as reactive approaches such as ways of reaching people such as the population health approach, so they could reach out to different cohorts of people, which would be done in the Summer with blood pressure in Surrey Heath which was in place for people that had trouble with access. For people that cannot utilise digital options then the front door and phonelines of surgeries remained open. At Park Road Surgery’s main site, there was a room where a patient could be guided through Rapid Health with a receptionist and come out with an appointment. They have seen many people convert to using the digital approach and recognised that it was a learning curve.

10. The Associate Director of Digital Primary Care added that a GP practice in Surrey Heath was also ensuring patients who had complaints were contacted and that by having conversations and taking a tailored training approach that it had helped to enhance the patient’s confidence. The staggered ‘go lives’ allowed for continued learning from each other.

11. A Member asked what was being done to ensure GPs were able to deal with automation tools appropriately, and how were GPs monitoring and managing the impact of the number of forms to review on the consultants’ workload. The GP and Clinical Lead for Primary Care Transformation explained that his practice served a population of just under 30,000 across three sites, with varying digital aptitudes among staff, and they supported each other, attending fortnightly clinical meetings which provided tips on managing it. A fortnightly induction period for new recruits provided training in all practice aspects, including operating computers. An advantage to collaborating on experiences was that standard responses to patients could be set up, which was a valuable tool. Rapid Health tended to automate the clinical triage process to a point. The system he used was called Anima which helped make tasks easier for the administrative staff and allows more time aside for clinicians to triage. Amongst the eighteen doctors at the practice some had access the very next day for routine appointments, while others had three-week waiting lists for it which added to their stress levels. Support was provided in the way enquiries were managed, to be more proactive and considered that there was perhaps a need for the profession as a whole to embrace the future and training required in order to equip medical professionals for the digital future.

12. The Member asked how burnout was being monitored. The GP and Clinical Lead for Primary Care Transformation said there were regular appraisals for colleagues. Colleagues had a global view of each other tasks so if work was mounting help could be provided, while also trying to be as proactive as possible. Coming out of the pandemic had created higher pressures for GPs in ways that many patients were perhaps unaware of. It is probably an area that did not necessarily come into what was being done in the digital sphere but was certainly something that was needed in the primary care support. The Associate Director of Digital Primary Care added that in terms of the digital sphere they were creating spaces for peer-to-peer engagement and learning about the change. In Surrey Heath that space was created to share experiences, for example to discuss what went wrong and open dialogue on that and consider how that information is captured and learnt from They were also starting to understand what the next level of development was in terms of digital literacy for their workforce and highlighted the journey had changed for the workforce, as well as for patients.

13. A Member referred to Rapid Health being an automated workflow system, but Rapid Health’s website claims it would “Use our intelligent software” but also stated that it would not learn like artificial intelligence. The Member asked how they would ensure that patients were clear on this point, noting some patients concerns with sharing details. Regarding patients that were on different stages with the journey as well as those GP practices at varying stages of the journey as well, how would they balance the fact that some practices would use Rapid Health before others. The Associate Director of Digital Primary Care noted the need to maintain communication and recognise that the new learning being undertaken with the changes it brings and that it was important to take a considered and staggered approach to use learning and get the messaging right. Challenges were fed back to the marketplace suppliers, holding them to account, to avoid mixed messaging and ensure consistency.

14. The Clinical Lead for Surrey Heath Place and GP Partner added that the phased rollout of Rapid Health across seven practices in Surrey Heath which started a phased rollout in December, would be using Rapid Health as their digital ‘front door‘ having moved away from E-Consult, by the end of March. Regarding the point made on managing burnout, previously his practice had typically triaged more than five hundred patients a day but with Rapid Health that had reduced their first month’s data by fifty-nine percent This allowed clinicians to spend more time doing the work needed for patients that could not find appointments, which had helped to reduce burnout.

15. The GP and Clinical Lead for Primary Care Transformation caveated that he was pleased to hear that the committee was enquiring about clinicians’ health which can be overlooked, and that they were in the early days for Rapid Health. To ‘go live’ with Rapid Health, practices had to clear appointment backlogs, and he had always encouraged practices to look at the style of practice to offer what was best suited for the patients’ requirements, and to involve patients with this. He also noted that in the future some changes might be seen in the way practice colleagues were deployed.

16. The Member asked about what checks and balances were in place regarding Rapid Health and whether colleagues were constantly monitoring the tool to ensure that it was working to avoid any potential for major problems to occur. The GP and Clinical Lead for Primary Care Transformation explained there was a non-clinical quality lead in place and if problems occurred, it was usually due to it not being used correctly. An example was provided regarding a patient that had presented at the surgery having been classified as ‘green’ and having seen the patient, it was clear that it should not have been categorised as ‘green’ but the fault was not with the software, despite the symptoms that had been entered having been more generic in that respect. There were cases where people filling in forms may have underplayed symptoms to avoid Accident and Emergency (A&E) or NHS 111, and the software responded to the information provided. The Clinical Lead for Surrey Heath Place and GP Partner added that Rapid Health was very risk-averse, and patients could reject the outcome offered, which clinicians had sight over and were for example, able to review the dashboard which offered oversight on whether people had been sent to A&E which allowed clinicians to suggest a different pathway. The Associate Director of Digital Primary Care stated that it was a considered move and other practices that had gone live with Rapid Health had been reached out to. There had been a lot of learning, such as how the data had been handled and processed and review cases to sense-check the data for learning. The Clinical Lead for Surrey Heath Place and GP Partner noted that within Rapid Health there was a button to allow the clinician to advise a different outcome and tell the software what they may have done differently which was not AI learning, but clinician-informed changes given in that real-time environment, every day.

17. Regarding women’s health which may concern presenting with symptoms that were often missed or misdiagnosed, for example being on the pregnancy pathway, a Member asked how this could be prevented with the Rapid Health system. The Clinical Lead for Surrey Heath Place and GP Partner explained that the system was dependent on what information was provided and how questions were answered. If patients felt Rapid Health did not offer the right thing the patient did not have to take the appointment and would be triaged and could be contacted by the practice to have a further conversation and get more information.

18. The GP and Clinical Lead for Primary Care Transformation added that when it worked well it could save everybody time by providing enough information meaning the GP only had to follow up with a couple more further questions. The nature of online consultation could encourage patients to discuss sensitive issues that could have profound health consequences easier. One area in which we could help residents to feel more valued and supported was by acknowledging the patients’ efforts to provide their detailed and intimate information to them.

19. The Primary Care Digital Programme Manager highlighted that Surrey Heartlands ICS had four practices using the Rapid Health tool, while ninety-four practices used an ‘open text’ platform known as 'Accurx,' and were not using the same algorithm tool. The open text platform was procured in the Summer 2023, and they were currently part-way through a three-year contract. Surrey Heartlands ICS was in the process of transformation and learning which had been ongoing, while planning what their needs and requirements were for the next procurement cycle. Recognition that the market has changed was acknowledged with the rollout of technology such as Rapid Health providing different opportunities. Surrey Heartlands ICS patients were used to the open text approach, so the impacts of changing that needed to be understood as they would have an impact, and new tools available would need to be tested.

20. The Contract Manager, Healthwatch Surrey referred to the earlier point concerning the Rapid Health tool being of help to people who may not want to talk to a receptionist about their intimate symptoms in a face-to-face approach, but also asked about those people who may be experiencing domestic abuse, for example and who may want to reach out to the GP practice for support and may be experiencing controlling behaviours within the home and not be able to explicitly express that, how might those people navigate a system like this so that the door was not closed to them and still ensure that they can get to the face-to-face appointment if needed. The Contract manager was concerned that this could be a barrier for those people being able to come forward and seek the help that they needed.  

21. The GP and Clinical Lead for Primary Care Transformation acknowledged the importance of that question and explained there were ways patients may use the system which was not as it was intended for their benefit. For example, a person may raise concerns of anxiety and there may be something in that which could pique the GPs interest, and a message could be sent to the patient through the system in a very careful and bland way with consideration of the patient’s situation, which may be that they are involved with a coercive partner monitoring the patients’ phone. There were occasions that a GP may just feel prompted to phone a patient or tell them to go to the practice. He noted the use of video consultations, which were particularly valued by mental health patients as well as for the non-verbal communication, could be beneficial for certain patient groups. Information about access to refuges and helplines was also published on the practice’s website. The Clinical Lead for Surrey Heath Place and GP Partner added that Rapid Health also had an administrative function, and they do get non-pathway approaches from patients. If there was no clinical pathway for the patient need, they could in theory request help with a domestic issue in an administrative task, which would be delivered to the clinician. The Chairman suggested an equivalent to the ‘Ask for Angela’ scheme that were found in pubs could be added to the system. The GP and Clinical Lead for Primary Care Transformation said this could be taken back to the suppliers.

22. The Vice-Chair expressed her interest with seeing a demonstration on what happened once a person had completed their details, how was it triaged and how were decisions made. It was suggested that may be helpful for a future Member briefing session for the committee outside of a public meeting. The Clinical Lead for Surrey Heath Place and GP Partner stated Members were welcome to receive a demonstration at Surrey Heath to see how it all worked.

23. The Chairman agreed that he would take them up on that offer and also suggested the importance of utilising councillors, who had good networks in communications to support with helping to provide that reach for them The Associate Director of Digital Primary Care stated this was welcomed.

24. The Clinical Lead for Surrey Heath Place and GP Partner noted his practice did provide some live demonstrations to groups before going live, and that they would be happy to do this again for patients. He noted Rapid Health was gaining traction and more people had been converted to utilise this digital front door.

25. The Vice-Chair asked if it would be a part of GP training. The GP and Clinical Lead for Primary Care Transformation noted it could be a matter of chance concerning what kind of surgery trainees were allocated to as part of their training as the GPs in training were allocated to more than one surgery where there were varieties of models of care. The Clinical Lead for Surrey Heath Place and GP Partner added that as a trainer, he could confirm that GP trainees did experience every part of practice ’live’ before they had qualified and learn about triage and the software that was being used.

26. A Member recognised that the approaches taken by the GPs all appeared to be doing the right things, but that the issue was much wider and that with regards to the other GPs, how all GPs thinking could be aligned, noting the value of experienced GPs but that they might not share the same creative thinking. The GP and Clinical Lead for Primary Care Transformation responded that he thought the future may not involve a facsimile of what a GP does across an area, rather it would involve identifying colleagues’ aptitudes and deploying accordingly. He noted face-to-face consultation were important and acknowledged patient rapport could also be built quickly through online or remote consultations, as has been demonstrated during Covid. Doctors were all different, which was needed and helped to future-proof a service.

27. The Member asked how this would be spread out across all GP services. The Associate Director of Digital Primary Care said part of that involved the environment that was created. The fact a blanket, single system move was not taken was because it would take time. A space was being created for people to learn and share with peers and have conversations so that people would be more likely to buy into it.

28. The Primary Care Digital Programme Manager explained that from a Surrey Heartlands ICS perspective, explained that building the case for change and bringing people along on the transformation journey with you, was fundamental. The workshops that took place in January with four workshops that encompassed twenty-five practice GP leads and business practice managers. Two important sessions were had, one of which involved talking about the work undertaken to empower patients to take up the digital transformation and to enable the channel agnostic access, by supporting patients who wanted to access digitally whilst ensuring people could still walk into the practice if that was their choice. There was also an opportunity to discuss proactive approaches and how to support continuity for more complex patients. Those peer-to-peer sessions were effective in building awareness of opportunities, understanding the challenges, collaborating to co-design and then bring the momentum and sustainable change across general practice.

29. A Member raised the question concerning the assumption that open text did not possess the benefits of automating elements of triage. Regarding building the case for change, the Member noted that there seemed to be a limited rollout of ‘Accurx’ and asked whether it was time to stop the rollout and reprocure. The Primary Care Digital Programme Manager explained that digital rollout and access take-up was high within Surrey Heartlands ICS as it was nationally. In 2023, the rollout previously mentioned moved them from the online triage tool that was rolled out as part of the response to Covid, and into a new approach. They wanted to create a consistent ‘front door’ across Surrey Heartlands ICS and rolled out NHS branded websites. They could be personalised by the practice but with a similar look and feel to the NHS App. This allowed people to choose how to contact the GP practice (face-to-face, phone, website or NHS App) and have the same practice needs assessment. A lot of the triage was managed by the GP team and was a well-evolved model in Surrey Heartlands ICS. Surrey Heartlands ICS had eighteen of the top one hundred practices in the Country using digital access with their population encouraged by this and keen to utilise the digital access. Surrey Heartlands ICS now had two thirds of its population, aged over thirteen, registered on the NHS App. Rapid Health was not yet integrated into the NHS App, which was one of Surrey Heartlands ICS ‘red lines’ in the previous procurement as a lot of their patients used the App for other aspects of their care and they wanted to ensure GP contact was available through the App, but Rapid Health was nearly there. Surrey Heartlands ICS also learnt with Healthwatch Surrey colleagues that they did find that with the more algorithm-based question online consulting forms it was not always easy for some people to follow, as opposed to patient’s using their own words. Surrey Heartlands ICS was keen to explore opportunities offered by automated solutions, as there were a few challenges, and its population needed to be included and understand the impact of change.

30. The Chairman thanked the witnesses for the presentation and noted it underlined the evolving and rapidly changing piece of the landscape and that there are huge patient concerns regarding access to GP services and due to the rate of changes, people did not always understand what was happening and how things worked.

RESOLVED:

• Integrated Care Boards commit to working closely with General Practice and local stakeholders to continue to enhance the service provision to address the health needs of the population.
• We recommend that significant effort is undertaken to ensure that people are not digitally excluded.
• Software including the Rapid Health system is continually monitored to ensure any flaws / bugs within the software are eliminated.
• Provide demonstrations that can be shared with the public (such as utilising online platforms) so they understand how the service works.
• To ensure that communications by those working within the GP environment are helping patients through the service in a seamless way, to get the best possible outcomes for them.
• We recommend that you demonstrate the key measurement data on patient satisfaction and patient outcomes and provide an update to this committee in one year’s time.