Quality of care: compromised in contemporary general practice?

This is a sad story. It’s a story of how technological transformation has spectacularly backfired. It tells how systems that were supposed to promote efficiency and improve access have too often introduced new inefficiencies, caused stress for healthcare staff, and made access to care harder for those who need it most.

The story is told in the paper “What are the challenges to quality in contemporary, hybrid general practice?”, published this month in the British Journal of General Practice. The data for this paper comes from the Remote by Default 2 project. This followed12 general practices for 28 months, as they introduced, used, and then often abandoned various forms of remote consulting and new technology. Practices across Britain were selected to provide a diverse mix, with some super-techy practices, and others much more traditional. Data from the practices was combined with patient reviews, interviews with experts and national reports. The data was analysed against 3 accepted quality frameworks – the Institute of Medicine quality framework, Ladds et al’s new ontology of continuity in primary care and Starfield’s primary care assessment tool.

The findings were stark and depressing. Many of the reasons it was hard to provide quality care sat completely outside the control of the practices. As our team analysed the data it became clear that (outside of a war zone), it would be hard to imagine a more adverse developed-world context in which to deliver high quality primary care. Austerity, a broken benefits system, increasingly complex patterns of illness and need, fragmenting social networks, challenged secondary care services and stretched social services meant that practices ended up juggling not just traditional primary care workload, but the consequences of the failures of other services too. Practical implications of this included extra workload – this might include ongoing treatment of patients traditionally managed in secondary care or performing home visits to isolated elderly people who might formerly have been brought in by a neighbour. All this caused extra stress for staff, as they worried about vulnerable patients, getting frustrated by hospitals “bouncing” back referrals, or felt caught in the middle between patients and the healthcare system.

Many staff chose to leave general practice. Some longstanding administrative staff found the changes too much to bear, and newly recruited administrative staff often didn’t stay. Some practices couldn’t recruit GPs, others just didn’t have sufficient funds to do so. Attempting to plug GP gaps with other professions often resulted in additional stress and even burnout for GP partners, who now saw just the most complex patients, but had to juggle this with supervising and training other staff.

Since the start of the COVID-19 pandemic, most parts of Britain have seen a dash-to-tech, with technologies such as digital triage systems often procured at locality level. This saw new products imposed on practices, many of which did not work with their existing processes or local populations. To make things worse, the basic infrastructure required to support simple technologies such as the practice telephones or IT system often didn’t work effectively. Patients trying to call their practices reported dropped calls, or long queues. Practices tried proactively to address this, some even implementing workarounds such as subcontracting calls to external call-centres. But this often resulted in an impersonal experience for patients as they spoke to a stranger, and an erosion in continuity.

It wasn’t just the technological infrastructure that was broken. Surgery buildings were often not fit for purpose. Challenges with space meant some staff had to work off-site. Even when staff were present in the building, in most surgeries, the days of a receptionist popping their head round with a cup of tea and a favour to ask had gone – impersonal electronic “tasks” replaced in-person conversations.

Such impersonal relationships were also common between practice teams and their patients. In-person conversations were often replaced with texts back and forth, with photos exchanged or information sheets provided. New and life changing diagnoses such as diabetes were often provided by telephone, making it hard to establish the therapeutic relationship needed for high quality ongoing care. Webforms might replace or supplement in-person chronic disease management reviews, with staff often concerned about the accuracy of the information provided, but insufficient appointment time to delve into the details. Although this could work well for some patients, others risked deteriorating health, poor management of conditions such as asthma and diabetes and the risk that new problems such as lung cancer in a patient pre-existing COPD might not be recognised at all.

For patients and staff, new technologies often introduced new inefficiencies. Patients had to navigate complex and changing routes through to care. Systems involving webforms and telephone conversations needed patients to present a simplified account of complex problems, easier for some than others. Patients often felt they went round in circles, with multiple points of contact with services, rather than having all their issues dealt with in a single GP appointment. New inefficiencies arose as a single patient might see multiple team members, using multiple modalities all of which chipped away at scarce staff time. Such tradeoffs were apparent across a range of quality domains and impacted most on the most vulnerable patients. 40 years on from the publication of the Black report, heralding a modern understanding of the inverse care law, it was clear that much of the contemporary delivery of general practice had made existing inequalities even worse. So much for “levelling up”.

Researching and writing this paper was depressing. It challenged my preconceptions and my views about what the future of general practice should look like. I’ve always been enthusiastic about the potential for technology to transform healthcare, but this paper demonstrates putting  technology into general practice without addressing basic infrastructure, poor working conditions, inadequate general practice funding, societal conditions that are making people sicker, a broken and harsh benefits system, stretched secondary care and social services means shiny new tech isn’t just “not the answer”, but can actually make things worse.

I told you it was a sad story. People keep asking me what the solutions are. General practice alone can’t fix that which is broken elsewhere. We need to create a better-functioning society, a welfare system that works without causing misery and harm, a restoration of social network that prevents individual isolation becoming a general practice problem. Adequate resourcing is needed across the health and care system so that general practice is protected from failures elsewhere. NHS workforce plans need reviewing. Practices need enough funding to be able to recruit GPs as well as other team members. The working conditions for administrative staff need urgently addressing. The basic tech needs to work and physical and technological infrastructure needs to be improved. This paper diagnoses many of the challenges to quality care, now it’s time for a cure.

Read the full paper, "What are the challenges to quality in contemporary, hybrid general practice?”, published this month in the British Journal of General Practice.

________________________________________________________

The Remote by Default 2 project is funding by the NIHR.