The access plan for general practice published last month by NHS England highlighted concerns over a minority of GP services delivering less than one in five appointments face-to-face.
The document said this was a level 'likely to be contrary to good clinical practice, even if it were to reflect the preferences of their patients'.
Suggestions that lower numbers of face-to-face appointments may not constitute good practice even if patients are satisfied raise questions over the model of digital-first providers that previously have been backed heavily by the government.
Digital-first GP services
Among the most high-profile exponents of digital-first primary care in the NHS is the GP at Hand service. The service, operated by private company Babylon, has registered well over 100,000 NHS patients and delivers the vast majority of its appointments remotely.
An evaluation published in 2019 said just 13% of appointments delivered by the service were face-to-face - well below the one-in-five threshold highlighted in the access plan.
So could services like GP at Hand - as well as other GP practices that have adopted aspects of the digital-first approach - come under pressure to change how they operate?
A government-backed review into remote consultations - to be carried out by management consultants RSM - will report back by May 2022 and could influence which way the NHS turns.
Remote consultations
The review will consider 'different remote consultation modalities' such as online, text message, video, telephone 'and their relative advantages and disadvantages'.
RSM said its findings would also 'help the digital-first primary care programme at NHS England to identify the types of support practices find helpful when implementing new digital systems and tools [and] what works well for patients'.
A House of Commons health and social care select committee inquiry into the future of general practice will also contribute to the debate - and leaders of integrated care systems are currently finalising plans to intervene at practices delivering lower proportions of care face-to-face.
Scrapping the commitment to digital services altogether seems highly unlikely. The NHS long-term plan set out a commitment that 'all patients will have a new right to choose a digital-first provider' - and the five-year GP contract that began in 2019 guaranteed that 'all patients will have the right to digital-first primary care, including web and video consultations by April 2021'.
Teleconsultations
In 2018, former health and social care secretary Matt Hancock said that technology like Babylon's should be available to all NHS patients - and as recently as July 2020 he argued that all GP consultations should be teleconsultations by default - a stance rejected by leading GPs.
Although the landscape has changed since Mr Hancock's comments, with his successor Sajid Javid prominent among those heaping pressure on general practice to deliver more care face-to-face, patient choice remains a key factor driving the government's agenda.
Mr Javid has insisted that in-person appointments should be available if that is what patients choose - and choice is likely to factor heavily in any assessment of digital-first services.
GP at Hand serves a patient population markedly different from that of other NHS GP services - with around 85% of its patient list aged between 20 and 39 years old - whose care preferences may differ significantly from those of a standard patient list.
It remains to be seen how factors such as this could be taken into account in defining what is appropriate - and the RCGP has made clear that the right balance between remote and in-person appointments will vary significantly between patient populations.
More clarity is needed on the basis for the NHS England statement that less than 20% of consultations taking place in person may be 'contrary to good clinical practice'. But the access plan and reviews getting underway look set to keep the balance between face-to-face and remote access in general practice under the spotlight for some time to come - and the process of settling into a new normal post-COVID may only just be beginning.
