GPs must define role for triage and remote consultations post-pandemic, says RCGP chair

Triage and remote consultations have a role to play in general practice beyond the pandemic - but GPs must be free to choose the right balance for their local population, RCGP chair Professor Martin Marshall has warned.

Professor Martin Marshall (Photo: Grainge Photography/RCGP)

The RCGP chair predicted 10 months ago that face-to-face GP consultations would not return to levels seen before the COVID-19 pandemic.

At the time, as the first wave began to tail off, he said that around half of consultations would continue to be delivered remotely after the pandemic - well below the 70%-plus level that was normal before March 2020.

A year on from NHS England advising practices to switch to total triage and consultations predominantly by telephone or video to maintain patient safety in the face of COVID-19, the RCGP chair tells GPonline that broadly he stands by his 50:50 forecast.

Face-to-face GP appointments

RCGP surveillance data show that in the first 10 full weeks of 2021, just 32% of GP consultations were face-to-face, compared with 72% over the same period last year.

But the figure for the first 10 weeks of this year - delivered with the UK in lockdown amid a second wave of COVID-19 - is well above the level of face-to-face consultations seen in the first lockdown, when in-person consultations accounted for less than 25% of GP contacts with patients.

Professor Marshall says the data show that general practice is already shifting the balance back towards more face-to-face care - and points out that across the primary care team as a whole, around 44% of consultations are now face-to-face.

But he says that as this shift occurs, GPs must be allowed to decide what the right balance is for services in their area in the long term.

Remote consultations

The RCGP chair is clear that for different populations in different parts of the UK, the right balance between face-to-face and remote care - and the right way to use triage - will be different. GPs must be allowed to find the right way forward in their area - and not be forced down one track or another by targets, he insists.

'Doctors are seeing about a third of patients face-to-face now - in my surgery, it's maybe maybe a little bit more than that,' says Professor Marshall. 'But certainly there's a there's an increase in expectation and desire on behalf of patients to see more of their doctors face-to-face, and also our doctors who feel that they're able to provide higher quality clinical care where they do it face-to-face.

'So I think we are gradually shifting towards that 50:50. But what I have said and I think is really important - I don't think there should be a target, or even guidance. Clinicians and patients in different localities should sort it out according to what their local needs and expectations are.'

This understanding that the right balance will vary across the UK underpins the RCGP's decision to push back against comments last summer from health and social care secretary Matt Hancock that in future all GP consultations should be digital by default.

Patient expectations

Professor Marshall explains: 'In my practice in East London, we serve a very young population, a very mobile one. It's socioeconomically deprived and it's very tech savvy, and I suspect we'll have a higher proportion of remote consultations in my practice than in practices in rural areas with older populations, and more traditional expectations.

'I think the issues will change over time as patients and clinicians become more used to different ways of working, and it becomes more acceptable.

'But this is why we're pushing back on anybody's desire to set targets or guidance for what proportion should happen - it has to be a local decision, made sensibly by thoughtful clinicians working with our patients. And our job as a college, I think, is to encourage that discussion. There's no right answer here. We need to balance patient expectations and patient experience, patient safety and availability of services - there are lots of issues to sort out and think through.'

Triage too will have a role in general practice in the years ahead, the RCGP chair believes - particularly given staff shortages in primary care that mean promoting self care and managing workload is essential.

Total triage

The adoption of total triage - which NHS England defines as 'every patient contacting the practice first provides some information on the reasons for contact and is triaged before making an appointment' - has been a major feature of the re-shaping of GP services in the pandemic.

Professor Marshall says around one in five practices used triage before the pandemic - but that moving almost overnight to 100% adoption was a 'massive change'.

Currently some GPs and patients 'love' the triage model, he says, while others see it as a barrier. But he believes that in the long run as more work is carried out to refine the best model, some form of 'digital triage' is likely to be 'the right way forward'.

He admits that 'a lot of evolution needs to go on' to reach a point where digital tools can be totally safe and patient friendly - although he says they are improving 'at pace'. But ultimately, he says: 'I'm interested in triage. I think we're operating in an environment in which demand outstrips supply, and I'm not actually sure I see any other solution.'

Overall, Professor Marshall says the reponse from general practice to the COVID-19 pandemic over the past year has been 'magnificent' - and has shown general practice at its best.

As general practice finds the right shape for services beyond the pandemic, the RCGP chair says the college will lead the conversation by ensuring it does not get 'carried away' with enthusiasm for new technology - and make sure that GPs have the evidence and evaluation available to understand the pros and cons of different ways of working as the profession resets after COVID-19.

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