Another view: of resetting the GP practice and A&E

Our GP columnist, Neil Paul, has been thinking about the huge changes that GP practices have witnessed during Covid-19 and he has got some ideas.

I’ve had two ideas on my mind recently, perhaps provoked by the huge changes we have seen regarding Covid-19. I think have both have merit.

Perhaps the biggest change in general practice from coronavirus is the move to telephone and video consulting. While there have always been evangelists, lots of us GPs have previously resisted. Stuck in a model where a patient has to come down to the surgery, sit in a potentially infectious waiting room and then doff their cap as they enter our room. We make a stab at equality by turning our desks sideways and have built a whole science about it asking about their ideas concerns and expectations and listening out for hidden cues and talking about closing or door stepping.

While those classic consultations exist, the harsh reality shown by Covid is that some people just want to speak to you about their earache or their kids spots while driving and just want a quick opinion and prescription. Some are after transactional medicine.

GPs as an emergency service?

Another change is that we aren’t seeing half as many really acutely unwell people in the surgery. At the end of last year, it wasn’t unusual for 10-15 ambulances a day to visit my surgery to take patients away to the A&E department and my fellow GPs to be managing all sorts of emergencies in their unprepared under equipped rooms.

A wife of one of our partners who had popped in to see him on her lunch break – she is a local anesthetist got involved in a pediatric arrest in one of our rooms and we all felt guilty when she called for a intra osseous needle and we didn’t have one. We have subsequently decided we should not have one, we aren’t an emergency service.

Yet some have previously treated us like one. Despite A&E being relatively close, some claimed they wanted to see their GPs with their acute chest pain. Partly our relatively open appointment system allowed people to book in with all sorts of stuff that wast really appropriate for general practice.

However now we pretty much phone triage everything by an ANP (allied healthcare practitioner) or a GP. Our ambulance attendance rate at the surgery has dropped. More unwell people go to A&E, which is where perhaps they belong.

The GP will see you in A&E now?

This led a colleague to say something like; “in the past we used to complain we saw A&E patients and A&E always complain they see GP pts, wouldn’t it be good if we swapped that around?”

Well GPs in A&E perhaps don’t work. There is evidence they tend to go native and just become a highly paid junior doctors and then you lose them from general practice

So how about video suites in A&E. On site staff do some observations, simple triage then video consult with a GP preferably their own or from their practice but could be a PCN or wider service. To some extent for some things a virtual remote GP with access to the records and EPS is perhaps all you need. The capacity of a virtual system could be huge – the end of 4-hour waits.

The image problem

Idea two is different. There is no doubt AccuRx has been a disruptive innovation for good.

The ability to send a text message with or without attachment to a single patient from my desktop is something I have been asking for ages.

Their latest feature, being able to receive back images into the notes of several images, has been really useful. We send a link to patients who have a mole or lesion, or rash and they photograph them and send them back, it goes into an inbox and the patient record and if the receptionists send it before the consultation you can look at it beforehand. Plus it’s all recorded in the notes for legibility.

However, the quality of images leaves something to be desired sometimes and need some image tech geeks to play with the camera, so more are in focus and perhaps they don’t have the correct colour balanced nor are they the right size.

I know other companies are creating apps that take 3-D views and auto measure things which would be a great help.

The ideal scenario for AI

What we know is suddenly we now have hundreds if not thousands of images of lesions and rashes and these are exactly the scenarios for AI.

The problem, however is who pays for the software? Why would I as a GP, pay for the AI from my pocket? We can’t charge the patient. Well I’m not sure it works at a single practice level, but it strikes me that we could in theory get to the point where we could take all this work off general practice.

Perhaps at PCN or bigger scale could we have one person, a consultant or GPSI working with an AI that processes all the images from an area same day and avoids any of them needing a GP appointment?

Risk of deskilling

This could take a huge workload away from normal appointments. Also given that quality of diagnosis can vary from GP to GP it could lead to faster diagnosis for some patients.

But does it deskill the average GP? Well it might, but we’ve been deskilled before. The counter argument is it builds a huge bank of images and potentially outcomes that could be used for learning purposes to teach people much faster than now.

So, two huge changes take a lot of simple dermatology off primary care and it free it up to see the patients going to A&E. A&E in return manages the acutely unwell where perhaps they should be seen.