Back in mid-March, when lockdown first came into being, a prominent GP asked for help to find the best method for holding video calls with her elderly parents. There was a strong sense of urgency as her parents required support and she wanted to get it right. She knew that anything that was not completely straightforward would fail and would in all likelihood add to her parents’ anxiety in what was already a stressful period. I know she got lots of advice and suggestions from friends and colleagues, proposing a plethora of different solutions.

My own experience was similar. The day before lockdown my mother-in-law’s broadband was installed. Re-using the trusty iPad and FaceTime has worked a treat although not without its share of drama. However, the critical part was adding in a safety net – a plan B for when the user manages to alter the settings so communications are lost. In our case this was an additional drop-in video product, with the ability to start a video call without any action by the recipient. The second channel – the plan B – is there to get the user back when things go wrong, as the telephone wouldn’t have been enough to talk her through the fix.

These stories, both in people’s professional and personal lives, are shared right across the UK and many parts of the world. They are an allegory for the incredible changes that occurred in the delivery of primary care after lockdown. Like the global increase in video conferencing, we have seen a radical change to using a distanced contact (NHS 111 website, remote GP consultations, virtual communities and outpatient clinics from the comfort of one’s own home) rather than face-to-face consultation. This period has shown that this method of delivering care is safe, efficient, scalable and (by-and-large) effective for now. However to what extent is the growth of remote contact desirable in patient care in the longer term, and what are we missing?

Touch is part of all human relationships. The way it is used is a key component of care, and we all are experiencing how painful separation can be at present. Whether it’s the welcome handshake that creates closeness, the empathetic touching of a hand when life experiences are hard, or the reassurance of a physical examination – reassuring of course as much for the clinician (who knows they’ve done everything they should) as for the worried patient. The remote consultation denies both parties these benefits.

I trained as a GP 40 years ago. Back then, and throughout my career, GPs have been taught about how to engage with a patient in a face-to-face capacity. Telephone consultations have been routine for years, but very much in the minority. Recently all consultations have been by telephone or video call. The latter was new for most and scary. Recent guidance about how to perform remote consultations has helped. And to be fair, the use of video consults has not had the take up that was expected with the default telephone call being the major channel of communication. But it will be hard for many GPs and patients not to revert to type when face-to-face once again becomes a viable and risk-free option.

During Covid some change has been straightforward. Take the expansion of electronic prescribing (ePS) and one-off nominations. This has helped prescribers from many settings (including hospital outpatients) to get prescriptions out faster. Patients like it, pharmacists like it and it saves money. Has there been a benefit to the enhanced summary care record being the default for patients? Much harder to assess, but no real cost to clinicians. Home working is great for employment diversity. Recruitment and retention will be easier with home working opportunities. Covid has created the impetus to hugely expand this, including direct internet access to clinical systems.
So how is clinical care going to work going forward? The crisis has given some services headroom to think differently, and for most the permission to adopt rapid change. We know that the best of this needs preserving.

• An open and honest discussion with patients
• A full explanation of what time has been gained by digital first approach
• Describe the digital channels on offer
• Provide a plan B to support the digitally disenabled
• Establish a patient agreement that promotes the patient held record (Airmid) as the communication channel between patient and practice, setting expectations and limits
• Explain that care delivery needs to embrace more computer driven care (exceptions) and patient directed self-care – with data being accepted from the patient
• Target those patients for whom digital first will be both sufficient and appealing
• Remove unnecessary work, e.g. blood tests done need to be filed into the patient record automatically without any clinician intervention. The computer should prompt the recipient as to which results are significant and need review.

Much of routine care must be remodelled. We have seen a huge drop in routine blood tests for LTCs since Covid and before just catching up we urgently need to stratify patients to find out who benefits from these routine blood testing and what the optimal testing intervals are. QOF should be rapidly modified to support this. In general, care for LTCs needs to move to a comprehensive exception reporting approach.

So let’s not waste what we have gained, but keep the backup plan available for those that need it.​

John Parry