Advances in technology and the availability of digital tools have changed how the NHS delivers care. Citizens regularly use digital technology in their everyday lives, and their expectation for experiencing and accessing healthcare is no different. The shift to digitally enabled primary care started before the COVID-19 pandemic.
The General Practice Forward View (2016) advocated for the greater use of technology to enhance patient care. National investment programmes supporting this goal have made this a reality. The NHS Long Term Plan (2019) stated that every patient in England will have access to digital-first primary care by 2024.
General practice is the front door to our national health service. Over the past decade, the pressures and demands on primary care have continued to grow. Digital tools have the potential to help manage these demands whilst enabling patients to manage their own health needs. Embracing these tools can help transform models of care in general practice.
Digital-first primary care sits alongside conventional care models, enhancing rather than replacing them. Practices can use digital tools to co-design care models that serve their local populations and their needs, whilst ensuring equitable access and inclusion for all.
There are four linked articles in this topic:
- Online consultation tools, covers the different types of online consultation tools and the important features of those tools
- Video consultation tools, covers the features and use of video consultation tools in practice
- Remote consulting, covers the important practical and governance considerations when consulting remotely
- Digitally enabled triage article covers the use of digital and online consultation tools when triaging patients
This guidance does not replace the DCB0160 standard or Data Protection Impact Assessment requirements for any of the individual tools or solutions practices may choose to implement. Further information about these requirements can be found in the relevant articles within these guidelines.
The five-year framework for GP contract reform (2019) agreed between NHS England and the British Medical Association (BMA) General Practitioners Committee introduced commitments to digital services in primary care. The commitments have been gradually introduced through successive GP contracts since 2019, resulting in the ‘core digital offer‘ for primary care. NHS England created a Digital First Primary Care programme to support the continual transformation and implementation of digital tools in primary care.
The core digital offer means practices must provide the following to their patients:
- online consultations that can be used by patients, carers and by practice staff on a patient’s behalf, to gather submitted structured information and to support triage
- the ability to hold a video consultation between patients, carers and clinicians
- two-way secure written communication between patients, carers and practices
- signposting to a validated symptom checker and self-care health information (e.g. UK) via the practice’s online presence and other communications
- an up-to-date accessible online presence, such as a website, that, amongst other key information, links to online consultation systems and other online services prominently
- shared record access, including patients being able to add to their records
- request and management of prescriptions online
- online appointment booking
To meet these needs practices are now required to ‘offer and promote’ the following to their patients (and those acting on their behalf)
- an online consultation tool (OC tool)
- a video consultation tool (VC tool)
- a secure electronic communication method (online messaging tool – OM – tool or secure email ) allowing the practice and patients to communicate securely with each other in writing digitally
- an online facility to provide and update personal or contact information
- a validated symptom checker and self-care health information (e.g. NHS.UK)
This guidance outlines the updated digital service requirements and provides links to other useful information.
Most OC tools have OM tools embedded within them. Despite this some practices choose to use separate OC and OM tools. This may be due to the commissioning arrangement in their area or by choice due to the different benefits each digital tool provides. In most circumstances, therefore, one of the two situations applies:
- fully function OC tool with OM features as part of the offering
- dedicated OC tool and separate OM tool
Many of these tools will also offer video consultation functionality as part of their feature set.
These services must be available for patients to access during core hours, and they should be easy to identify and navigate to from the practice website.
If demand becomes dangerously high, practices may have the ability to temporarily turn off their OC tool in order to ensure safe patient care. If this occurs, there must be a contingency plan in place so that urgent requests are still managed appropriately.
There is no contractual requirement to make these tools available outside of core hours but practices may choose to promote these services outside of core hours if they inform patients that their requests may not be processed outside of core hours.
Promoting digital-first primary care also means informing patients how new tools change the way they access care. Patients should understand when to use these tools versus telephoning or visiting the practice in person.
The Using Online Consultations In Primary Care Implementation Toolkit has a range of communication templates that practices can use to help promote digital tools.
The scope of these guidelines will focus on the first three requirements for practices and will not cover online facilities to provide updated personal or contact information.
Practices must continue to maintain existing safeguards for vulnerable groups and third-party confidentiality whilst ensuring they are not creating barriers to care through digital exclusion.
Revisiting the different types of consultations in primary care is essential to avoid confusion when discussing digital tools in the context of these guidelines:
- Face-to-face consultations allow patients and clinicians to interact in person at the practice or patient premises.
- Telephone consultations allow patients to interact with clinicians using the direct voice-to-voice function of the telephone- this includes the internet telephony systems.
- Video consultations allow patients to interact with clinicians using video conferencing technology.
- Video group consultations allow practices to provide group-based consultations to cohorts of patients; an example would be delivering lifestyle intervention sessions to a group of diabetic patients virtually using a video conferencing platform
- Online ‘written’ consultations allow patients and clinicians to interact with each other using a secure two-way online messaging via SMS (text messaging) secure email or OM tools to complete an episode of care. In most cases this is carried out asynchronously, meaning there is a time delay between message exchanges. The time delay may range from a matter of minutes to several days.
Commissioners purchase licenses for online and/or video consultation (OCVC) tools on behalf of practices. The Digital First Online Consultation and Video Consultation Framework provides a streamlined route for supplying and purchasing these tools. The framework sits under the Digital Care Services (DCS) Catalogue. This ensures that suppliers of these tools meet strict regulatory and safety standards before they can be listed.
The framework means commissioners for primary care can buy digital tools that are technically and clinically assured. At the point of procurement, commissioners will also assess digital tools against the Digital technology assessment criteria (DTAC). When practices or PCNs chose to use an OCVC tool that their local commissioners have recommended, the tool will have met the relevant thresholds regarding clinical safety, data protection, interoperability, usability, and accessibility.
This does not, however, eliminate the legal requirements for practices and Primary care networks (PCN) to carry out their own risk assessments.
Practices or PCNs can decide which OCVC tool they want to use. Commissioners usually provide a list of fully funded solutions that meet their compliance requirements. Practices/PCNs may work with unfunded or partially funded tools that comply with the above frameworks. In these instances, they should contact their local commissioners to understand the impact of doing so.
PCNs may have different criteria regarding the choice available to members of that PCN. Some PCNs, for example, will advise all members to adopt the same solution to help deliver regional eHub triaging models.
Risk assessment and risk management
Under the Health and Social Care Act 2012 practices must carry out their own risk assessments when implementing digital tools into their services or systems. This applies even if commissioners have recommended the tool for use in primary care.
DCB0160 standards are clinical risk management standards all NHS organisations (including primary care providers) need to comply with when using health IT or digital solutions during the provision of care.
Practices need to undertake formal risk assessments on the digital tool or solution before it goes live to users. Generally, DCB0160 assessments are carried out by local commissioners on behalf of practices, however, practices must check this is in place or work with their local commissioners to carry them out.
Further information can be found in the Using online consultations in primary care implementation toolkit and the Digital clinical safety assurance article in this series.
Patient data and information
Patients need to know their data is being safeguarded effectively. Practices must comply with the General Data Protection Regulations (GDPR) and Data Protection Act (2018). If a digital tool does any automated processing of personal information, the practice must have a Data protection impact assessment (DPIA) under GDPR Article 35(3)a.
Automation applies when humans are not involved in the triage or decisions being made about a patient. If the use of digital tools means your practice is going to process and share confidential patient information in ways not already covered by existing DPIAs then a new DPIA will also be required.
Before practices implement digital tools, they must, therefore:
- carry out information governance risk assessments including any DPIAs before the processing of any patient information
- inform patients on how their personal data is processed under the general data protection regulation and the Data Protection Act (2018) – this includes informing patients when a tool processes their information automatically
- ensure updated privacy notices are accessible online and within practices, and are easy to understand
- carry out clinical risk safety assessments under the DCB0160 standards
- carry out internal risk assessments and update any relevant policies and protocols. examples of internal policies that may need updating, including, but not limited to:
- safeguarding adults
- safeguarding children
- proxy access
- intimate examinations and chaperoning
- receiving and storing clinical images
- did not attend (DNA) and was not brought (WNB) policies
- health and safety
- lone working
- emergency management protocols
The practice level considerations for policies and protocols listed above are covered in the Remote consulting article of the Good Practice Guidelines.
OCVC tools and online messaging interactions are accepted as normal patient interactions between patients and practices. Practices do not need to inform their insurance bodies when providing services to their registered patients when they have access to the patient record.
Remember, the General Medical Council’s (GMC) standards of good medical practice still apply to online consultations, video consultations, telephone consultations and online messaging interactions. Similarly, the Care Quality Commission (CQC) expects all the standards for good care to apply to remote consultations. The CQC has a myth buster to remind practices of these requirements.
Choosing and implementing OCVC tools
Practices will all be using OCVC tools as part of their services. Others are facing new choices presented to them by their local commissioners. Effective digital transformation in primary care needs planning, engagement, evaluation, and a culture of continual improvement to deliver its benefits.
The Using Online Consultations In Primary Care Implementation Toolkit supports practices and PCNs with the successful adoption of digital tools alongside existing services. The FutureNHS Digital transformation toolkit (log-in required) contains various resources to help practices transform models of care using digital tools including:
- implementation summary checklists
- detailed patient information leaflets
- communication toolkits
- implementation evaluation forms
- guidance on training and educating staff, patients and other stakeholders
Reviewing these toolkits will benefit practices regardless of their current levels of digital maturity.
Figure 1: Implementation and transformation
The infographic above pulls on key themes from the toolkits referenced above and recommendations from the Design Council. NHS England has also created a suite of templates and frameworks to drive sustainable transformation via its Change Model. Transformation and change models can be daunting, but the key take-home messages are detailed below.
- Problem-led decision-making: identify the key challenges first and pick the tool that will best allow you to solve them.
- Early engagement with staff and patients enables effective transformation and the early identification of potential pitfalls.
- Train, educate and communicate with staff and patients how, when and why digital tools are used.
- Consider any future changes in the broader landscape of your current care models. Do not isolate the process from your existing pathways.
- Develop a system to effectively measure the impact of new pathways and use data to drive continal improvement.
- Do not fear failure and expect the system to need continual adjustments or improvements
- Remember to work directly with providers of these digital tools – they can offer support, guidance, and data to help you make future decisions.
Related GPG content
- Remote consulting tools – procurement, regulations, governance and transformation
- Video consulting tools – to follow
- Digitally enabled triage
- Online consultation tools
- Digital clinical safety assurance
- Primary Care Networks (PCNs)
- Online appointment booking
- Online repeat prescriptions
- NHS.UK online resource for patients
- Practice websites
- Online access to new GP health record information
- Health equalities and inclusion
Other helpful resources
- NHS England, Dynamic Purchasing System (DPS) for digital social care record solutions – Procurement frameworks – NHS Transformation Directorate
- Digital Social Care, Assured Supplier List for social care
- FutureNHS collaboration platform, General practice communications toolkit (log-in needed)
- e-Learning for Healthcare, Essentials of digital clinical safety
- NHS Digital, Why digital inclusion matters to health and social care
- NHS Digital, What we mean by digital inclusion
- Good Things Foundation, Building a digital nation
- NHS England, Virtual group clinics primary care
- NHS England, New digital and online services requirements: guidance for GP practices)
- NHS England, Using video conferencing and consultation tools
- Information Commissioners Office (ICO), Data protection impact assessments
- NHS England, Digital First Primary Care DPIA Template example (on the FutureNHS platform, so log-in needed)
- North Central London Training Hub, Digital transformation leads role description.