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Innovating under pressure: Primary Care, COVID-19 and online consultation.

What primary care teams need to support rapid innovation to meet the current crisis

There is mounting evidence that COVID-19 will pose a significant threat to health systems around the world. Not only the increased demand for services for the unwell and the potentially worried well but also the real likelihood that health care staff themselves are likely to need time off sick during the crisis. A health service model that is reliant on face to face, where patients wait together in small rooms for consultations — seems ill-prepared for a highly contagious virus. This much is apparent.

There is a contender in the digital technology arena to support a change in services that could be of great value in this context — online consultation. The shift from face to face consultations with all patients, to a remote digital triage that affords services the ability to remotely identify which patients are best served, in the health service. There is anecdotal evidence that this model speeds up access to services, provides more immediate responses to patient requests for assessment and could quickly funnel those at risk of spreading COVID-19 (or other conditions) to specialist service sites. This solution appears to be rising as the innovation goal for Primary Care — at pace.

This could provide a quick sense of relief. However, the introduction of online consultation is not new and has been a priority for the NHS for some time now — with contractual obligations on primary care to meet this innovation shift, that few primary care teams have embraced or succeeded with. This is a problem and is not a representation of stubbornness in the system.

The challenge of large scale change

For Primary Care teams, the task of adapting their access models to support full-triage online consultation is not a small challenge. It is a full system revision. This is difficult for any team, in any organisation, where systems or processes are long-established. Particularly for medicine, where processes and practice is trained into all of the team as a part of their professionalisation. Everything about Primary Care teams has been pre-built to host staff who meet patients, who come in person (or telephone).. and the whole system is familiar with this (including patients).

Change always raises fear and resistance in systems. Nobody really likes a change, unless the merits of it are really obvious or really desired. Online consultation has not proven that yet. In fact, patients often react against it as a concept — feeling that a loss of contact with clinicians is a second rate service… and many clinicians feel the same. COVID-19 may create an appetite for service change, as many might agree that meeting each other and sitting in small spaces with coughing / sneezing people is a bigger fear than a change in the model. Others may feel that there is just no choice and the crisis will push the change through quickly. But this cannot be assumed and needs support.

Change at pace?

The NHS is not famous for its ability to change rapidly. There are many references to how good ideas can take 5–7 years to implement across the system. The system rarely has to change at a large scale in a short time to meet a pandemic, and so its capability to do so is not tested. Appetite may be present, but it is feasible that many staff don’t believe the rapid change is possible. Even in a world where all teams say yes, there is the issue of the ‘soft stuff’ that underpins success in most change programs.

There is enough written in the change management sector to demonstrate that the psychological and organisational structures around change challenges are crucial in the success of innovation. Most change projects that fail, fail for these reasons. If the correct environment of support, engagement and skill development is created — the chances of success are much higher.

Currently, Primary Care is already in the context of staff shortages, staff burnout, unmet demand and increasing pressures to innovate. This has not gone well, with repeated publications relating to the sustainability challenge for Primary Care and the exodus of staff. If the government decides on rapid change as a goal and is prepared to “spend whatever is needed”, it will want to put change capability on the top of its list.

Change capability Need