Royal College of Physicians – Written Evidence (LOL0073)
The Royal College of Physicians (RCP) plays a leading role in the delivery of high-quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the UK and overseas with education, training and support throughout their careers. As an independent body representing over 39,000 fellows and members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare.
Our response to this inquiry focuses on the impact the increasing use of digital technology has on the delivery of healthcare and in particular the relationship between doctor and patient, and what needs to change to ensure we maximise the benefits and address the challenges this shift presents.
Executive summary
The pandemic has accelerated an already growing trend of reliance on digital technology in healthcare, whether in diagnostics, monitoring or communicating with patients. This will mean profound changes in the way healthcare is provided, and the relationship between physician and patient.
There are clear benefits to this shift, with many patients finding virtual services more convenient and remote monitoring more effective in understanding and managing their condition.
Many RCP members are however concerned about patients who struggle to access digital services, such as older people and those from lower socio-economic backgrounds. To ensure that digital technology is used in healthcare in a safe and accessible way that recognises digital inequalities, services must be co-designed with patients, carers and clinicians. There must also be investment in a digitally-enabled health and social care workforce, and action from government to reduce digital inequalities.
Together with the Royal College of General Practitioners, in July 2020 we outlined key principles and recommendations for the reset of a key part of the healthcare system that has been significantly disrupted by the pandemic – outpatient services – in Rebuilding the NHS: Resetting outpatient services for the 21st century in the context of COVID-19. A central part of this reset is how we design new clinical processes to maximise the benefit of new technology to patients, carers and clinicians.
Physical health:
How digital technology is changing the doctor/patient relationship
While the COVID-19 pandemic has rapidly increased the use digital technology in healthcare, this was a trend that was already emerging and would have likely happened anyway, albeit at a slower pace. In our 2018 report Outpatients: the future, adding value through sustainability, we called for an overhaul of outpatient care and greater use of digital technology.
In many specialties, traditional outpatient clinics have been replaced by a mixture of virtual clinics conducted by phone or video and remote monitoring. Most patients now access outpatient services through their digital devices. While these devices are constantly improving and increasingly accessible, we must not forget that the quality of the device affects a patient’s experience of the service. In some clinical scenarios, face-to-face clinics may be the best way to deliver care. Getting this balance right requires a focus on patient-centred care and clinician leadership.
Many patients will find virtual clinics more convenient, as they no longer have to travel to hospital or waste time in a waiting room before seeing their consultant. This does however mean the nature of the relationship with their doctor has changed.
The long-term increase in reliance on digital technology means an increase in asynchronous communication between people and health professionals. For example, patient portals enable patients to access and provide their own data and send messages to their physicians, who can reply with advice or recommendations at a convenient time. This could mean more timely advice and reassurance to patients, but also an increase in physicians’ workload on top of a regular clinic.
There may however be a difficulty establishing rapport and trust between patient and doctor without a face-to-face consultation. Our members tell us that patients are more likely to be distracted during phone clinics. They may be in rooms with other people, or doing other tasks such as shopping or driving. This means they may not be able to take in as much information as in a face-to-face consultation. Digital communication can also mean it is more difficult to involve partners and carers, so their valuable input is lost.
The risk of exacerbating health inequalities
The increase in reliance on digital technology will particularly affect those who struggle to access digital services. Older people and people from lower socioeconomic backgrounds may have worse health outcomes because their communication with their doctor is affected by their lack of digital skills or the quality of their devices. This could exacerbate already existing health inequalities.
For example, someone with heart palpitations who can afford a smart watch with a reliable heart rate tracker could collect this data for their doctor to analyse, picking up a potential problem virtually. This would not be an option for someone who cannot afford a smart device or struggles to use technology.
Most medical specialties can adapt to digital technology to varying degrees. In many cases digital technology will bring specific advantages, such as enhanced digital imaging in endoscopies leading to advances in diagnosing early cancers.
The reduction of face-to-face assessment and examination could mean there is an increasing reliance on further investigation such as radiological or interventional tests, which could cause capacity issues further down the line.
Some diagnoses and investigations will require a face-to-face appointment as well as a phone or video call. Some examples are diabetes, bone marrow biopsy, Cushing’s Syndrome and early thyroid disease.
Digital consultations may result in a reduction in incidental diagnoses, as patients are less likely to stay and chat about their health on a telephone or video consultation than they would face-to-face.
Investing in a digitally skilled health and social care workforce is crucial. The growth of digital technology in healthcare means greater investment in the workforce is needed. The increase in reliance on digital technology often comes hand-in-hand with an increase in workload for healthcare staff. For example, the increased data generated by remote monitoring devices needs to be analysed and managed by healthcare professionals on top of their existing workload. As well as new digitally-focused roles in areas like clinical informatics, the existing NHS workforce must be digitally upskilled.
To ensure that digital technology is deployed in a safe and accessible way, healthcare services must be co-designed with patients, carers and clinicians. An important part of this process will be making sure that existing digital inequalities do not lead to those without digital skills or with lower quality digital devices receiving a worse service.
But government also has an important role to play in supporting people to develop digital skills, so they do not miss out on the benefits digital healthcare can offer. This is especially pressing in healthcare, as it is often older people who have the most to gain from accessing these services but will most struggle to access them due to lower digital skills.
11 December 2020
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