Written evidence submitted by the Digital Healthcare Council (FGP0268)



1)      The Digital Healthcare Council represents digital providers that span the breadth of health and social care, either delivering care directly to patients or by working in partnership with others.


Barriers to access

2)      Every week, Digital Healthcare Council members ask millions of patients how they want to engage with general practice, and what sort of appointments they prefer. Their top priority is to have their issue addressed effectively.

3)      Just 11% choose face-to-face provision when offered a genuine choice of consultation types, and we see many patients choosing to change their GP provider for a digital first option when that is available.

4)      Patients preferences therefore contrast sharply with the recent NHSE policy paper which overemphasises face-to-face provision.


Likely effect of the Government and NHS England’s plan for addressing these barriers

5)      We welcome the emphasis on honouring patient choice but question its framing which assumes patients overwhelmingly want face-to-face appointments.

6)      NHS data and information collected by digital healthcare providers suggest a profound misalignment between provision, policy and the stated preferences of patients. Specifically, there is an undersupply of high-quality remote appointments and an oversupply of face-to-face appointments when compared to patients’ stated preferences.

7)      We welcome proposals for cloud-based telephony as they should remove barriers to making appointments, but we need greater transparency of data that describe patients experience accessing care.

8)      Given minor ailments account for around 20% of total available GP workload, there is significant scope to divert this provision to other care providers, but to achieve this we need to do more to ensure the effective and consistent implementation of digital triaging.

9)      The pursuit of a specific percentage to describe the “optimal blend” of face-to-face and remote provision is misguided. Rather each decision should consider patient preferences and clinical need.


Impact when patients are unable to access general practice using their preferred method

10)  Recent statements about a lack of face-to-face GP access leading to pressures in A&E are not supported by the data. In fact, the opposite is true:

a)      A&E demand is in line with pre-pandemic levels

b)      But pressure on waiting times at A&E has risen exactly as the proportion of face-to-face appointments has risen in recent months

11)  We therefore conclude that lengthening A&E waits are more likely due to infection control measures rightly put in place to respond to Covid and longer-term pressures which pre-date the pandemic.

12)  If we made wider and better use of digital first solutions and total triage, we could achieve around 2.4 million fewer A&E attendances per year if implemented nationally.



13)  Making greater use of digital provision would be an effective way to rapidly address variation across the country.

14)  When considering the impact of digital services, we should consider the benefits across the entire health ecosystem, so as we widen access to digital consultations, we also free up capacity for more face-to-face provision where it is needed.


The prevention agenda

15)  We can significantly reduce workforce and capacity pressures on general practice created by carrying out routine tests by making more use of digital services. Where we have done this, we have seen significant increases in provision to traditionally under-serviced populations, including ethnic minority groups, non-binary and trans-people, and the most deprived populations.



16)  Many general practitioners, particularly those returning from career breaks, greatly value the flexibility that can be achieved by providing care digitally. Evidence suggests that this can allow up to 25% more hours per week of consultation time per GP. If that switch were to occur across 26% of our current workforce, this would create additional capacity equivalent to an additional 6,000 GPs.


Current contracting arrangements, payments and incentives

17)  Too often we see a contradiction between the message of system change conveyed at the centre, and the more transactional mechanisms enabled through frameworks which reduce the scope to innovate and provide generally transformative change.

18)  Over the course of the past few months, we have sadly seen several highly innovative digital providers choose to prioritise investment in other countries in response to the difficult operating environment that has been created in the UK.


Partnerships with other professions in primary care

19)  By making significantly greater use of digital triage and incentivising innovation in this area, we believe the NHS could benefit from savings of around £812 million by channelling patients to other care professionals such as community pharmacy, while allowing GPs to work up top of their skill set.






Main response


About the Digital Healthcare Council


20)  The Digital Healthcare Council works to inform the development of policy and regulation.


21)  We represent digital providers that span the breadth of health and social care, either delivering care directly to patients or by working in partnership with others. Many of our members work in primary care delivering online and remote consultations. Some provide whole practice GP services through a digital first model; some work in partnership with traditional NHS GP practices; and others offer specific services that sit alongside general practice, such as prevention and screening services, and online pharmacies with prescribing capabilities.


22)  We believe that digital healthcare can transform the quality of patient care and experience of care.


Response to specific terms of reference of the inquiry

23)  Our response focuses on the aspects of the terms of reference of the inquiry where we have particular expertise, rather than covering all areas under discussion.



Barriers to access

24)                                                                                                                                                                               To understand the barriers to access, we should first consider what patients want and contrast that with what is delivered.


25)                                                                                                                                                                               Every week, Digital Healthcare Council members ask millions of patients how they want to engage with general practice, and what sort of appointments they prefer.


26)                                                                                                                                                                               The most important message that comes back is that they want their issue(s) addressed effectively. The channel, i.e., face-to-face, telephone or digital appointment, while important is secondary to addressing their condition or health need.


27)                                                                                                                                                                               Their preferred channel of communication strongly depends on what is available and the confidence that patients have in different routes. When patients have confidence in the full range of options available to them, just 30% of patients in pre-pandemic times expressed a preference for face-to-face appointments, with that number falling to 11% in recent months[1].


28)                                                                                                                                                                               To be clear, we are not saying these should be target figures – the decision about what is the most appropriate channel should ultimately be a clinical decision that takes patient preferences into account and there will always be a need for face-to-face appointments for some patients – rather we cite these figures to highlight that there is a considerable gap between patients’ preferences and what the general practice across the country offers. Further, this suggests that the current drive towards increasing the proportion of face-to-face appointments runs contrary to what patients say they want.


29)                                                                                                                                                                               While such low levels of patients choosing face-to-face provision may at first seem surprising if we listen solely to campaigns in certain media outlets, these preferences are more understandable if we reflect on what a full return to face-to-face provision would entail: more travel, greater inconvenience and longer queues in GP waiting rooms squashed cheek-by-jowl with fellow coughing and spluttering patients.


30)                                                                                                                                                                               As well as asking patients what they prefer, many patients have deregistered with traditional providers so they can register with digital first practices to receive a more responsive digitally led proposition, as evidenced by the growth of digital first practices in different parts of the country.


31)                                                                                                                                                                               While digital providers collect detailed metrics about access to general practice consultations, we sadly do not have that level of granularity for more traditional practices. Services that throttle provision by effectively limiting booking times for appointments to telephone appointments during a short window at the beginning of the day deny opportunities for care to many of their patients. We should be able to quantify this gap, but as a country do not currently collect and publish such metrics. We believe this should change.


Likely effect of the Government and NHS England’s plan for addressing these barriers

32)                                                                                                                                                                               We welcome some elements of the plan but are sceptical about other aspects. For example, the emphasis that the plan places on respecting patients’ choices is welcome. However, the plan principally frames this by talking about respecting their choice for face-to face consultations, when surely if we are serious about honouring patient choice, it should talk about respecting patient choices for whatever mode of consultation is best suited for them.


33)                                                                                                                                                                               Further, throughput rates for face-to-face appointments have slowed due to Covid to allow adequate distancing and infection control measure to be implemented. A policy that places an emphasis on a blanket increase in the number of face-to-face appointments is therefore likely to be counterproductive if its overriding aim is to widen access.


34)                                                                                                                                                                               Despite these reservations, we welcome the plans support and recognition of many of the benefits that digital innovation in general practice has already achieved. If we are to make the most of these innovations, we need to build digital skills across general practice, but this area is conspicuous by its absence in the plan, despite being widely acknowledged in other policy documents[2].


35)                                                                                                                                                                               We welcome the proposals for moving to cloud-based practice telephony. This means that patients should no longer be denied access if they are unable to get through on the telephone to make appointments at the point at which they are released for a given day. However, the details of the plan for cloud-based telephony are not yet clear and it is important that these do not cut across practices that have already introduced such functionality and have a fully functional mechanism to capture patient demand.


36)                                                                                                                                                                               Given minor ailments account for around 20% of total available GP workload[3], there is significant scope to divert this provision to other care providers. The aspiration to make better use of community pharmacy is therefore welcome, but this will only be achieved if patients are triaged towards the most appropriate form of care quickly and effectively. Digital triaging represents the most effective way to achieve this, but there is considerably more that could be done to ensure that all practices benefit fully from these innovations.


37)                                                                                                                                                                               The additional funding announced in the plan is welcome, but it is not clear how this will be distributed, and conversations between providers and local NHS decision makers show little sign either of awareness of new funds to promote access, nor of the transformational change they are supposed to deliver.


38)                                                                                                                                                                               The plan’s proposals to review levels of face-to-face care and determine an “optimal blend” of remote and face-to-face provision are problematic and potentially contradictory. We believe it is a mistake to talk about a given percentage and to arbitrarily single out the 20% of practices with the lowest proportion of face-to-face GP appointments. The same patient may well need a range of consultation types depending on their condition, specific issue, and wider life pressures. The paper assumes that those practices which are offering fewer face-to-face appointments than their peers have access issues, when the contrary may be true. We should instead focus on what patients want in the context of the clinical requirements, rather than arbitrary percentages. Other more outcome-focused metrics are far more important when measuring access. For example, we should ask whether every patient had their needs met with a timescale and channel that worked for them.


Impact when patients are unable to access general practice using their preferred method

39)                                                                                                                                                                               Given that only 11% of patients would currently choose face-to-face provision when given a meaningful choice, and the latest NHS England data[4] shows 64% of appointments were face-to-face with GPs in October 2021, this suggests a profound misalignment between provision, policy and the stated preferences of patients.


40)                                                                                                                                                                               When patients are unable to access general practice using their preferred method, one of four broad outcomes typically occurs:

a)                                                                                                                                                                       they go without the healthcare they need;

b)                                                                                                                                                                       provision is delayed;

c)                                                                                                                                                                       their lives are unnecessarily disrupted while they access provision in a suboptimal form, for example having to make alternative arrangements for work and/or childcare; and/or

d)                                                                                                                                                                       they go to a different provider, for example presenting at accident and emergency departments.


41)                                                                                                                                                                               Although some have suggested that a lack of face-to-face appointments has led to increased demand on Accident and Emergency waiting times, this view is inconsistent with the data. If this opinion were accurate, we would expect to see more patients presenting at A&E than before the pandemic. We should also see falls in attendances at A&E as the proportion of face-to-face appointments has risen in recent months. However, the evidence paints quite a different picture.


42)                                                                                                                                                                               NHS data show that as the proportion of face-to-face appointments has risen over recent months[5], so has the pressure on the number of people waiting over four hours at Accident & Emergency departments – 60% higher than pre-pandemic levels[6]. However, the total number of people recently attending A&E is broadly level with the number attending before the pandemic[7] and emergency admissions are 8% below pre-pandemic levels[8]. In turn, the evidence does not support the assertion that pressures at A&E are due to higher numbers of patients or blocks in emergency admissions. Rather we should look for an explanation about the pressure on waiting times that is consistent with the evidence.


43)                                                                                                                                                                               Much more plausible explanations are that the pressures on A&E as manifested by longer waits (but not more people in total) are much more likely due to a combination of the infection control measures rightly required at A&E to protect patients and staff from nosocomial Covid infections and a continuation of the pressures described in the 2015 report by Monitor that asked Why did patients wait longer last winter?[9].


44)                                                                                                                                                                               Of course, if we can take steps to reduce the number of people attending A&E who could be treated elsewhere, or improve the efficiency of the emergency admission process, this would be helpful. Evidence from Digital Healthcare Council members shows that:

a)                                                                                                                                                                       flexible digital first access to primary care has reduced A&E presentations by 6% where these services are available to patients[10];

b)                                                                                                                                                                       total triaging has reduced the use of emergency care facilities by around 3.4%[11];

c)                                                                                                                                                                       taken together, these reductions could lead to 2.4 million fewer A&E attendances per year if implemented nationally.


45)                                                                                                                                                                               The evidence therefore suggests that greater use of digital first provision would be a far more effective route to alleviate pressure on Accident & Emergency departments, than the current policy direction.


Main challenges facing general practice

46)                                                                                                                                                                               There are many challenges facing general practice. The main ones include:

a)                                                                                                                                                                       GP appointment data published by NHS England suggests that general demand, as measured by appointments, is at its highest level on record.

b)                                                                                                                                                                       The pressure from record number of GP appointments is further exacerbated by media and policy pressure to increase the proportion of face-to-face consultations because infection control and distancing requirements to prevent the spread of Covid mean face-to-face appointments now take longer than usual with lower levels of throughput.

c)                                                                                                                                                                       We are already beginning to see that as the elective waiting list grows and people wait for longer, many will turn to general practice for immediate help and support. We expect this trend to increase over the coming years.

d)                                                                                                                                                                       Demand is also likely to increase as patients cope with new conditions related to long Covid.

e)                                                                                                                                                                       Wider trends in long-term conditions related in part to an ageing population continue which were well-documented before the pandemic.

f)                                                                                                                                                                        Workforce pressures. Including variation in the number of GPs per head of population across the country.


Regional variation

47)                                                                                                                                                                               There is considerable regional and local variation both in terms of pressures faced, due to local population needs, geography, and how practices and their wider health economies have responded.


48)                                                                                                                                                                               We note that the development of new physical practices to address unmet needs can be costly and will take time to implement as physical facilities are built and commissioned. By contrast, digital services can be deployed far more quickly in response to specific local needs. These services represent important opportunities to plug emerging gaps, but they offer the potential to do so much more.


49)                                                                                                                                                                               It is a mistake to view digital provision in isolation. Every consultation that can be delivered remotely, every test offered direct to a patient to be taken in their own home, and every appointment channelled directly to the right healthcare professional, who may for example be located within community pharmacy or physiotherapy, rather than being routed via GP appointments, represents valuable time saved. In turn, this frees capacity for face-to-face provision where it is both wanted by patients and clinically necessary.


General practice and the prevention agenda

50)                                                                                                                                                                               As long as general practice is the principal gatekeeper point for patients to access healthcare, there will always be a role for general practice in the prevention agenda through the many direct contacts it has with patients every day.


51)                                                                                                                                                                               However, if we are to alleviate pressures on general practice, we need to be smarter about how we enable general practitioners to work at the top of their skill set. This means we should avoid placing burdens on them to do things that can be achieved far more effectively and efficiently elsewhere. For example, digital providers of testing and screening services, especially in sensitive areas such as sexual health, can deliver tests and results at far greater scale than can be delivered by face-to-face services. As Covid has forced the entire country to become familiar with carrying out tests at home, we can take advantage of testing at scale through digitally enabled providers and in turn free general practice from this time-consuming activity.


52)  Because digital services remove the geographic constraints associated with traditional face-to-face services, they are ideally placed to tackle the postcode lottery in access to testing. For example, home-based testing can be structured so services integrate seamlessly between local authority public health responsibilities and NHS provision, freeing the staff burden that would be needed to deliver face-to-face provision to provide other forms of care.


53)  In 2020, face-to-face consultations for sexual health services decreased by 10% compared to 2019, however during the same period the number of internet consultations for sexual health testing doubled to over 1 million[12].


54)  Integrating digital into patient pathways supports inequity and equality of access. For example, during the pandemic there was a 90% increase in orders of digital STI testing services from all ethnic minority groups, non-binary and trans people, as well as a 65%+ increase in orders from the most deprived 20% of people[13].


Reduction of bureaucracy and burnout, and improving general practice so that it becomes more sustainable

55)                                                                                                                                                                               There has been considerable focus on the number of GPs working in general practice in recent years. That debate has often focused on training and recruiting new GPs, while perhaps not paying enough attention to how we retain and get the most from existing GPs in a sustainable fashion. Specifically, many GPs when returning from career breaks, for example after starting families, are unable to do high volumes of shifts based in physical premises because of other commitments. However, many are willing and keen to work flexibly providing remote consultations. We benefit in several distinct ways from enabling this flexibility:

a)                                                                                                                                                                       we ensure highly skilled GPs are not lost from the profession due to work-life pressures;

b)                                                                                                                                                                       evidence from Digital Healthcare Council members suggests 90% of GPs who work remotely carry out up to 25% more hours per week due to the flexible working this enables[14];

c)                                                                                                                                                                       we build on existing skills and experience rather than having to replace that knowledge from scratch.


56)                                                                                                                                                                               It is worth noting that if 26% of our current 45,600 GPs were to work remotely through a fully supported digital service, this would create additional capacity equivalent to an additional 6,000 GPs.


The current contracting and payment systems in general practice and their impact on proactive, personalised, coordinated and integrated care

57)                                                                                                                                                                               Too often we see a policy narrative that talks about funding to support transformational change from the centre, yet discussions with practices and local commissioners are far more transactional. For example, the current framework for digital video and online consultations does little to incentivise transformational care. Rather, the focus is on squeezing transactional costs.


58)                                                                                                                                                                               By contrast, other countries take a far more ambitious approach to incentivising innovation and are better at aligning incentives. For example, Germany’s digital health law allows providers to prescribe proven digital health solutions without navigating uncertain and complex procurement processes. Sadly, in recent months we have therefore seen numerous digital healthcare providers making the regrettable decision to prioritise investment in other countries.


The impact of effective partnerships with other professions in primary care

59)  As well as making the most of existing capacity, we can do far more to take pressures away from general practice while increasing access and improving patient experience. For example, research by Digital Healthcare Council member Ada Health, suggests that digital triage can reduce administration and allow clinicians to work at the top of their skillset by redirecting patients with minor ailments suitable for self-care to a pharmacist instead of the GP, leading to savings for the NHS of around £812 million. Yet, so far we are only barely scratching the surface of this potential.



For further information, please contact:

Graham Kendall


The Digital Healthcare Council



Dec 2021

[1] Source: askmyGP. Full time series here: https://askmygp.uk/live/

[2] For example the recent independent report, Putting data, digital and tech at the heart of transforming the NHS emphasised the importance of building basic data and digital literacy and capability at all levels”.

[3] https://selfcarejournal.com/article/the-economic-burden-of-minor-ailments-on-the-national-health-service-in-the-uk/

[4] Source: https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice/october-2021

[5] 56% in May 2021 rising to 64% in October 2021. Source: https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice

[6] The proportion of attendances with waits above four hours has changed considerably: there were 472,515 attendances with waits over 4 hours in Nov 2021 compared to 358,128 in Nov 2019 (a change of 31.9%). The previous month, Oct 2021, saw 502,938 attendances with waits over 4 hours in Oct 2021 compared to 320,025 in Oct 2019 (a change of 57.2%). In May 2021, the number was 301,161. Source: https://www.england.nhs.uk/statistics/statistical-work-areas/ae-waiting-times-and-activity/

[7] In Oct 2021 there were 2,167,480 total A&E attendances compared to 2,170,885 in Oct 2019 (a change of -0.2%). Type 1 attendances followed a similar pattern with 1,384,402 Type 1 A&E attendances in Oct 2021 compared to 1,376,347 in Oct 2019 (a change of 0.6%).


In Nov 2021 there were 2,040,323 total A&E attendances compared to 2,143,505 in Nov 2019 (a change of -4.8%). Again, type 1 attendances followed a similar pattern with 1,300,577 Type 1 A&E attendances in Nov 2021 compared to 1,366,383 in Nov 2019 (a change of -4.8%).


Source: https://www.england.nhs.uk/statistics/statistical-work-areas/ae-waiting-times-and-activity/

[8] In Oct 2021 there were 517,062 emergency admissions compared to 563,133 in Oct 2019 (a change of -8.2%). In Nov 2021 there were 506,238 emergency admissions compared to 559,556 in Nov 2019 (a change of -9.5%)

[9] Source: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/458764/AE_delay_main_report_final.pdf

[10] Source: Livi and consistent with data published by local HealthWatch teams

[11] https://health.org.uk/news-and-comment/charts-and-infographics/how-are-total-triage-and-remote-consultation-changing-the-us

[12] Source: PHE Sexually transmitted infections and screening for chlamydia in England, 2020

[13] Source: Preventx

[14] Source: Livi