Written evidence submitted by Livi (FGP0316)

 

About Livi

 

Livi is part of Europe’s largest digital healthcare provider, delivering digital care services to over 6m NHS patients in the UK. Through the Livi app patients can access a video consultation with a Livi GP, manage their medication, access self-help content, create personalised treatment plans, track their health data, and much more.

 

Our software is also used in over 4,000 NHS GP practices to help GPs and Practice staff communicate with their own patients, including coordinating vaccination campaigns, conducting video consultations, appointment booking and remote monitoring questionnaires.

 

We partner with a range of NHS organisations including GP practices, GP federations, CCGs, ICSs and other NHS commissioning bodies.

 

In June 2021 Livi became the first and only digital provider to be rated Outstanding by the CQC.

 

Overview

 

Before Covid-19 primary care was under intense pressure. Demand was rising and overall GP numbers were flat. The Government’s ambition of ‘Building back better’ in primary care needs to not be about returning to this model but about building a new one. A model that works for patients, primary care staff and delivers for the wider health and care system.

 

The pandemic has clearly accelerated the shift towards a hybrid primary care model, with remote consultations now accounting for 50-60% of all appointments.

 

These consultations have helped keep patients in touch with the NHS during this difficult time. As we hopefully look beyond the pandemic there is now an opportunity to decide what the positive benefits of these changes have been and what risks we need to manage.

 

Patient choice: For some patients face-to-face appointments will absolutely be the preferred and correct mode of interaction. But for an increasing number of people digital care is a preferable and important way to interact with their practice, including for a wide range of conditions such as mental health support, mobility, MSK and dermatology. It is notable the President of the Royal College of GPs estimates only 30% of appointments need to be carried out face-to-face[1]. This is supported by patient demand for digital healthcare services - polling conducted by YouGov shows that 65% of patients would rather access a same day video appointment than wait longer for a face-to-face consultation[2].

 

In providing a mixed-mode approach to primary care appointments, better and quicker access to face-to-face appointments can be secured for those who need and want them. Those needing face-to-face appointments will often require more intensive physical examination. Making it easier for these groups to access the care they need should be a central part of a future primary care strategy and will support overall efforts to tackle health inequalities that have been clearly exposed during Covid-19.

 

Equality of Access: Similarly, for those where physical appointments are unnecessary or challenging (e.g. because of caring responsibilities or their working hours don’t align with the opening times of their practice) providing digital choice will be critical for ensuring equity of access and the broader aims of the new NHS system in delivering improvements in population health management.

 

Central to delivering this model is how we enable an integrated digital and physical service moving forward, when the majority of patients will at various points require or desire both. Providing practices with the appropriate digital tools and support that enable them to consult digitally, and not solely via telephone, as well as ensuring all touch points of patient care are connected digitally will help to drive this shift.

 

To be delivered this will require investment in underlying health infrastructure and tools that can support improved data flows and connectivity. As part of the forthcoming NHSX data strategy and the integration white paper, there needs to be clear investment in primary care data and technology.

 

Open IT systems: One of the major barriers to integrating services within primary care is the legacy clinical systems which hold patient medical records. These closed systems make it very difficult for patient information to flow freely between different providers or settings. The Government set out its ambition for universal interoperability standards in The future of healthcare: our vision for digital, data, and technology in health and care whitepaper. Yet three years on there has been little progress in enforcing primary care IT systems to open to other accredited providers, which is crucial to foster a wider digital health ecosystem.

 

Regional variation and under-doctored areas: Alongside this is a need to ensure that the primary care workforce, particularly the GP workforce, is effectively deployed and utilised. Analysis of September GP appointments data shows that 11 of the 15 CCGs which have the highest proportion of 28-day wait times for an appointment also have appointment : GP ratios above CCG averages. Meanwhile 8 of the 10 CCGs with the lowest proportion of 28-day waits have appointment : GP ratios below average.

 

Equalising the distribution of the primary care workforce would clearly narrow inequalities of access, and help areas where access is constrained the most. However, central direction over where GPs should relocate to live and work will take a long time to instigate and there should be a realism around the impact of how many GPs will respond to these directives. Digital tools can redistribute clinical capacity into underserved areas in a much quicker and more effective way. For example, 28% of Livi patients in France live in what are known as ‘medical deserts’ (where there is poor access to physicians). Developing a funding mechanism and framework that enables GPs in areas where ratios are higher to work digitally in areas where overall numbers are lower is one solution to ensure this capacity is redistributed.

 

Performance and outcomes metrics: While progress has been made towards meeting the Government target of delivering 50 million more GP appointments within this parliament (even excluding vaccination appointments), continued appointment growth will require attracting and retaining new staff through flexible working conditions, including a mix of physical and digital that makes a long-term career in general practice more appealing.

 

Activity levels (appointments) are a narrow way of assessing the performance of the primary care system. A more useful scorecard of metrics to assess system performance would be based on a range of outcomes. A balanced set of measures would include patient experience, equality of access, time efficiencies, cost savings, patient and population health outcomes, and levels of integration between primary and secondary care.

 

Summary policy asks to ‘build back better’ in primary care

 

        A primary care infrastructure fund to improve data flows and the deployment of technology. This would help deliver an effective mixed physical-digital model that delivers a triple win for patients, primary care staff and the wider NHS and care system.

        A targeted fund which enables primary care capacity to be redistributed into under-doctored areas, including through digital channels, to ensure patients can access care in a timely manner and that primary care is supporting wider system efforts to tackle health inequalities.

        A balanced scorecard of measures to monitor the performance of the primary care system covering patient experience, access, number of appointments, value for money and levels of integration with other parts of the NHS.

 

Below is a response to the key questions set out by the Committee most relevant to our experience and expertise.

 

Main barriers to accessing general practice

        As has been well documented, primary care is under extraordinary pressure as demand and activity levels exceed pre-pandemic levels[3].

        The topical debate of whether patients can or should access care through traditional face-to-face methods or remotely via digital technologies masks the real issue patients are most concerned with - the ability to receive timely help in a way that is most suitable to them.

        For many patients speed and convenience of booking is a priority, with the ability to secure an appointment at 8am via the surgery’s busy telephone line simply not an option.

        Similarly, the need to access routine care outside usual surgery hours for working parents, shift workers etc, is a significant logistical barrier for these groups to access care. This often results in being marginalised by the system, or going without care, which creates additional overall future cost through missed or late diagnosis.

        The rapid digitalisation of primary care resulting from the pandemic is clearly welcome. However, some digital services, such as blunt triage systems, have made it more difficult for patients to access help, and added to clinician workload as a result. This is evidenced in many practices choosing to turn their digital triage systems off outside of core hours[4] due to a significant increase in demand, which ultimately leads to poor patient experience.

 

How does the Government and NHS plan address these barriers

        The investment to increase capacity and resilience in primary care through the Winter Access Fund is welcome.

        The fund will provide support for practices through difficult winter months, but it is notable that the investment will expire in April next year, despite many of the challenges facing general practice being structural in nature. Therefore, a longer-term strategy that addresses some of these challenges and provides a clear roadmap for the future of primary care is needed.

        The additional funding of £250m is important, however this is only one element in addressing the acute access and capacity challenges facing general practice.

        While the overall number of GPs entering the system is increasing, the FTE headcount is stagnant[5] as many more retire, work part time, or leave the service early.

        The key to increasing capacity in the coming years will depend on maximising the input and efficiency of the existing workforce. Increasing the use of digital consultations is a rapid way of increasing overall supply by creating a more flexible and attractive workplace environment.

        For example, 90% of Livi GPs report that they work more hours overall because of the flexible nature of our service than if they solely worked in physical practice, with 25% working 20 hours or more extra a week. This is particularly important for working parents or those clinicians wishing to pursue a portfolio career.

        Given the desire of the primary care workforce for a more flexible working lifestyle, as has become the norm in many sectors, increasing the options to work flexibly through digital channels will ultimately increase overall supply.

        However, enabling the primary care workforce to work in this flexible manner is difficult to deliver at an individual practice basis, and is best done at scale with a supporting technological and administrative infrastructure.

 

What are the impacts when patients can not access care

        Patients who are unable to access routine general practice will naturally find alternative healthcare settings to seek out help. Ensuring appropriate routes to care, both during core hours and out of hours, limits the amount of primary care appropriate patients who turn up in urgent care settings.

        Consistent patient feedback shows that 20% of Livi patients report that they would have otherwise attended A&E or an Urgent Care Centre if they had not had access to our service.

        An independent report by Healthwatch North Tyneside found that almost 20% of respondents said they would have sought some form of urgent care had they not had access to Livi, with 6% saying they would have attended A&E, and 11% saying they would have visited an urgent care centre[6].

        Our ‘upstream’ digital primary care service is taking pressure off the local system and ensuring patients are treated more effectively and efficiently much earlier.

        An evaluation by Plymouth University of Livi’s service in Cornwall found that the NHS saved up to £1,946.28 per patient, in saved A&E and admission costs alone.

 

What role does a named GP have for patients and continuity of care

        When examining the benefits of continuity of care, it is helpful to assess the two main types of demand coming into general practice.

        A majority of patients present with one-off episodic care needs, usually seeking a speedy and convenient resolution to their problem, without the need for the same named GP.

        The other main cohort of patients are those with ongoing or complex care needs who may benefit from seeing the same GP who is able to understand changes in their condition or has built a specific relationship with the patient.

        For Livi patients where continuity of care is important they can choose to see the same Livi GP through a bookable appointment within the app. It should be noted that the majority of patients chose speed of access over continuity, however for particular conditions such as mental health consultations the proportion of appointments with a named GP is higher.

        Of potentially higher clinical impact is the ability to match patients with the relevant clinician that has the most appropriate skillset and training for their particular condition(s). Patient matching through Livi’s algorithmic triaging tools has shown an aggregate 20% reduction in avoidable hospitalisations by ensuring patients are being treated by the most suitable clinician for their needs[7]. This would be impractical to deliver in small scale physical surgeries.

 

Main challenges facing general practice in the next 5 years

        Recruitment and retention - how can we attract and retain a workforce that is either burnt out or put off by a career in general practice. In Livi’s CQC inspection report we were rated as Outstanding for the wellness and welfare of our staff. We feel investing in our clinicians wellbeing and careers is paramount to having an engaged and satisfied workforce.

        Upskilling digital knowledge and capabilities in the workforce - if we are to move to a new model where digital is at the heart of general practice then we need to invest in training clinical and other frontline staff as part of wider change management.

        Investing in digital infrastructure - providing practices with the digital infrastructure to deliver hybrid working.

        Integrating primary care properly into ICS structures - otherwise the opportunity of a truly integrated system risks falling flat and being too secondary care focused.

        Managing the needs of elective waiters and long covid patients - a growing cohort of patients waiting for treatment will require ongoing primary care management, as well as the emerging long-term needs of long covid patients.

 

Regional variation in general practice across England

        The Government has set a commitment to deliver 50m more GP appointments in this parliament, which will require a continued growth in GP headcount owing to the above mentioned challenges of flat FTE growth with many leaving frontline practice.

        GP appointment numbers have grown year on year compared with pre-pandemic levels, yet there are significant variations in % uplift and the length of time patients are waiting for an appointment across regions.

        Looking at the % increase in appointments (excluding vaccinations) from September 2019 to September 2021, the London region has seen a 19% increase in appointments yet the South West region has seen only 5.9%.

        Other regions, including the Midlands, North East & Yorkshire, have similarly seen single digit growth (9.4% and 8.4% respectively), where others have seen higher growth (16.9% and 14.9%).

        Analysis shows that 11 of the 15 CCGs which have the highest proportion of 28-day wait times for an appointment also have appointment : GP ratios above CCG averages. Meanwhile 8 of the 10 CCGs with the lowest proportion of 28-day waits have appointment : GP ratios below average.

 

Primary care and prevention

        Primary care remains the gateway into the NHS, meaning it is well suited to lead the shift to more preventative care. The increase in the use of technology within primary care has created many more touchpoints for patients, facilitating an ongoing dialogue around their health beyond single clinical appointments often months or years apart.

        For example, Livi patients can create tailored health plans which can assist with managing a range of conditions or general wellness, monitor their own health data over time and submit healthcare questionnaires directly into their medical record.

        This creates a more personalised and intuitive dialogue about their health, where the opportunities for early intervention and prevention significantly increase. This could enable practices to monitor patient health outcomes in real time as part of the evolution of the QOF framework - an important first step towards wider wearables and device integration.

        As primary care is arguably the area of the NHS that is digitisting most rapidly, this makes it even more suited to leading the prevention agenda.

 

 

 

Contracting and payment

        Fundamental to delivering a successful digitally-led model of primary care is the ability to operate at scale, enabling patients to access a wider range of services and delivering cost efficiencies.

        The move towards PCNs is a first step in this direction, however this still only covers populations of circa 50,000. As such, there needs to be an assessment of what is reasonable for PCNs to deliver in terms of proactive and coordinated care. This neighbourhood level may be beneficial for multidisciplinary team working, however is unnecessarily sub-scale to cope with the demand for one-off episodic care.

        Given general practice remains the gateway into the NHS, it is crucial that primary care is deeply embedded across the pathways of emerging ICSs. It is much easier to join up a patient’s care experience through a seamless digital end-to-end journey.

        A key challenge for local GP providers and digital suppliers is the current lack of consistent contracting and payment mechanisms. Contracting digitally enabled primary care services can be done through a myriad of routes. Recent procurement frameworks, such as the Digital First Online Consultation and Video Consultation (DFOCVC) framework, have focussed on the provision of technology, rather than technology enabled care, meaning there is still no clear commissioning route for digitally contracted care provision.

        This reinforces the false and unhelpful separation between technology and the delivery of care, meaning technology is seen as something that is to be procured and used separately from frontline service provision.

        There needs to be a clear and easy way for practices to contract digitally enabled care. For example, the German Government’s digital health law allows any citizen regardless of geography to access a digital consultation that is reimbursed by the national healthcare system. Sweden also takes a similar national reimbursement approach that has led to the healthcare economy being one of the most digitally advanced in Europe. 

 

Working in effective partnerships with other professions within primary care and beyond

        Uptake of the Additional Roles Reimbursement Scheme (ARRS), which is currently operating at significant underspend, could be bolstered by better use of digital provision. One of the reasons cited by the BMA[8] and others regarding the lower uptake of ARRS is the limited premises and site space for practices to accommodate additional clinical and support roles within their buildings, which are often cramped and ill suited to multi-disciplinary working. Increasing the amount of ARRS roles delivered digitally would overcome this challenge.


[1] https://www.dailymail.co.uk/health/article-9941041/Which-symptoms-mean-GP-face-face.html

[2]  Polling conducted by YouGov on behalf of Livi, August 2021

[3]https://www.gponline.com/gp-appointments-top-30m-october-two-thirds-delivered-person/article/1734146

[4]https://www.pulsetoday.co.uk/news/technology/gps-invited-to-turn-off-online-consultations-to-manage-demand/

[5]https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services

[6]https://cdn.whitebearplatform.com/hwnorthtynes/wp-content/uploads/2021/09/16160441/Livi-users-experience-and-public-views.pdf

[7] Defying Distance? The Provision of Services in the Digital Age, Amanda Dahlstrand, 2021

[8]https://www.gponline.com/gp-premises-need-major-investment-let-pcns-recruit-warns-bma/article/1708204

 

 

 

 

Dec 2021