EHI Live 2017 interview: Dr Neil Paul

Dr Neil Paul, a GP from Sandbach in Cheshire and well-known IT columnist, talks to Informa about the changing face of general practice, what that means for its systems, and why we need a new generation of primary care IT leaders.

Dr Neil Paul has worked at Sandbach GPs, a practice based at the Ashfields Medical Centre, since 2000. The practice is a large one, with no fewer than 23,500 registered patients.

It’s also modern and innovative; click the ‘services’ tab on its website, and a long list of clinics comes up, led by staff ranging from midwives to pharmacists. Despite this, the practice is facing the challenges that seem to be facing general practice almost everywhere: unceasing demand and a shortage of GPs to meet it.

One big problem: recruitment  
“We have never had problems recruiting,” says Dr Paul. “We are a modern practice with lots of additional services. We are high-earning. We don’t do on call. Yet we advertised recently and we had no response. No applications at all.”

The Royal College of General Practitioners reckons vacancy rates across the country are now more than 10%. And in the medium term, things don’t look as if they are going to get better. A survey earlier this year suggested that in seven out of 11 areas at risk of GP shortages, a fifth of the GPs in place were over 55.

One idea for tackling this problem is to get other staff to do some of the work traditionally done by GPs. Sandbach GPs has already done a lot of that, and is currently thinking of trialling the latest big idea: physician assistants.

These are people with post-graduate qualifications who can take on some medical work under the supervision of a GP. But, as Dr Paul points out, that means they need supervision.

IT can help here: In his column on digitalhealth.net, Dr Paul has argued that online and video meeting services will help at lot as GPs take on more supervisory and team-leader roles.

“Never mind having Skype as yet another way for patients to try and reach their GP,” he says, “let’s use it so I can provide some quick advice to somebody I am supervising, or to get a whole bunch of people together without them wasting time on commuting.”

Smaller, more traditional GP practices are not going to be able to work this way, though. Which is one reason that the future of general practice looks as if it may lie in GP federations.

This means practices banding together to, as Dr Paul puts it: “Find productivity and efficiency savings in business processes, reduce the variation in clinical delivery that can affect patient care, develop new services, share expertise and retain power in the health system that is increasing dominated by the acute trusts.”

A federated future
Dr Paul helped to set up a not-for-profit GP federation that covers 30 local practices. One of the things that he often writes about in his column is the need for new types of IT to make this work.

At the moment, he has argued, GP systems are not set up for federated working. Records that are held in one practice may not be easily accessible to GPs and other staff working in another.

Or, going back to the support point, he has argued that the NHS has been slow to adopt the kind of systems that businesses use routinely for staff communication (his federation has developed GPAsk on the Stack Overflow model to let staff ask questions and get them answered and uses Slack for internal communications).

Or, telephony and appointment systems are not set up so that receptionists in a quiet practice can take the load from a busy one. Or, primary care lacks the kind of analytics that would enable it to predict where the busy and quiet practices will be. The list goes on.

The really big problem: demand
Another issue that exercises Dr Paul is how technology could help to tackle that unremitting wave of demand. In Sandbach, at least, he says this is not being driving by the ageing population or a big increase in the number of people living with long-term conditions – although these are happening.

Instead, it is coming from young people, who have a more consumerist demand for access, even though they may have less true need. Tech companies should be perfectly placed to create new services for tech-savvy patients like this. But at the moment, this is not really happening.

“Companies don’t really target the health market. They say they do, but they don’t,” Dr Paul says. “Wearables are a good example. They are not targeting health but wellness, and that creates a lot of health-seeking behaviour.

“These companies tell people: ‘You can use our product to measure your blood pressure very ten minutes and then send the results to your GP.’ But what am I supposed to do with them?

“Or they hear about the aging population, and they say: ‘We can put a sensor on every care home resident and send an alert as soon as their temperature goes up’. Well, so what? They might just have a cold and need some paracetamol and a nice cup of tea.

“We don’t need more alerts. We need something that helps people manage their health better and use less resource not more. There is a need for a breakthrough product and I haven’t seen it yet.”

Dr Paul once suggested that the NHS should invest in Google AdWords, so it could pick up when a search like ‘hay fever’ or ‘flu’ started trending and address it at source.

“I suggested the NHS should buy the keywords and show banners saying: ‘You can treat this yourself, go to Asda and buy some tablets or click here to have them delivered to your door’. But no, it puts banners all over the internet and social media saying: ‘Call NHS 111’ and when people do, what does it say? ‘Go and see your GP.’

NHS Digital is trying to reboot NHS 111 and the online NHS Choices to address some of these issues. Ministers and policy-makers have talked about using more clinicians on the new NHS.uk, so they can address people’s problems immediately, instead of passing them onto other services. Dr Paul thinks artificial intelligence could be the answer here.

Catching up and getting back ahead
But that still leaves all those practice business and federation issues. GPs led the charge for digital health in the 1990s and early 2000s, but now find themselves with old systems that were developed for old ways of working.

“My PC crashes all the time; and I’m the IT lead!” Dr Paul says. “My wife [who is also a GP] emailed the other day to say it was taking her eight minutes to print a prescription; in a ten-minute consultation.”

If these basic, infrastructure issues can be sorted out, then existing systems will need to be rethought, or new applications will need to be invented to support those GP-as-team-lead and federated models of working.

On this, Dr Paul says the key will be getting from innovation to product to deployment faster; which will mean forming better relationships with NHS IT teams and with suppliers.

Primary care needs CCIOs
Dr Paul often talks about patients who work for major aerospace firms and banks, who can come up with an idea, get it built and tested, and then rolled out. This kind of relationship will require scale – and money – which, interestingly, acute care is now starting to have.

“I think hospitals have struggled to catch up to where primary care has been, but now they getting sorted,” he says. “The IT lead at my local hospital has a decent budget, good people, and can attract the big companies to work with her. So I think hospitals will start to accelerate past primary care.”

Changing things will also require new skills. “There has been a huge amount of interest in the chief clinical information officer role for hospitals, but we need something similar for primary care,” Dr Paul argues.

He’d love somebody to set up a similar network for young clinicians with an interest in how IT works or a passion for data.  Primary care information officers, anyone?

About Neil Paul: Dr Neil Paul trained in Manchester and has been a GP partner in Sandbach since 2000. He leads on IT and external services for the practice and has helped it to set up a wide range of clinics and services.

Dr Paul was heavily involved in the local primary care trust and is still involved in the clinical commission group that replaced it. However, he has also helped to set up a not-for-profit GP federation locally that covers 30 practices.

Dr Paul is an honorary senior lecturer at the University of Liverpool in the school of Management. He will be speaking in the primary care stream at EHI Live 2017, which takes place at the NEC in Birmingham from 31 October to 1 November, about primary care, the issues facing it, and the role of IT in tackling them.