GP websites – just what is their primary purpose?

A colleague recently shared a research project they are working on; ‘What does a good Primary Care Digital offer look like?’ We chatted a bit about GP websites and ways that we try to communicate with patients and I delivered one of my usual unstructured ramblings, so thought I’d share some of this with you and ask for views please.

Introduction to the project

When I heard about this research, my first response was to ask if I could join the project too.   Primarily I wanted to be sure that someone who worked in general practice could offer an operational perspective. I also wanted to avoid ‘a solution’ that would make more work for already very stretched, practice staff. Having been a PM for 8 years and been working with Patient Groups for more than 15 years, I have an interest in using digital solutions to communicate widely and have a few connections in the world of digital and user experience design; I thought it would be a nice opportunity to work together on this.  Like many practices, I knew that our practice website was due a refresh; we’d signed up with our Website provider in 2012 and although fiddled with it a bit, not really changed its look since.  There have been software updates, but as we had been on the cusp of joining a new organisation for some time, I kept thinking we would wait then create a combined practice site with a more corporate look and better functionality. So, here’s the first question, as a patient or carer, how do you receive information from your GP surgery? Have a look at your GP’s practice website and see when it was last updated and ask yourself, does it contain the information I need?  What other stuff is on there that you didn’t know? If you have a health related question, where do you search for information? Let me know and we can try and ensure we signpost to this.

Why are websites never up to date?

The word Everything on a To-Do list on a dry erase board to remind you of your tasks, priorities, goals and objectives

Reasons for not updating websites frequently are many, but usually due to time pressures. I also had a fear that if we changed the layout, we’d be inundated with concerns from patients asking where things had moved to – a bit like moving items in the aisles in the supermarket.  Although we add information fairly regularly, the process is clunky; the site’s formatting and design aren’t that user friendly and from a practice perspective, it’s just another job to do.

Value for money or too expensive?

Funding a new website is also a thorny issue. Bigger (or better funded) practices may invest in a bespoke product, smaller practices may see this as an added luxury. A good website should deliver value for money, especially if provides patients with information about the right service for their needs or links to local, relevant advice on ill health and disease prevention and selfcare. A priority for the health service right now is the need for people to use services responsibly. The NHS is so complex, how do people know where to go; use 111, local walk-in centre, general practice, specialist community service, A&E – the list goes on. General Practice is viewed as the front door to the NHS so the assumption is that its their job to signpost patients. But is it really the GPs job to describe all of the various options? Good website content and design should help with quick access to information and good signposting to services without having to wait in a telephone queue. Yet many practices buy the basic off the shelf, template based site for less than £500 per year and give little direction in terms of where to go in the NHS. Perhaps all of those other services should provide information about when to visit the GP?

From a site ‘visit’ perspective, we can no longer access visitor and page view statistics, so we don’t really know how many people visit or if the information is of value.  The world of website analytics is unknown to many practice managers. 

So, where do Practices look for a website provider….

There are a number of proprietary providers that most practices use because they are recommended on Forums (Practice Index, Practice Manager facebook forums etc) or linked to other existing service provision (MysurgeryWebsite, Wiggly Amps, Egton). The question ‘who do you use as your website provider’ has been posted numerous times in the last 12m.

These sites are usually hosted and come with an element of local tailoring with set templates for you to choose from.  Many practices just go with the basic product as delivered from the supplier on day one, others clearly spend time thinking about the look and content. Historically, they tended to be desktop based versions, but increasingly they are adapting to be suitable for use with mobile options as more patients use a range of devices to access healthcare information. I’m told by our provider, that we have a legacy system and waiting to see the demo of the new Digital alternative.

A GP website is a repository of information with links to other useful sites, but often they contain lots of repetition and page changes, with the user losing their way from an initial enquiry. Patients can spends time surfing around for key information, yet still many practices don’t even have the basics of an email address or a number to text for general contact enquiries.

Functionality –   Front facing and back office?

There are website providers that not only host information but also gather patient information too, through use of online forms.  They attempt to ‘stream’ patients enquiries through to specific teams i.e. admin, medication enquires or clinical care (e.g. asthma questions).  They are sometimes partnered with other recognised ‘Online consultation’ forms.  These sites are helping practices to carry out vital data capture and also provide a form of triage, but how are practices assured of the risk i.e. data protection, clinical good practice etc.  Some practices are cautious of opening up other channels to receive additional work streams, especially as not all are integrated with the practice Clinical Health Record system, so clinical coding is missing. Maybe these functions should be viewed not as ‘additional’ but alternative ways of dealing with enquiries; better than a wasted GP appointment for a simple non-clinical enquiry, no?

Many website providers also offer a ‘back office’ or intranet function for practices to create and store information such as contact lists, room schedules, staff rotas, significant events, fridge temperatures, procedures and policies etc. These are used by the whole team and contribute to appraisal preparation and evidence of compliance for regulators. Increasingly these functions are being replaced by better compliance and collaboration tools such as GPTeamnet, Fourteen Fish etc

Do practices have the right design and communication skills?

I don’t mind admitting, I’ve got ‘font and layout’ issues and the limited text style irritates me, so I don’t enjoy this job when there are so many other things to do, but I never seemed to make the time to learn how to use it properly and I know that many Practice managers are the same.  I also don’t have the design skills to make the layout effective or to incorporate graphics or images that replace the written word.

Although template websites have a range of options to choose from, the design and formatting functionality can be somewhat limited and clunky.  It’s fairly easy to spot a bespoke high quality design from an ‘off the shelf’ template.  Most practices wouldn’t know where to start in terms of placing the most frequently used pages/items at the front, or create eye-catching designs that engage users or communicate effectively.

Web designer

NHS Digital have kindly provided guidance for us to follow – I shared it recently with other Practices and doubt anyone has actually read it or made changes as a result – I know I haven’t had time.

This is part of NHS Digital, creating standards intended to ensure accessibility and inclusion and good user experience.  Many websites still don’t address the increasing need for good accessible design and practices buy with the hope that their site meets the legal requirements for accessibility and inclusion. This guide is great for designers, but well above the skill and knowledge level in most practices and I wouldn’t know where to start checking our current provider against these standards. What would be helpful is that anyone who provides a website service can demonstrate they meet this standard, so that practices can be assured before they purchase.

NHS Generic information repeated?

The new GMS GP contract requires practices to have an up to date and informative online presence by 2020 (page 35). If we are to adopt a ‘Digital first’ approach, for those users who choose this, then a website’s original function is being overtaken by many other products. There are apps here, there and everywhere and more practices are using social media to share information quickly and widely, as well as traditional newsletters and posters in the surgeries.  There are many more online services to offer or ways for patients to access these services via alternatives to web browsers.

But don’t forget that NHS.UK (not called NHS Choices any more) has already created a unique site for every practice and some of the National dataset for performance links to this site i.e. star ratings and comments about service provision.   Having a practice website has been a minimum General Medical Services contract requirement for some time, but I doubt many practices update their NHS.uk one as well as their own site.  Most will just link to their own website. So each practice probably has links to GP survey comments, star ratings, who’s who, when we are open etc held in multiple places and this is another reason for out of date information. The connection to NHS.uk is provided from the clinical system provider (i.e. what online services are connected) and feeds into national contract management tools such as the Primary Care Web tool.  This is also the place where CQC look for feedback and comments.

Primary care working as networks

As more practices federate and work as networks to deliver shared services, access and common information should be provided via one page and not duplicated on separate sites.  Although some practices want to retain their own ‘front door’ to maintain familiarity for patients, most would happily hand over the ‘back office’ role of updating websites and linking to other NHS services and content. Will this be high on the priority list of any newly formed network?

Social Media, Reviews and Comments

Now things start to get interesting as people ‘check in’ and review their experience using tools like Facebook, Google review and I Want Great Care .  These platforms encourage patients to ‘like’ or ‘comment’ following attendance – practices can choose to ‘own’ these sites and respond, or ignore but are unable to remove comments so they may sit there, open for others to view unanswered.  Some practices hate this and are really fearful of data breaches as well as opening up other channels of communication. They may have a negative experience of social media and don’t want additional work of training staff to work safely and professionally in an area that crosses over with leisure and out of work activity.

However, if used wisely, social media offers highly effective alternative methods of communication for mobile users.  This recent post by one practice reached over 1m people to advise them about cervical screening services. This encourages interaction rather than one way push of information and has the ability to reach quickly and widely with little effort. 

More and more practices use social media and message solutions to communicate with individuals, groups and whole sections of the practice population as well as providing opportunity for ‘communities of interest’ and large scale communications at federated levels of General Practice. This has to be part of any new communication system.

Access to online services

As more services are delivered online, then application developers are providing better alternatives to the GP practice website for transactional services like booking, cancelling appointments, ordering medicines etc. There is a market approach to the development of these online services and practices are struggling to keep up and train teams to offer knowledge and advice on the options to their patients.   Each app seems to deliver different functions which means that app of choice will depend very much on the need of the individual patient.
Depending on the provider, some websites link to a practices clinical system for online services but can only offer one online service and not multiple options. Although patients can choose from a number of different platforms to access online services currently, website providers haven’t enabled this choice. This limits practices and patients if people want to offer and use a variety of online services. The only way to do this is to signpost using weblinks rather than widgets to apps to advertise the options to patients.  All four current  providers; Evergreen Life, Patient Access, Dimec and Iplato all have apps to access booking, cancellation, messaging, medication ordering, medical records viewers etc but not all have browsers. Conversely, some of the online consultation systems only use browsers. The NHS app is due to roll out imminently, but as yet, we don’t know how this links to a practice website or browser option.

Conclusion

As you can see, its detailed and complex and really does need a review.
The work that UCLAN are doing with the NHS Primary Care Digital Transformation team will help inform what a good Primary Care Digital offer looks like. We need this to help practices buy and recommend the best products with confidence. We also need to know what content is most useful so that we help guide patients to the right service for their needs, quickly and easily.  So I’m glad this project is started, but let’s think first, what’s the purpose of a website and who is this project aimed at?  Please do add your comments and we will see if this can be added to the research.

Access to your Medical records online – It’s hard work for practices, even to do the right thing….

It’s hard enough dealing with illness, worry and the pressure that results from this, without having a system which seems to be hindering rather than helping.  I’ve been touched by an event where someone who cares for their son (he has a life changing, long term illness) is despairing because of the struggle to get access to his medical records to make sure he is cared for safely and receives the right medical treatment for his conditions.
I thought I would try and explain why some practices have not prioritised this area of work.  That’s not to excuse them but more to give context to the problems.  I hope this provides a broader understanding of the challenges so that if you too are struggling to get access to your records and need to have a conversation either with your practice or local CCG, this is easier because you know some of the background details.

 I work as a Practice manager in West Cumbria and I’m also working across Lancashire and South Cumbria to spread digital working so Online Records Access is a bit of a passion of mine – largely inspired by the work of Ingrid Brindle and Dr Amir Hannan.

 

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Haughton Thornley Medical Centre had a specific reason to start the records sharing  – they had to rebuild trust after Shipman.

Dr Hannan describes this as a Partnership of Trust and often a critical event like this triggers a huge swing in the opposite direction, hence their policy for openness and transparency.  He is driven by this almost like a crusade and has been doing this for 13 years.

Unfortunately, the majority of GPs do not have either his reason or understanding of the benefits of providing full records access.

This post isn’t to debate the pros and cons, more to explain why it’s not as easy as presented.   Most practices have only started in the last 2 years which have been an increasingly pressured time in General practice due to dwindling resources and increased demand.  Our practice started to provide detailed online records access in 2015 following an evening training session with our patient group, staff and with Dr Hannan and yet according to the lastest NHS statistics, we still only have 33% of records access.  I have been unable to spread this work across the practices in my area of Cumbria largely due to the chicken and egg situation; ‘patients don’t ask, so we don’t have to provide’ vs ‘patients don’t know what to ask for, or when they do ask, its too hard to do’ for the practice.   I also support our local group of PPGs and help to raise awareness about the benefits of records access and I’m often frowned at by my PM colleagues, who are finding it hard enough to do the day job with multiple complex priorities and change.

We are dealing with a society where increased litigation is creating more fear in clinicians than ever before, ramped up by risk aversion and caution in the medical indemnity and professional bodies such as RCGP

 

The guidelines we have to follow and assurances we have to give to regulators (CQC)  are confusing and completely at odds with patient experience and NHS policy directive ie our GMS contract See Section 3.
Pulse, like many other organisations provide both detailed and summary guidelines to address the new GDPR regulations but interpretation is varied across practices, some  provide the absolute contract minimum records access, others have increased their provision rather than deal with Subject Access Requests.i
I know there are really good General Practices, with Outstanding recommendations from CQC, who still only have 0.27% for their Detailed Care Record Access.
As a member of a patient group, I have asked my practice to enable some of this functionality, but have stopped asking as I’m aware that I could be perceived as a nuisance and that this may affect our relationship.  So I appreciate the experience from both sides of the divide.
If you are interested to see how your local practice compare, here is the latest data  so you can find your CCG and practice and see where they benchmark.
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Many of you will know that General practice income is reducing year on year and expenditure increasing.  The Independent contractor business model means that any additional unfunded work comes directly from the bottom line of GP Partners income.  If Partners have a choice to pay locums to keep the service going, rather than spend this on clinical and admin time to carry out the data checking required to ensure the records are accurate, readable, viewable and cleansed (I mean redacting any 3rd party information which is required by law), then they will spend their money on the locum every time so that patients get seen.  It’s a continual balancing act between providing access and shifting to new ways of working.

GDPR has increased this anxiety and whilst from a patient perspective, the regulation is a good thing i.e we should know what’s in our records, this has created a huge amount of work in practice.  Software to help carry out this process is available such as iGPR but at a cost to the Practice or the CCG and is only recently developed.  Initial feedback is good, 6A916A36-EFBE-408F-96A7-C73BF15A2D2Bbut their earlier versions of their insurance reports were clunky so many practices were put off by this.

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Think back to the days when your GP wrote in Lloyd George paper notes, probably in medical shorthand to describe what your symptoms were.  Many of these old records are illegible, some contain inappropriate comments as societal norms and subsequent language has changed.  These were always the ‘GPs notes’, not the patient’s – but now thats changed, even if the content in the notes is the same.

Each time a patient moves from one practice to another, your new GP then becomes the data controller for someone else’s data entries.  Would you be happy with this responsibility and be willing to share without checking the historical records?  Until recently, none of this was taught in Medical School and I suspect its still skipped over. Our practice teach medical students – this topic is always on our training schedule – even if the Student tells me they want to be a surgeon.

Roll forward to today when people are requesting 10-30 years of this history to be viewable and I think you can appreciate the workload to share this in a presentable way.

Another feature of GDPR (in addition to the increased workload and anxiety) is the removal of the ability to charge for the work.  Hence, some practices suggesting to all patients that online access is the answer and then realising the workload to tidy the records is no less onerous than printing them.  Yet Practices still have to put in place mechanisms to ensure that records are continually checked for external 3rd party content and protect this information from disclosure.

I’m not aware that NHSE have provided any direct resource linked to the volume of this work to practices since 2012, when they funded a Direct Enhanced service for online services for a short period.  This work is now incorporated as a GMS contract requirement for online services, with a ‘stretch target’ for further adoption.  The current figures mainly reflect use of transactional services (online appointments and medication requesting) to present the story of ‘14million users’, so this satisfies the DH & Secretary of State’s headlines of success, but provide little support in terms of detailed care records access.  NHSE Patient Online team have reorganised as the ‘Empower the Patient team’ and whilst offer presentations and promotional materials to support practices, they do not have any budget for deployment or direct training at a practice level.

 

CCGs are responsible for the Infrastructure to support General Practice in terms of IT and local Training capability and capacity varies from area to area, so unless the Practice team has some understanding of what the patient can see through the various record viewers, then they wont understand the consequences of scanning correspondence, without details being attached to the images.  Correspondence may have scanned historically before this became a priority, hence many online records have no valid descriptions on the attachments.  Practice priority is to get the correspondence into the records asap so that if a patient comes into the surgery, the clinician can view the letters or act on the information contained therein.  Bulk adding of correspondence is a common task, followed by summarising of ‘read coded’ information and if a patient has a large record, then often the GP2GP (thats the electronic system for transferring the electronic record) fails.  So someone has to painstakingly read every piece of correspondence to glean the pertinent details and manually code this information.   There are add on software products that can help, but stable infrastructure is required or else this adds further risk if documents cant be accessed by the clinician in the consulting room.

 

In our practice we have 3 years worth of scanned images from 2006-09 that are unable to be converted into a viewable format.  That was due to the scanning system configuration at the time and long before records access was even considered.  Our CCG paid for the remainder of our historical scanned images to be converted to a readable format.  Many practices have to fund this cost themselves.
As Ingrid Brindle regularly points out, complex patients or their carers often have the best knowledge of their history – she says ‘it’s their life’s work’ and patients can be a great support to help practices correct any inaccuracies.  Patients can help by highlighting all of the pertinent information and checking with their practice that this is:
A. Read coded
B. In a format that is shareable across the health organisations in their area
C. Visible through whatever records viewer a patient chooses to use.

The introduction of Snomed might make it easier for hospital coding to be automatically transferred into GP records but this has been in the pipeline for many years, although expected later this year.

Sorry this was a long post, but as you can hopefully see, this isn’t an easy or quick fix and it shouldn’t be left to individual practices to resolve.  NHS Digital seem to be focussing on front end entry to the NHS through apps and also single identity authentication to remove the need for multiple passwords and sign ins.  They are currently working with existing market providers like Evergreen Life and Patient Access for the records viewing element but its not clear yet how this will impact on records access at a practice level.

Alongside this, CCGs and clinical system/Electronic health record providers are focussing on large scale inter-organisation data sharing, but not direct sharing with the patients.   It will be interesting to see if the launch of the NHS app for accessing all services increases the requests from patients for records access online and how this will be resourced.