• Do we want to do this?
• Are we confident in it?
• What are our exclusion criteria? Some practices offer only for children over 1 (although online consultations can be done for children over 6 months old), and also exclude some of the more complex patients. It is totally OK to do this – you should still benefit from the bulk of people who can do an online consultation.
• How will we manage the online consultations? What is our process?
• How can we support people to move to using online consultations?
• What shall we stop ? This is key or you will feel over worked.
• For practices already using online consultations– can we promote this more? Are our systems optimized?
• What approach – gentle offer, all on the day consultation requests, or as part of total triage?
  See below for more detail.

• Total triage – main route for assessing appts. Under Covid19 this is becoming the norm. It’s the easiest model to introduce. Lots of benefits. DNA zero! Response by end of the working day.
• Same day appts model – all requests for on the day appointments have to go via an e consult – here we have to specify a same day cutoff time.
• Routine model – Online consultation is the preferred route but is not mandated … respond by end next working day.

1. Online consultations can be accessed from the practice website or via the NHS app. So pushing the NHS app is a good idea.
2. Online consultations allows the patient to ask the practice an admin or clinical question, for example:

• Admin queries – test results, sick notes, letter requests, immunisation records
• Clinical (adult) – there are 109 Adult conditions . Various ways to access – simple list or body map. Adult online consultations can be closed off by AccuRx or a one way patient message system.
• Clinical (children) – 24 conditions covering from 6 months old to 18 years old.  There is also a  new unwell child template. These differ from the adult templates in that they must be closed off by the end of the next working day and via a F2F appointment or phone call. Direct messaging is not allowed.

Once a clinical question is asked the online consultation will offer these options:

1. I want to help myself. Really helpful. Linked to NHS. Has helped practices a lot
2. Pharmacy advice is also NHS syndicated info and finds pharmacy from post code
3. I want support online. Need to let e consult know what you have eg podiatry sexual health mental health etc. All of this gets linked to the relevant condition. People now can find self referral routes this way rather than phone practice.
4. I want treatment and advice from my GP, this is what we traditionally see in practices but remember the above offers also help reduce practice demand.

Many patients choose the self help options but for those who go on to ‘I want treatment’ and ‘Advice from my GP’ they fill in a template:

• Every template first asks Covid19 questions. Tells them to contact 111 if they are at risk.
• The next questions rule out an emergency and directs people to 999 if very unwell.
• Then patients fill in the template. The free text is limited to 500 words.
• There are lots of yes and no questions – and if yes there may be more questions.
• If a red flag emerges then they are stopped from using the platform. Even a trigger word in a text box eg ‘suicide’ can trigger this. The next step then depends on the time of day.
• Remember patients can exaggerate their symptoms. The online consultation will then end with advice to contact 999 but they can then cancel this and go back – and ponder if their pain from a stubbed toe really a 9?!
• At the end they get a message thanking them and saying what happens next. Patients are also safety netted then.
• The response time is specified to them.

• Set up of an online consultation list and appropriate slot types (admin and clinical online consultations)
• A process by which the online consultation received by reception is allocated to the list
• Adequate staff to manage the online consultations coming in
• Adequate training in managing online consultations including a template to help capture outcomes.
• A check that all have been actioned in the right time frame.

More detail:

• Online consultations get sent to a practice email account. Best to have that separate to usual practice email account.
• If you have teams then can triage the online consultations to appropriate team members eg Admin Pharm GP. Slide 7 in the slide pack has suggested routes.
• Looking at the online consultations: the online consultation report is never more than 2 pages unless it’s on mental health. However there you get GAD7 and PHQ9. Orange icon in the online consultation means pay closer attention The online consultation also tells us how many need close attention. Photo upload on a lot of conditions is imminent now. Questions are reduced if they upload a photo
• Responding: Blue box on PDF let’s you respond one way. This is tricky though as it only works from the emailed PDF and not from the file attached in EMIS. It is probably easier to respond using AccuRx. Also AccuRx codes the response into EMIS, whereas the PDF response does not.
• Amount of time needed: Best evidence from the Hurley Group is that 32 can be processed well in 4 hours with the best closure rate. Trying to do them too quickly results in more people being brought in un-necessarily for F2F appointments. Hurley analysis showed 70%  could be managed remotely, with 30% needing a F2F appointment.
  • 40% need prescriptions or advice
  • 30% need phone back or video call
  • 30 need F2F which may be on the day or next routine
• With Covid19 we are now seeing remote closure rates of 95%.
• Feeling: Clinicians find an online consultation list is much better than a telephone list. There is a massive benefit of having all of the history up front.

• Quarterly SMS campaign (34). For suggested messages please see slide 11 of the slide pack.
• Active sign post from clinical and reception team (31) – reception super important to push this. Hurley have crib sheets. Get whole team to use the demo site and they will promote it better. Use pop up banners and other promotional material in reception.
• Banner on website with weaving in of an online consultation into website offer (20) – also good to put practice phone number at the bottom of the website. For a good example see Royal Arsenal Medical Centre. Hurley have good marketing material.  See Needham Market county practice – has a video.
• Telephone info on an online consultation highlighting it as part of recorded message (15) – do not tell them when they get to a receptionist after queuing ! Use the lead GP to record the message. Have it playing as soon as the phone is answered and also while they are waiting.

1. People struggling to do an online consultation.

• Can put on call back list and reception fill it in on their behalf.
• Ideally a full online consultation but if needs be there are also EMIS clinical lite templates which are shorter. Maybe only use for core vulnerable people eg frail, homeless…
• For people who are not confident or have no tech then do a full online consultation with them. Usually the numbers needing this drop as time passes. The reasons are that people see how easy it is, don’t want to wait for a callback, or were not confident. Remember there should be fewer phone calls so reception can manage.

2. People diverted away from an online consultation– these may have been told to call their GP because of a red flag in their online consultation– here use the EMIS lite template.

3. Everyone else will use it! People already shop and bank! Don’t assume people won’t like or use it. It’s our chance to take back control of the practice.

• By using the right slot types and Edenbridge you can collect data and reflect on how this is going.

• Monday mornings may require more online consultation processing time.
  Look at your demand patterns – you may find that between Friday evening and Monday morning there are lots of online consultations waiting to be actioned. This means that you can make special arrangements for Monday morning to include more online consultation processing slots first thing.
• Don’t be daunted if you have a lot of requests! Online consultations may not need to be reviewed by a GP.
  Online consultations allow you to share the workload as long as it is within your scope of practice. Just be clear about who is responding.
  
• Prepare everyone well to deal with queries and to advertise.
  The most successful online consultation practices are the ones that prepare protocols, scripts for staff to relate messages to patients, and advertise well. You can get even more from an online consultation by sharing usage figures and feedback across the practice – it will motivate everyone to keep improving.
  
• Online consultation emails have the condition name and flags in the header.
  This means you can easily identify clinical online consultations from admin ones, and there may be certain conditions which you can send to the appropriate member of staff with ease.
  
• Use the LTC templates for asthma and hypertension, and also for repeat Oral Contraception.
  For example send a text re hypertension review with a link to an online consultation. Hurley Group have examples of text messages that work. Get clinicians to look at LTC reviews on demo site.
• Push the NHS app (see youtube link on the left).
  This now has includes consult (nice and clear – one question per page) but also reduces phone line pressure by allowing booking of appointments (into say a total triage session) and medication requests.
• Explore video consultations using AccuRx or Qdoctor (see youtube link on the left).
  Please note that we are working on how to make accessing Q health much easier for practice staff and have been working closely with the Q doctor team on how to streamline the user journey and improve the experience – more details soon!
• Make sure children’s templates are turned on
  If you would like support on this, please email EQUIP.

• Online consultations can also manage some LTCs – asthma and hypertension plus oral contraception reviews can be done via an online consultation.

• More LTC reviews coming
• New patient Registration