Primary care has transformed and continues to adapt at great pace, Miriam Lemar – Chair of the BCS Primary Health Care Specialist Group – explains. We must not, however, lose sight of our customers’ needs as we design, build and deploy.
Before we go any further, let’s get some definitions cleared up. They’re important, explains Miriam Lemar, Chair of the BCS Primary Health Care Specialist Group. ‘When most people talk about primary care they’re actually thinking about general practice,’ she says. ‘Primary care itself includes GPs, dentistry, optometry, pharmacies and community pharmacies… It’s big with the GP working as the gateway to the system.’
Miriam started her working life as a programmer, having completed a computer applications degree at Dublin City University. That pathway, she quickly realised, wasn’t for her and she moved into management consultancy with Coopers & Lybrand.
In 1998, following a merger with Price Waterhouse, Miriam found herself working for the newly fledge professional services giant, Price Waterhouse Cooper.
‘I've been involved in all sorts of business transformations,’ she says. ‘Mergers and acquisitions, insolvencies… change programmes. But, everything I have done usually has a technology element and an element of change too.’
A crisis and an opportunity
The 2008 financial crisis forced her to refocus her career and, she explains, serendipitously she found herself orbiting cost reduction in acute care – a shift which introduced her to the concept of integrated health. Over the next decade her involvement and fascination with health and care deepened and, today, she runs her own management consultancy which specialises in helping primary care organisations deliver change.
With the definitions done, it’s time to jump to a possible endpoint for primary healthcare’s technology story and ask: ‘What might a fully transformed primary care sector look like?’ If we could deploy all of today’s glamour technologies – AI, cloud, the metaverse, wearables, IoT – what would it feel like going to the doctor’s surgery? Indeed, would you even attend one? Or, would we, more likely, stay in the community and report telemetry by 5G to our AI surgery which could, if it spots a problem, simply dispatch drugs by post?
‘Would AI replace doctors?’ Miriam asks. ‘We explored that question at one of our conferences a number of years ago. I think it’ll have a huge place to play and we’re still learning about AI. But, no. We’ll always need the people aspect of care.’
Care, she explains emphatically, is about people. It’s about people – humans – needing help and people being driven and passionate about providing that help. This relationship, she explains, is founded on a word she uses a lot: trust.
For all its apparent efficiency and speed, nobody – neither GPs nor their patients – want a purely digital primary care system. ‘People want to see a person,’ she says. ‘We’re social animals.’
Striking the AI balance
But, she says, AI is a promising technology that does have a place to play in a trusted and human-to-human healthcare system.
‘One of the things we examined, again at our conference, is decision support. I can absolutely see a place for that,‘ she explains. ‘If somebody presents in general practice with symptoms – confounding symptoms… There's only so much GPs can remember, particularly if they haven’t seen [these symptoms] on a regular basis. How do you go about finding out what [the [problem] is? Go back and check in books? GPs have brains the size of planets but there's only so much that they can remember.’
The relationship between AI and GPs, she says, will be collaborative. The AI might ingest medical papers and books, take in patient records and suggest a set of probable diagnoses to the doctor.
Prevention is better than cure
Much closer to home, Miriam explains, prevention is better than cure. Fitness trackers, sleep monitors and home blood pressure recorders – though often not able to provide medical grade data – can nudge us to take more exercise and live healthier lives. In a way, an Apple Watch a day, may well keep the doctor away.
‘There are,’ Miriam says, ‘eight thousand seven hundred and sixty hours in a year. I saw a case study with somebody who had type two diabetes. The patient has to check their [blood sugar] numbers. But, of all those hours in a year – they spend maybe three in the surgery. The rest is up to them. They've got to manage their own care. You need the tools to be able to do that and you need advice… Information that is right and is validated.’
Despite technology’s relentless advancement across many industries, visiting the GPs’ surgery can feel much as it did decades ago: make an appointment by the telephone, wait in the waiting room and finally sit opposite your GP in their room.
Don’t be fooled though, Miriam explains. This feeling of a familiar and time honoured process belies considerable change and ongoing transformation.
‘The systems that are most beneficial to GPs are their patient record systems – I call it a filing cabinet – seamless systems that hold coded data, text and pictures. That's where they hold all of the information about the patients,’ Miriam says. ‘There are other systems in the background too. Things like Docman that help with flows of documents in the practice. Practices get inundated with stuff from hospitals and other places. So, all that needs managing. Patients really only see the top of the iceberg of work they have to deal with.’
The COVID pandemic, of course, brought about huge changes in how we all interact with services and support across primary, secondary and social care. Almost overnight, it felt from a patient’s perspective, telephone consultations became commonplace and video meetings with your GP became an option.
Looking back, Miriam says: ‘Up until COVID, everybody was still desperately trying to do their ten minute face-to-face appointments, with a few exceptions. From my perspective, I thought it was amazing and fantastic how quickly people – both patients and also the practices – adapted.’
This fast paced transformation wasn’t however perfect, she says. ‘There just wasn’t enough time being spent on the actual implications of such a wholesale change.’
By way of an example, she says: ‘If you make it easier for people to access services, then people will access them. We need to understand that and what the implications are in terms of flow through the practice. There's a whole change management piece which we tried to do remotely, which isn't the ideal way of doing it.’
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But, on balance, Miriam explains that primary care should be proud of the transformation it made during COVID. Looking forward and thinking about the positives which the pandemic produced and the things worth keeping and building on, she says: ‘I think it would be brilliant to have more access into a practice, using some sort of online tool, because that would suit me as a patient and also access to information that I know is trusted versus that from Dr Google.’
Again though, she warns against focusing on building towards a purely digital patient experience – one where appointments are booked and consultations delivered via the internet and apps. For those digitally equipped and literate enough to embrace these opportunities, the positives and convenience are great. But, for those in society who either can’t afford a capable and modern phone or lack solid enough broadband or data minutes to participate, the shift to digital could prove excluding.
‘You've got to be aware of what your population is around your practice because what you're doing has got to be customised for that population. It's about you knowing your population and their requirements,’ Miriam warns.
Beyond patients, the software designed and deployed in general practice also has another set of customers: GPs and their teams. People whom, she says, want to focus on giving care and not on using and mastering software systems.
‘I think we need to put effort into this as well,’ Miriam explains. ‘There are GPs I meet as part of the Primary Health Care Group or through digital health networks… People whose first love is health. That's what they do. But, also, you’ve got GPs who are interested in technology and how it can be applied. We know any number of GPs involved in developing apps for different things. But, a lot of people don't want to be in that space… These GPs just need it to work.’
We need systems that meet the needs of both GPs and patients simultaneously. ‘Everybody uses tech in a different way,’ Miriam summarises. ‘I think there's something about changing the narrative with patients and asking patients what they need. I say that because, historically, we've trained patients to ask for an appointment, whereas actually, in a lot of cases, they don’t really need or want an appointment… A face-to-face visit with the GP. There are a lot more resources in practices now. And those can be used. We need to change the narrative…’
