Proliferation of private online healthcare companies

Should the NHS try to keep up?


Safety of online consulting
Online consultation methods, although widely used in countries such as Denmark, 3 are relatively untested, with recent Cochrane reviews concluding that insufficient evidence exists to make recommendations about their use, 4 and doctors and patients voicing safety concerns. 5 UK professional bodies advise that emails should be reserved for "appropriate matters" such as scheduling appointments, repeat prescriptions, and test results. 6 7 The American Academy of Family Physicians supports online consultations for "established patients" who have previously received care from the practice. 8 Private companies however, have no access to patients' medical records, leading to concerns about continuity of care, and they lack the safety net of bringing patients in for face to face consultations. There are also ethical concerns related to the privacy and security of personal data. One recent study found that although 86% of NHS approved health apps transmitted information to online services, 66% did not use encryption and 20% did not have a privacy policy. 9 What might the effect of the new services be?
Online companies may deal with demand that otherwise would have been met by the NHS, thereby reducing NHS workload. However, if they meet unmet demand for quick, convenient care, it may increase expectations that NHS general practice will be unable to satisfy without additional resource. And if online companies adopt cautious safety net procedures, referrals to GPs, walk-in centres, and emergency departments could increase. Such "supplier induced demand" will be desirable if it meets important needs, but if patients mainly consult with minor self limiting illnesses the health gains will be minimal. Moreover recruitment to online companies could further reduce an already depleted workforce if NHS doctors leave to work for online private companies offering less stressful and more flexible working conditions.
Online private healthcare companies offer access to prescription-only medications previously controlled by GPs. This has implications in terms of safe drug monitoring, risks of drug interactions, and scope for drug companies to influence prescribing decisions. This is particularly relevant to antibiotics.
While NHS GPs try to reduce antibiotic prescribing, websites such as Dr Morton's offer travel packs containing clarithromycin for self diagnosed chest infection, trimethoprim for urinary tract infection, and ciprofloxacin for travellers' diarrhoea, with further "add on" antibiotics for additional fees (albeit subject to a doctor's decision after an email or phone consultation). 10 Such practice potentially undermines continuity of care and completeness of the medical record and exacerbates problems of antibiotic stewardship.

EDITORIALS How should NHS general practice respond?
There is a need to improve access to NHS general practice, and the prime minister's £50m challenge fund was set up to "stimulate innovative ways of providing primary care services," including online consulting. 11 However, despite considerable rhetoric, a recent survey of 696 respondents in 319 NHS general practices found few had any plans to introduce online consultations. 12 If online consultations are a government priority, sustained financial investment is likely to be needed to encourage overstretched NHS GPs to introduce additional services. This has been achieved in Denmark, where GPs receive a fee per email sent, encouraging widespread adoption of email consultations. 13 Without increased investment, hard decisions must be made about what the NHS can afford within limited budgets. Online access to healthcare at any time may not be a rational, effective use of healthcare resources if the goal is to maximise population health. If the NHS does not respond it risks being seen as technologically backwards and resistant to change. This could lead to a two tier system-one that is quick and responsive, paid for by the patient, and one which is slow and inconvenient, paid for by the government. If the NHS cannot meet demands for more convenient care within current resources, and no further investment is provided, another option may be for patient copayments for online consultations. However, experience from other countries shows that copayments can increase health inequalities without reducing demand, 14 with attempts to introduce GP copayments in Australia being so unpopular they were recently abandoned. 15 The challenges highlighted by private online healthcare companies are therefore a microcosm of the problems facing the NHS as a whole, with burgeoning demand requiring tough decisions to be made about what the NHS is willing to fund. Lessons should be learnt from the history of information technology in the NHS, which has been one of high profile overspend and failure to deliver expected outcomes. 16 New models of healthcare must be evaluated and evidence based but also timely and relevant to the population. If the NHS does not supply relevant services, the private sector will be unafraid to do so in its place. The consequences represent a step into the unknown, with potential substantial adverse and far reaching effects.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: CS, HA, BM, and SZ are coinvestigators on a National Institute for Health Research funded project to explore the potential of alternatives to face to face consultations in general practice. BM is chief investigator on a Chief Scientist Office funded project to explore the use of remote consulting to manage long term conditions and reduce workload. JC is chief investigator and CS is coinvestigator on an NIHR funded project to explore issues relating to GP workforce; CS is coprincipal investigator on an NIHR funded analysis of GP workload.
Provenance and peer review: Not commissioned; externally peer reviewed.