Loneliness is endemic. There are people who live alone, and who will see someone else rarely. Often, people who are lonely can’t get out much – unsteady, lacking confidence, afraid, anxious – and rely on relatives or rare visitors to help with shopping or outings. Many people – often older people – will still dress up to come to the doctors. There are people in waiting rooms who chat, there are babies to admire, there is weather to discuss. When patients and doctors talk, there is an exchange of information, a touch of conversation. Many doctors are part of the community where they live and work; many say that they get back as much, if not more, than they give, a kind of living exchange.
I am also a fan of the internet. Social media has enhanced, not diminished, my friendships in the world at large. I have met people and had conversations with folk I wouldn’t have met otherwise. But here is Jeremy Hunt, declaring that GPs and district nurses should be doing more by ipad and Skype; the assertion that 2.9 billion could be saved ‘almost immediately’ by having online rather than real life consultations. Where this figure has arrived from is unknown; whether this new direction could work or be dangerous may be rightful concerns but have fallen by the policy over evidence, technological wayside. This latest initiative is staggering for it’s unreasoned nature and ignorance of what currently happens in the world of primary care.
I’ve been in practice for over a decade, and have never worked in a practice where the telephone wasn’t a vital part of communicating with patients. It does, however, have serious shortcomings. I can’t listen to the patients’ chest or check reflexes in the legs. But I can discuss results, plan for follow up, or explain hospital letters or tests. Used well, it can help continuity of care, and promote an ongoing relationship. Often a phone appointment is the most useful and efficient way of seeing a plan through. But I can’t do everything by phone. The very most difficult, rewarding, and essential part of general practice – and what we are trained to do- is to pick up on cues, to notice the unsaid and the almost unseen. It’s about understanding what a person is worried about and why, what symptom they may be almost too uneasy to disclose, what is behind and around what we say and the gestures that we make. This isn’t some kind of bizarre parapsychological nonsense – it’s about listening and responding in a human interaction.
When people consult with doctors, they tend to discuss more than one problem. What and why they are raised is a matter of urgency and trust, and of the space to speak being allowed. I have been a doctor for almost twenty years, and I am still a little nervous when I see my own doctors – I expect that many others do too. We are vulnerable, we want to discuss matters which are important to us, we have questions, and we may be afraid. The issues which are discussed are not simply functionary, but are packed with information which may seem inconsequential, as thin and slight as tissue paper, but are multilayered, explaining and aiding the story not just of this pain, but of where it came from, how it is being dealt with, but where it shall be endured. Some home visits could perhaps be dealt with by telephone, but there are many people – again, often older – who will try their best to minimise their symptoms, and where a visit will explain more about their social circumstances and illness than half a ton of technology ever could. Mental illness is a large portion of GP workload: I would want proof that Skype consultations were not harmful before proceeding.
For in the brave new world of telehealth, with multiple tests results being monitoring, and protocolised healthcare, it would be easy to think that one day your healthcare will be possible without needing to see a doctor or a nurse. Your symptoms or measurements will be fed into a computer which will calculate the tests that need to be done and the actions that are therefore required. This was revealed with NHS Direct, which has been noted to use multiple protocols and produce many vast over reactions to symptoms which appropriately qualified humans have been able to deal with far more nuance and less inappropriate ambulance intervention. Telehealth costs vast sums in terms of equipment, but is hoped – by the government – to eventually reduce staff time in directly caring for patients as well as to reduce hospital admissions. We do not have enough good evidence that this is the case, but policy dictates that we should do it anyway. Yet computers cannot attend to personal hygiene, offer a spoon to the lips, lift a person to the commode. Telehealth will not be able to sit down and have a cup of tea or fetch a pint of milk. There will be no point in wearing a pressed suit for a computer monitor, and there will be no conversation to be made in when we press a button to send our results down the line.
We can already do much healthcare without the patients’ presence in the room, by simple use of the telephone. The people who will gain from bigger technology spends the government plans are the companies who manufacture them, and the politicians who can say they are investing in them. Only some patients will gain. People who were capable and mobile to start with also have lower need of monitoring or consultations, and will paradoxically be more likely to use them. People who find technology difficult, or who are frail, or who need human care more than they need their blood pressure numbers extracted and transmitted down a wire will lose out.
Spending on unproven technology continues despite carers often being paid at minimum wage and with barely enough time to do essential tasks. We need science and technology to help us provide the best care for patients. But we also need humanity. Jeremy Hunt, proceed at your peril.