What is it that doctors actually do? The answer is not obvious and I say that as a physician who has spent the past 30 years in hospitals. But the question matters. Which tasks can be done better or more cheaply by nurses, paramedics or AI depends upon it. So, too, does the government’s push to create NHS Online.
Trailed last September in Sir Keir Starmer’s speech at the Labour conference, the service is due to open in 2027. ‘The NHS’s new online hospital will see a huge shift in the way we deliver care,’ said Stella Vig, clinical director for elective care at NHS England. What she doesn’t say – what nobody says – is how anyone could know such a shift will be an improvement.
NHS Online will provide 8.5 million virtual appointments in its first three years; officials have been keen to point out this is four times as many clinic appointments as the average NHS trust. The initial focus will be on a range of common conditions: women’s health, eye problems, anaemia and others.
To practise medicine without walking the wards would be fraud
This week, the NHS published a survey showing the opportunity to work flexibly – to see patients without needing to be in the same room as them – was popular with doctors. Two-thirds expressed interest in working for NHS Online, with the ability to work from home being a commonly cited advantage.
On screen, medicine is all diagnosis, but diagnosis is far from the core of the job. As young A&E juniors, in quiet shifts, we played a game of making diagnoses as we watched patients arrive. Usually, we were right. The point is that although diagnosis can occasionally be fiendish, more often it is routine. Pattern recognition is everything and diagnostic insight occupies a tiny part of what doctors do.
Nor is following guidelines in situations where care is delivered algorithmically at the core of what doctors do. We’re not even any good at it. We get bored too easily. Nurses are consistently better, and many nurse-led services involve precisely this sort of thoroughness, with doctors on hand for the occasional case that doesn’t fit the flowchart.
Doctors are the high priests of hospital cathedrals. ‘Cure sometimes, treat often, comfort always.’ To take ultimate responsibility, to contain anxiety and absorb fear, to make difficult decisions, and to breach protocols or break rules when necessary: these are among the duties of doctors. Sometimes the most useful contribution I make is to reassure everyone that there is no need to panic, and what is going on in front of them is merely death.
On ward rounds my main job is to be benevolent, encouraging and mildly threatening. To get a smile from patients who wish to smile, to applaud juniors who have done well and buy them coffee, to highlight error and raise an arch eyebrow at omissions: this is my work. Most of the technical knowledge I bring to bear is used in the pursuit of parsimony.
The most desirable quantity of medical care to receive in life is as little as possible. Will NHS Online encourage that restraint? We train juniors to only do tests that will alter care and only intrude when they are likely to do more good than harm. We also train them in one of the great lessons of medical history: assume new interventions are harmful until good evidence proves otherwise.
The NHS was once efficient; our outcomes were good, our spend as a percentage of GDP was low. Now we are inefficient and our outcomes are poor. Any intervention that makes the NHS better is to be welcomed, but recent years show our proven ability to make it worse. NHS Online would require interoperability between different hospital and GP systems which is currently inconceivable.
How much easier it is to look at a screen in one’s own home than to have to face patients. But which is better? Reports on the latest NHS England survey celebrate the 60 per cent of doctors who like the idea of working online; I was more struck by the 40 per cent who do not. I have a colleague whose health confines them to working from home. They feel impoverished; their work feels like a grotesque shadow of what it should be. I, too, can access all the notes and records and live observations from home – but to practise medicine without walking the wards would be fraud.
We are trained to recognise that new interventions cannot be judged by good intentions or optimistic theory. They need to be properly tested. NHS Online is a novel intervention and deserves the same treatment. Perhaps much of what doctors do can be delivered online. Perhaps it can be done by doctors 500 miles away or by software that never asks for a salary. These questions are worth asking, but only if they’re asked properly.
My prognosis is that there will be no such effort. NHS Online will be brought in with the maximum of political fanfare and such a muddle of measurement that no one will ever be sure whether it is effective or efficient or merely a good headline for politicians and worryingly comfortable for doctors.
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