Christmas parties are once again on the calendar, but while some aspects of daily life are returning to pre-pandemic routines, others seem to have changed forever, not least GP consultations.
According to figures from NHS England, 29.1% of appointments in October were conducted remotely.
This is a dramatic decline from May 2020, when Covid meant that 48% of consultations were remote. Yet the proportion remains higher than in February 2020 – shortly before the pandemic hit the UK – when the figure was just 14%.
That remote consultations should now be more common is not a surprise. For many patients, a phone or video call is welcome, removing the need for an inconvenient trip to the GP, while overstretched GP practices can also benefit from the flexibility.
But as a recent paper has highlighted, on rare occasions remote consultations can go badly wrong.
Writing in BMJ Quality & Safety, a team of researchers identified 95 safety incidents related to remote appointments. They trawled complaints, settled indemnity claims and reports for England and Wales. While much of the data relates to 2020 onwards, some stretches back to 2015.
While details of specific cases have been changed to preserve the anonymity of those involved, the incidents described are shocking.
Among them, was one where a receptionist was so distracted by another patient that they forgot to ask a GP to give a call back to an elderly woman with breathlessness. The patient later died. In another case, a teenager with sepsis – which later proved fatal – was misdiagnosed as having glandular fever. Other lightly edited accounts include cases of cancer being missed and patients not realising – or perhaps not feeling able to say – that their case was an emergency.
Tragic incidents such as these might suggest that remote consultations are a poor choice, but experts say that would be a mistake.
For one thing, the type of events identified by the study appear to be rare.
Jeremy Dale, a professor of primary care at the University of Warwick, who was not involved in the work, acknowledged that some incidents would not have been captured in the data. Nonetheless, he noted that fewer than 100 incidents were identified out of hundreds of millions of remote appointments.
“[The study] seems to demonstrate, in terms of the number of very serious events identified from national data sources, that remote consultation is extraordinarily safe,” he said.
Second, experts stress that doctors are not infallible, even with face-to-face appointments.
“General practice is all about managing risk. It’s impossible to manage that risk down to zero because there’s always going to be uncertainty,” said Dale. A patient could present with minor symptoms that might then develop over a day into something much more serious, he said.
Trish Greenhalgh, a professor of primary health care at the University of Oxford and a co-author of the study, said that important signs could be missed even with an in-person consultation.
“The idea that face-to-face is always safe – it’s only safe if you’ve got a competent person,” she said.
It is also unclear whether the number or type of safety incidents linked to remote appointments has changed over time, and it is not easy to directly compare their safety with that of in-person appointments.
Yet despite the caveats, the research offers important insights. Chief among them are the difficulties facing GP surgeries, including staff shortages and high demand, and the challenges of remote consultations, which can include communication problems, a lack of rapport, inappropriate clinical pathways being followed, and insufficient information being asked for, available or provided.
“I think a lot of the challenge we’ve had about remote consultations is we haven’t known how to apply them well,” said Dr Rebecca Payne, the first author of the study. “We’ve had to employ them indiscriminately, particularly in the early stages of pandemic, because we had no safe way to provide care to patients without it. But now we’re starting to get that detail on where and when they’re helpful and when they aren’t.”
Based on the findings, the paper offers suggestions as to which symptoms, scenarios or demographics would be better suited to in-person assessments.
Greenhalgh said there were some rules of thumb. “Elderly people with multiple health problems, babies, people who can’t communicate over the phone – that’s a no-brainer. They’ve just got to come in,” she said. On the other hand, blood test results could easily be given over the phone, particularly if they were good news.
But flexibility is crucial: as Dale noted, some elderly patients who struggle to travel may prefer a remote consultation, while Greenhalgh said doctors must be able to follow their hunches.
“Once you start putting [rules] down rigidly, particularly inexperienced staff will then follow them to the letter,” she said.
The team stressed the need for patients and healthcare staff to be given better advice on how to get the most out of remote appointments. For example, patients could be asked in advance to consider how they will describe their symptoms before the appointment, think about whether an in-person appointment is needed, and mention if they have other medical conditions.
There is more research to be done, and more data is needed. Azeem Majeed, a professor of primary care at Imperial College London, said the NHS should collect information on the safety and quality of remote consultations.
But while remote appointments bring specific challenges that must be addressed, some are not new.
Dale said: “What the paper illustrates is the importance of careful, thorough assessment, skilled communication, [and] providing appropriate safety netting so that the patient knows what to do if their symptoms are worsening, and has confidence to know when to seek further care.
“[That] is the basis of general practice consultation, whether it’s taking place face-to- face, over the phone or by video or online.”
