Practices in England face the clock on online consultations

THE new GP contract in England calls for all practices to offer online consultations to patients by April 2020 and video consultations by April 2021. But what about the risks?

 

IN early 2019, NHS England concluded negotiations on a new contract with the GPC that outlined specific digital improvements for primary care. These include a requirement that all practices offer online consultations to patients by April 2020 and video consultations by April 2021 (subject to available IT infrastructure). This is in line with the NHS Long Term Plan, which aims to provide every patient in England access to digital-first primary care by 2023/24. Online consultations form a key part of achieving that commitment.

Some practices may be caught unawares by this but NHS England has produced a guidance document – Using online consultations in primary care: implementation toolkit. The first half of the guidance is for practices and the second half is aimed at commissioners.

Most GPs will be familiar with the opportunities and challenges presented by telephone consultations, but the use of online systems and video technology are relatively new media for many health professionals and, as such, carry different types of risks compared with traditional face-to-face patient encounters.

Being able to access healthcare in a convenient way from the comfort of home or even the workplace will appeal to many patients. It could be particularly beneficial for patients with conditions that make attending the practice difficult, or in more remote rural settings where a long journey can be avoided. It may also provide patients with the option of seeing a preferred GP sooner than arranging a face-to-face appointment. There is also the public health benefit in terms of avoiding transmission of infectious disease in particular circumstances.

The NHS England implementation toolkit addresses three distinct forms of digital consulting that practices can choose to implement:

  • Questionnaire-based online consultations using a web-based form.
  • Online triage, where the patient enters their symptoms and receives algorithmically-generated advice and/or is directed to the right person or service in real-time.
  • Video conferencing – remote consultations via video technology between a patient and a clinician in real-time.

Each of these modalities comes with particular risks. Questionnaire-based consultations can be dependent on the patient’s ability to express themselves clearly, and patient demographics and other characteristics must be considered. The need for manual triage in assessment also brings the risk of delay in identifying red flags and providing a timely response in busy periods.

Automated tools will only work for problems that have been programmed into the system. The automated forms often take longer to complete and this may deter some patients. Tools can vary in the quality of their questions and patients may not accept self-care/pharmacy advice when delivered by a computer and will fill out the form differently a second time or phone for an appointment. There is also the risk that over-cautious implementation of red flags could increase unnecessary triage to urgent care pathways.

Most online consultation tools also warn patients that they should not be used in emergencies. The implementation toolkit advises that risk may be reduced further by either the tool taking an automated history that picks up red flags (such as chest pain) and instructs the patient to call 111/999, or practices operating on the basis that online consultation requests are triaged promptly (during core hours) to identify and action urgent queries so that symptoms don’t go ignored for long periods.

Online prescribing is another area of risk. GMC guidance advises that before you prescribe for a patient via telephone, video-link or online, you must satisfy yourself that you can make an adequate assessment, establish a dialogue and obtain the patient’s consent. You should prescribe only when you have proper knowledge of the patient’s health and are satisfied that the medicines serve the patient’s needs. More specifically you must consider:

  • limitations of the medium through which you are communicating with the patient
  • the need for physical examination or other assessments
  • whether you have access to the patient’s medical records.

The GMC is currently engaged in a consultation on remote consultations and prescribing by telephone, video-link or online and clinicians are encouraged to offer their views.

Video consultation provision also requires careful consideration in terms of risk. It may be potentially safer than conventional telephone consultations in that the doctor can see who they are talking to, providing better visual cues. However, video consultation will not provide the same level of assurance as a face-to-face consultation, given the limited scope for examination – even with good image quality.

GMC guidance states that "good clinical care must include adequately assessing the patient’s conditions, taking account of the history (including the symptoms, and psychological and social factors), the patient’s views, and where necessary examining the patient".

Patient confidentiality will be an additional area to consider – as the health professional cannot be sure that others are not present but out of sight during the consultation. This of course may be the patient’s choice but a check can be undertaken before the consultation commences.

Practices will also have to be alert to the risk of potential patient coercion, where a patient may come under duress to give someone access to their personal and confidential information during an online or video consultation. Clinicians will have to be prepared to raise and address this with the patient.

Allowances as to suitability of this medium will also be important for patients with limited technology skills, communication difficulties, complex conditions or severe mental health problems. A video consultation would obviously never be an appropriate medium to deliver bad news.

Practical training is obviously important to consider for any practice before digital consultation technology can be used safely and effectively.

In summary, MDDUS advises primary care physicians in England to consider the implementation toolkit and contact their CCG for further advice on both meeting contractual obligations for digital patient consultation and ensuring adequate risk mitigation.

ACTION

  • Ensure there are agreed protocols in place to identify and manage patients and conditions that are appropriate for online consultations.
  • Consider adopting a staged introduction of online consultation services, and monitor effectiveness.
  • Adopt a lower risk threshold when using new and unfamiliar technologies, and be prepared to turn an online encounter into a face-to-face consultation where a fuller assessment or physical examination is indicated.
  • Evaluate any specific training needs that practice staff will require before implementation of a digital consultation service.
  • Contact your CCG for further advice.

OTHER UK DIGITAL HEALTH PLANS

Find out about digital plans in other UK health services:

Alan Frame is a risk adviser at MDDUS

Advice & Support

For advice and support in a potential claim or other matter, please login to your account and complete the contact form.