Remote consulting in the coronavirus outbreak

IF Covid-19 has shown us anything in these fast moving and uncertain times, it’s how resilient NHS staff are in the most strained and stressful situations. Patient demand has probably never been higher across the UK and yet – given how quickly coronavirus is spreading – the health service must also contend with the need to reduce the risk of exposure both to staff and patients.

GP practices have little choice but to change the ways in which they normally operate – and one key approach is increased utilisation of online, telephone and video consultations. Many practices have stopped offering routine face-to-face appointments and hospitals will also be exploring greater use of video to consult with patients and manage ongoing care where appropriate to reduce unnecessary close contact.

Government advice is under constant review but MDDUS would like to reassure members about the overall safety of using remote consulting at this challenging time. It is a sensible approach that allows patients access to new or ongoing medical advice while protecting other patients, staff and clinicians from possible exposure to the virus – but healthcare staff must be aware of the risks and take practical steps to mitigate these and avoid patient safety issues.

Each practice will have their own particular approach to remote consultations but here we offer some general advice.

Procedures and technology

• Not all staff will be accustomed to assessing patients over the phone or using remote technology, so it is important to recognise that some will be uncomfortable and inexperienced at conducting these types of consultations. Increased time may need to be allocated to appointments and more training/peer support put in place. If you have a colleague who is already experienced at consulting remotely, you may want to ask for them to support and supervise you.
• Triage and call-back procedures may need to be more structured. Patients requesting a remote consultation should be given a clear timeframe when then can expect to hear back from a healthcare professional and when to re-contact the practice if they are not contacted in this timeframe. This will act as a safety net for any technical issues or potential misunderstandings – for example if the patient’s phone number has been incorrectly recorded. Reception staff can help by making sure contact details are correct and clear information has been obtained and recorded about the reason for their call.
• Ensure that those undertaking remote consultations have clear guidance on pursuing call backs and how many attempts should be made before recording a failed contact. It may be necessary to be more flexible and make further attempts to call back than in normal circumstance.
• Manage remote appointment allocation equitably to ensure that the most assertive patients are not prioritised at the expense of others who may actually have more serious problems. This may require further training of reception staff.
• Be flexible in the choice of technology – if one approach does not work, try another.
• Have procedures in place for patients or others that may not be able to partake in remote consultations, balancing the risks to the patient, staff, healthcare professionals and the wider public.

The consultation

• Remember that the patient’s safety always come first and you must be confident that assessment via remote means will be adequate. Establish quickly whether the patient may need further review or examination and direct them to the most appropriate service if the practice is not the right place for them to attend.
• Stay up to date with local health service arrangements and processes to be able to advise and signpost your patients.
• Remote consultations may be held with the patient or someone making contact on behalf of the patient. Establish the identity of the patient and/or their representative, confirm patient consent where necessary and ensure that adequate measures are in place to maintain confidentiality. Telephone consultations can make this difficult so ask basic questions to check identity and record that you have done so. Ensure there is no risk of being overheard in a patient consultation, especially if you are working outside of your usual work surroundings.
• Check that it is understood why a remote consultation is necessary in view of the current circumstances and that arrangements can be made for a face-to-face assessment if indicated. Where there may be doubt, check that the patient has capacity to understand the advice you are providing and make decisions. Where they do not, ensure decisions are made in the best interests of the patient where there is no person with legal authority to make decisions on behalf of a patient. Allow sufficient time in remote consultations to listen carefully to the information provided and to ensure that the individual you are consulting with is clear on what you are advising.
• Be aware of the increased importance of “para-verbal communication”, i.e. tone and nuance of voice and body language (in video consultations). Being unable to see or examine a patient is an obvious disadvantage and may require additional time for an individual to “open up” more fully on the presenting complaint. If in doubt, bring them in but only if it is appropriate to do so.
• Prescribing can be particularly difficult in remote consultations. Checking understanding of dosage, contraindications and other issues can be slightly more problematic. Again, adequate time is important to ensure safe compliance. Remember, telephone consultations can take just as long, if not longer, than face-to-face consultations – particularly for patients who may have more complex conditions and for whom a remote consultation may have usually been avoided.
• Record in the patient notes that due to coronavirus restrictions the appointment has been via remote consultation. Make an adequate record of information relayed to the patient or carer, including specifics on medications prescribed and safety netting advice (red flags relevant to that patient). Record also if you have signposted the patient to another service or clinician. Where a decision has been made that the patient does not require a face to face assessment ensure that the medical records make it evident that this is an appropriate approach.
• New patients can present a particular challenge if you don’t have access to their medical records. Should you feel unable to adequately or safely assess and manage a patient you should recommend an alternative route for medical assistance and record that advice.
• Patients may contact the practice from outside the country, especially now with restricted travel. It is important to remember that your indemnity may only cover you for patients you consult within the UK. When consulting remotely with a patient outside of the UK, it is important to explain to them that for their own safety they should seek advice and assistance from local medical services. They should be assessed and treated by a clinician locally, who can offer a face-to-face assessment or prescription, if needed.
• Be sure to restate the agreed position and any required actions to the patient at the conclusion of the consultation as this may be your last chance to ask for clarification and pick up something important (in case you have been “barking up the wrong tree”). It will also better conclude the consultation for the patient who should be more reassured.  

Departing from established procedures

The GMC has published recent guidance, including specific advice on adapting practice to cope with patient demand during the coronavirus outbreak. They understand that special measures may need to be taken to protect your patients and yourself. They say:

“It is likely that as the situation develops, some doctors will need to depart from established procedures to care for patients.”

They also address patients within their guidance to prepare them for changes in normal practice:

“Doctors, and the whole healthcare team, may be under considerable pressure at the moment. The impact of coronavirus means they might need to deliver care in different ways.”

Ongoing communication with patients is key in order to reduce uncertainty or resistance to these temporary measures. Significant business announcements, such as changing all appointments to telephone triage only, should be shared promptly, for example via your practice website, organisational social media channels or through your text messaging service.

Summary points in remote consultations

• Maintain patient confidentiality in your own workspace at all times. Ensure you are confident the person on the other side of the phone is who they say they are and that it is appropriate to speak with them if they are not the patient.
• Take more time to establish the needs of the patient and to be clear they understand the advice you are providing.
• Keep adequate records of all information given to the patient, including any medication prescribed and safety netting advice.
• Consult GMC guidance on Good Medical Practice and follow this as much as is possible, given the circumstances.

Other useful guidance

• GMC: Remote consultations
• GMC: Good practice in prescribing and managing medicines and devices (2013) which includes a section on remote prescribing
• GMC: Coronavirus information and advice - Our guidance for doctors

Alan Frame is a risk adviser at MDDUS