Dr. Martin Scurr, columnist for Good Health, believes that online consultations cannot replace personal appointments
Can online GP appointments replace a personal meeting?
NO, says Dr. Martin Scurr, Good Health columnist:
My 93-year-old neighbor has congestive heart disease and has not seen her doctor in two years.
Recently, she has experienced a worsening of her condition – she is showing signs of heart failure – and I think she needs referral for treatment. She’s too weak and tired too fast to talk on the phone for a long time, so I called the surgery on her behalf.
I was on the phone (“Thank you for your patience. You are in line 10th and your call will be answered as soon as possible”) for 20 minutes, only to hear that I was not authorized to speak on behalf of my neighbor.
Finally, I was able to book a call from a surgery nurse to my neighbor’s house. But when the call came in, I wasn’t there to pick up the phone. The nurse let it ring 15 times and then cut it off.
I had tried to warn them that my neighbor’s condition means that even in her small bungalow, she cannot make calls in less than 20 rings.
There will be millions of people in similar circumstances – people who, like my non-European neighbor, need a medical assessment.
By insisting on an initial assessment by phone or website, the RCGP is effectively excluding millions of people, says Dr. Scurr
But last week, the Royal College of General Practitioners (RCGP) announced that there is a “ compelling case ” to continue the “ total triage ” emergency measure – assessing patients online or by phone before making a decision about whether or not do not book an appointment with a family doctor during surgery.
Total triage was determined during lockdown to minimize the spread of coronavirus. It was never intended to be a permanent change in the way GPs work. It was also never claimed to be a satisfactory substitute for personal consultation.
But the system was judged a success, partly because it reduced the number of appointments GPs have, allowing them to tackle the endless forms, risk assessments and assessments of the modern NHS.
It means that red tape takes precedence over real people.
It also means that many more ‘silent’ illnesses and injuries are missed, especially among the most vulnerable members of society – the elderly, victims of physical and mental abuse, and those on low incomes.
I don’t blame the doctors. Many are under cosh, buried under a bureaucratic workload that should not be their priority.
But it means that people like my neighbor, without access to health care, will now be effectively abandoned.
I think the scheme will cost lives.
Recently I saw a 54-year-old woman complaining of a nagging cough. She had spoken to other doctors twice, but was shy of a good examination.
At first she didn’t want me to look at her chest either; she just wanted a recipe to make the cough go away.
I was able to persuade her to have her checked. She removed her top and then, with real reluctance, her bra – and I saw a peptic ulcer, meaning her tumor had broken through the skin. She wanted me to find the wound, but she couldn’t get around to talking about it. And it’s a good thing I was able to examine her – the cough she called about initially was due to the cancer spreading to her lungs. A telephone consultation would never have discovered her condition.
By insisting on an initial assessment by phone or website, the RCGP is effectively excluding millions of people.
The call for ‘total triage’ to replace one-on-one GP consultations is the latest in a series of deadly blows to what was at best the jewel in the NHS’s crown: the primary care system.
The first blow, which was performed almost secretly under Tony Blair, marked the end of home visits for the elderly by health visitors.
Then came the withdrawal of the 24-hour care – night calls -, followed by the disappearance of your right to treatment by a named GP.
These are all nails in the chest of the first line.
The RCGP has seriously underestimated how few people are willing to speak out loud about their medical concerns. Any obstacle, even as mundane as a phone call, will scare them off. They need personal contact with a professional who can lure them.
The most important moment in a consultation often comes when a patient gets up to go. Indeed, I have lost count of the thousands of times I saw someone hesitating at the door just before leaving and saying, “Actually, Doctor, while I’m here. . . ‘
That’s often when the real medical problems are discovered – when they report a lump, pain, a family crisis, perhaps a bruise that is evidence of beating or sexual assault at home.
And those are the kind of problems that are missed during telephone consultation or via video link.
There is a real risk that Britain’s health care will move to Third World standards, and we will look back on 2020 as the point when the GP system became unusable.
Former President of the Royal College of GPs physician Clare Gerada believes the online consultations could replace a face-to-face meeting
YES, says Dr. Clare Gerada, former President of the Royal College of GPs:
Recently I examined a woman who she feared had a cancer in her breast.
Nothing exceptional – after all, I am a nearly 30-year-old family doctor in a busy operation in central London with nearly 22,000 patients. But this appointment was unusual because it was my first personal consultation in weeks.
Covid-19 has ensured that what would normally take ten years of transformation would take just over ten weeks.
Before the pandemic, about 90 percent of GP consultations were face-to-face; only a small part happened remotely: online via email or via video call or telephone.
But at the height of the pandemic, this reversed and now about 70 percent of the consultations are done remotely.
Therefore, the woman with the nodule – who did not need further investigation – was the first patient I physically examined in weeks.
I can’t see things ever going back to how they were. I don’t think so either, because it gives the GP more time and that can only be good for patients.
Don’t get me wrong, I miss seeing patients in person and enjoying their company.
But remember this: how much time does the average family doctor spend walking into their surgery waiting room, calling their next patient, waiting for the person to respond, and walking back to their doctor’s office?
Then there is the time when the patient – quite reasonably – takes the time to relax and take off his coat. I believe it is days every year. Still, there are better ways to use that time, such as helping patients.
And let’s not forget that before the pandemic, people had to wait on average for more than two weeks for a GP appointment. Thanks to less personal consultation, we can now see you more quickly when you really need it.
In our practice, we initiate most of our appointments online through an electronic consultation, similar to an email.
The patient completes a specially designed questionnaire on our exercise website and answers questions that a GP would normally ask if they were sitting in front of him; the patient explains in his own words what concerns him.
This comes in an online ‘hub’, which we monitor during operations.
If a response generates a red flag – a potential medical emergency – the system instructs the patient to call 111 or 999 or to seek emergency medical advice.
For others, the family doctor decides whether an email answer is appropriate or whether a prescription should be sent to the pharmacist. Or, indeed, if it is necessary to call the patient or suggest that they enter.
It’s not a system that’s for everyone – maybe not for the elderly and those without a computer or smartphone (about 26 percent of people over 75 don’t have one) – and some doctors may be reluctant to use this new way of working.
But don’t just think about time, but how much less embarrassing it is to start a consultation this way for a mental or sexual health problem. It is much less intimidating to fill out a form than writhing in a doctor’s chair.
The system has proven to be safe and effective, but even video calls don’t tell the whole story.
As a general practitioner, you build a picture of a patient from his position, even the time he needs to walk out of the waiting room. And it is difficult to pick up emotions digitally, so we should never lose personal consultation.
But there are plenty of benefits to getting the most out of modern technology.
This change has not only taken place in general practice; surgeons and hospital doctors are increasingly using video calls and say it helps them see more patients.
Before the pandemic, the NHS was notoriously slow to change. But suddenly needs have to. Healthcare will never be the same again.