We are all aware of the increasingly important role of remote consultations in the primary care setting. Telephone and online consultations are becoming more commonplace as time goes by, fuelled, to some extent, by time limitations on the part of both clinicians and the general public, and facilitated by advances in digital technology.

However, with the great benefits that remote consultations afford, come risks, particularly in the out of hours’ primary care setting.

Dr Pierre Campbell, MDU head of underwriting, has explained that there are “unprecedented increases in the costs of claims from general practice overall. However, nowhere is this more apparent than in the provision of emergency unscheduled care”.

In January 2017, The Medical Defence Union (MDU) announced that it had made payments in excess of £30 million to cover compensation and legal costs on behalf of GPs undertaking out of hours and unscheduled care work during a 3-year period. These cases included some individual cases settling for more than a million pounds. The higher indemnity risk of out of hours and unscheduled care work is reflected in higher indemnity costs for GPs, as compared to in hours’ GP work. The MDU, having undertaken a review of MDU claims, highlighted that claims involving medication issues accounted for 9% of cases, including the wrong drug, dose or regimen prescribed, or a failure to appreciate the patient was suffering from known side-effects.1

In March 2017, the CQC advised the public to take care when using online primary care services, saying: “CQC’s inspections of some companies that provide online primary care have found significant concerns about patient safety. Although CQC acknowledges that well-run services can offer a convenient and effective form of treatment, inspectors have found services that were too quick to sell medicines without doing enough to check whether they were appropriate, meaning that patients could be at risk of harm.”2

The four regulatory bodies – the CQC, the GMC, the General Pharmaceutical Council, and the MHRA (Medicines and Healthcare products Regulatory Agency) – have highlighted that providers and healthcare professionals working for these services must deliver safe and effective care, and adhere to professional guidelines.

Their joint statement says: “Technological advances have brought opportunities to deliver healthcare in new ways, including online primary medical services. Potentially, this innovation allows patients easier access to care and treatment when they need it.

“We share a joint commitment to ensure that the same safeguards are in place for patients whether they attend a physical consultation with their GP or seek medical advice and treatment online.

“We will continue to work closely together to share intelligence where we have concerns and take action where necessary to protect patients. We will ensure providers and clinicians are clear on their responsibilities to protect people who use their services and deliver safe, high quality care.”

Professor Steve Field, Chief Inspector of General Practice at the Care Quality Commission, explained: “The growth in online technology presents a real opportunity to improve people’s access to medical advice and treatment. It is important that healthcare services continue to innovate.

           

In March 2017, the CQC advised the public to take care when using online primary care services

“However, in some cases we have found websites which in effect allow people to select their own medication, including medicines restricted as prescription only, with little or limited clinical oversight. Patients can go online, self-diagnose their condition, order their own medicine and obtain a prescription from the online doctor service, with minimal checks on who they say they are and whether the medication is safe or appropriate for them, often within a matter of seconds.

“We know there are often inadequate identity checks, no checks on patient history or suitability, no checks with patients’ GPs, and no follow ups or monitoring.”

Gerald Heddell, Director of Inspection, Enforcement and Standards at the Medicines and Healthcare products Regulatory Agency, said: “Prescription-only medicines are prescription only for a reason and should only be taken under the supervision of a healthcare professional.

“They should only be prescribed following a full assessment as to their suitability for you. A proper consultation with a medical professional is essential to ensure that an appropriate diagnosis of your condition can be made, your medical history can be reviewed, your recovery can be monitored and any adverse reactions can be dealt with.

“Anyone selling medicines to the public via a website must be registered with MHRA and display the common logo on every page of the website offering medicines for sale.”

GMC guidance counsels us to weigh up carefully as to whether a remote consultation is appropriate. The GMC tells doctors: “Effective consultations allow you to establish a dialogue with your patient, and make an adequate assessment of their condition.”

However, remote consultations can be challenging in terms of communication between patient and clinician. It is important to clarify who you are speaking to over the phone, or during an online consultation, and to bear in mind issues of capacity, consent and confidentiality.  

When speaking to a patient’s relative, their friend or a healthcare professional, for example a nurse at a nursing home, it is important to seek to obtain consent from the patient wherever possible, and regardless of the patient’s reported diagnoses, e.g. dementia. This is in accordance with the Mental Capacity Act 2005,3 which states: “A person must be assumed to have capacity unless it is established that he lacks capacity.”

Remote consultations in the GP out of hours setting carry particular risk in terms of patient care and safety, including due to the often limited, or total absence of, access to patients’ medical records, total lack (during telephone consultations), or limited view of non-verbal cues; and the fact that a physical examination cannot be undertaken.

           

GMC guidance counsels us to weigh up carefully as to whether a remote consultation is appropriate

Bearing in mind that there may not be access to the patient’s medical records in the out of hours’ primary care setting, the GP may not have all the necessary information regarding the patient’s past medical history, full drug history (including any OTC medications being taken), allergies, and any contraindications to the medication, despite having sought to obtain this information from the patient, or a third party in the course of the out of hours’ GP consultation. When prescribing remotely by telephone – and when we do not have access to the patient’s medical records – we are unable to obtain physical proof of a medication, having been previously prescribed when a repeat medication is requested, e.g. a recent prescription, or labelled medication box.

In light of the limitations of remote consultations, and in order to mitigate risk, clinician communication skills during the course of remote consultations require empathy, clarity, finely honed listening skills – so as not to miss verbal cues – and attention to the clinician’s tone of voice. A consultation conducted in an unintentionally harsh or brusque tone of voice, despite appropriate content, may nonetheless lead to a patient complaint.

Notwithstanding the limitations and risks of remote consultations, and the potential pitfalls of remote prescribing, Charlie Massey, Chief Executive and Registrar of the GMC, said: “We welcome innovations in medical practice that enable good care for patients, and support the use of remote prescribing that follows our clear prescribing guidance used in consultation with a person in person or online.” (https://www.gmc-uk.org/ethical-guidance/ethical-hub).

                        
           

Dr Sharon Raymond Experienced out of hours GP, GP appraiser and independent trainer

Part 2 of this series will look at the nature and practicalities of prescribing

                         

References

  1. https://www.themdu.com/press-centre/press-releases/mdu-pays-over-30-million-in-compensation-for-gp-out-of-hours-claims (Last accessed May 2018)
  2. https://www.cqc.org.uk/news/releases/care-quality-commission-advises-people-take-care-when-using-online-primary-care (Last accessed May 2018)
  3. http://www.legislation.gov.uk/ukpga/2005/9/section/1 (Last accessed May 2018)
  4. https://www.gmc-uk.org/ethical-guidance/ethical-hub (Last accessed May 2018)