The publication of the new standard operating procedure for GPs has not been without controversy. The NHS England document states that patient preference for either face-to-face or remote care, should usually be respected. However, it also sets out that a blended approach to online and in person consultations, according to what is clinically appropriate, will continue. This may include remote triage and virtual consultations.
In an MDU survey of almost 200 GPs, three quarters said they would continue with remote consultations and triage. The MDU has issued advice on avoiding risks from remote consultations previously and the RCGP also has guidance on ‘Remote versus face to face consultations: which to use and when?’
In the meantime, it’s important to share lessons from the types of issues that can arise with a virtual consultation so that risks can be managed. The following anonymised cases are based on those raised by MDU members.
Clues to domestic abuse
A 25-year-old woman contacted the practice complaining of poor sleep and requesting a phone consultation with a GP. The GP noted from the recent records that the patient had anxiety and depression and periods of poor sleep which seemed to be resolved by taking diazepam for a couple of nights. The GP felt a video consultation was more appropriate in order to make an assessment. The patient reluctantly agreed to this.
During the consultation the patient described some stressors at work although she seemed distracted and hesitant. At the back of his mind, the GP felt the consultation was a little strange – the patient seemed uncomfortable and was sitting far away from camera and the room wasn’t well lit. He prescribed a short course of diazepam and arranged to ring back in a couple of days.
The GP was contacted by the police the next day. The patient had been the victim of domestic violence, had been sexually assaulted and badly beaten by her partner and possibly other men. A number of drugs had been found in her system, including diazepam. She was found to have old bruising on her face and arms.
The GP checked the records and found a historic reference to domestic abuse and social services input which he hadn’t noticed before. When reflecting on the consultation, he realised there were clues to suggest she was in difficulty and he felt it was possible that her partner may have been in the room with her.
With hindsight, the GP felt he perhaps should have offered a face-to-face appointment. This would have been an opportunity to assess her social situation and ensure that there was no coercion involved.
With a remote consultation it may not be easy to obtain all the relevant information from the patient emphasising the need to thoroughly check the patient’s records and, where appropriate, flag the records of patients who may be vulnerable.
Missed diagnosis of brain tumour
A 49-year-old patient rang the practice for an appointment due to an increase in frequency of migraines and visual symptoms which affected his ability to work. His usual analgesia wasn’t working.
During a phone consultation the GP took a history of the pain and associated features noting that the pain seemed to last longer than before, tended to be one sided but also affected the neck area. The patient described experiencing visual aura more often than was usual with flashing lights, zig zags and possibly blind spots. He didn’t describe any other neurological symptoms. The GP suggested prophylactic medication.
The patient contacted the practice on five more occasions over the next two months, speaking to a different clinician each time, including two locum doctors and an advanced nurse practitioner.
Each one reviewed the records and noted the past history of migraine and the decision to start prophylactic medication. The patient was reassured and advised to continue with the medication, take pain killers when necessary and to contact the practice again if symptoms didn’t improve. No other safety netting advice was given.
Two days after the last appointment the patient suffered a fit and was taken by ambulance to hospital. He was found to have a right homonymous hemianopia and some right hemiparesis and brain imaging revealed a tumour.
On reviewing the care at a practice significant event meeting the clinicians felt that they had been influenced by the patient’s past history of migraine and the diagnoses of ongoing migraine.
They agreed that the patient should have been seen face-to-face. This would have allowed a full neurological assessment and examination of visual fields. The clinicians felt it was likely that a serious pathology would have been picked up sooner had this happened.
While video or phone consultations can be more convenient for both the doctor and patient, it is important to consider carefully whether enough information can be gained this way.
As these cases illustrate, it can be the case that social or emotional concerns or particular signs are missed. It’s important to have a low threshold for a face-to-face consultation if patients contact the practice on a number of occasions complaining of the same symptoms or if the patient is known to be vulnerable.
- The MDU’s website has further information on medico-legal aspects of remote consultations including a video in which GPs explore the skills needed for video consultations.