Will undertaking online consultations affect a GP’s indemnity arrangements?
If you are conducting online consultations with NHS patients in your practice and you have access to the patient notes then this should not affect your current indemnity arrangements. However you may need to discuss some aspects of this work with your provider.
The MDU asks its members to inform it if they will be conducting online consultations with patients under the age of 16. The MDDUS requires its members to provide information about the platform they are using to conduct the consultations.
You should also inform your provider if you are undertaking online consultations for a private provider or if the patient is paying a fee. In such cases your provider will generally require further information about the work you are doing and it may affect the cost of your indemnity.
The MDU says: ‘GPs undertaking online consultations with their own patients can include this work within their standard GP indemnity. We do not currently expect members to tell us if they are undertaking this work provided they are not using online consultation for patients under the age of 16 and that the work is being carried out by GPs.’
The MDDUS says its members will not be expected to pay more for indemnity if the online consultations are being conducted ‘for NHS patients and providing both the GP and patient are within the UK at time of consultation and GPs have access to patients’ NHS GP records’. However, additional subscriptions would apply for MDDUS members who are consulting with private or fee paying patients online.
Medical Protection says that members who ‘use telemedicine as part of their practice for their registered patients within the UK would not specifically need to inform us they were doing so - subject to them following all relevant legal and regulatory guidance such as GMC and CQC requirements in the UK and any guidance issued by Medical Protection. The use of telemedicine for registered patients in general practice would have no impact on the member’s subscription rates.’
Is there anything else that GPs need to tell their MDO if they are undertaking online consultations?
The MDU and the MDDUS both expect GP partners to inform them if any staff other than GPs, including nurses, are providing online consultations. This may or may not have an impact on the cost of your indemnity depending on the situation, but the MDU and MDDUS say that they need this information in order to assess your level of cover.
If you are concerned about any aspect of providing online consultations and your indemnity arrangements, speak to your MDO to make sure you have appropriate cover.
What are some of the medico-legal risks associated with online consultations?
The medico-legal risks around online consultations are mainly linked to your ability to examine the patient, ensuring consent and patient confidentiality.
‘There are advantages to remote consultations with greater access to care and reduced waiting times,’ says Dr Pallavi Bradshaw, senior medicolegal adviser at Medical Protection. ‘There are however, inherent limitations with remote consultations such as difficulties in spotting non-verbal clues and inability to examine the patient. Triage is therefore important to ensure the appropriateness of a virtual consultation.
‘The quality of the link is dependent on equipment and internet connections of both users. If it becomes apparent that a face-to-face consultation is required for whatever reason this should be arranged within an appropriate time frame.'
What advice do the MDOs give to GPs undertaking online consultations?
Dr Sharmala Moodley, MDU deputy head of underwriting, says that GPs should warn patients about the limitations of clinical assessments by remote consultation and also of any security risks associated with conducting the consultation over the internet before starting a consultation.
‘It is important to make an assessment of the patient’s capacity to make decisions about any treatment proposed,’ she explains.
‘You must ensure you carry out the consultation in an environment where you can maintain patient confidentiality. Just as with face-to-face consultations, careful contemporaneous notes should be made of the discussion with the patient, any assessment and management plan. Even with the best will in the world, technology does go wrong and doctors must ensure that they have plans in place for a patient’s treatment if the system fails.’
Dr Bradshaw adds: ‘The consultation should be documented fully in the patient’s records and if still images or any part of the consultation is to be recorded then patient consent should be sought and care taken as to how and where they are stored. It is important to follow GMC guidance, be satisfied that a face-to-face consultation is not necessary and ensure that appropriate safety netting and follow-ups are arranged.
‘Itt is important to consider the security of virtual consultations, and it may be wise to seek specialist advice to ensure that the system used is fit for purpose and meets information governance requirements. GPs should develop practice protocols to minimise these risks and ensure there is the ability to arrange face-to-face consultations and urgent consultations in the practice when necessary.’
MDDUS medical adviser Dr Naeem Nazem offers the following advice: ‘Practices allowing the use of online resources to enable patients to access information about symptoms, treatment and self-help options, should ensure that:
- whoever is managing and monitoring the system is suitably trained
- measures are in place for identifying the patient and protecting confidential information
- access to relevant healthcare records is available
- the system is used for the purpose of triaging patients, with face-to-face consultations required for complex issues
- the system links to the practice medical records so that the GP can see if the patient attending for a consultation has sought online support
- a safety netting system is in place to ensure patients with serious conditions are directed to seek urgent medical attention
- any patient accessing the system is based in the UK - if the patient is abroad the doctor needs to be indemnified and registered to work in that country
- any online resources should act as a source for educating patients so that they can, for example, realise in which circumstances they need to see a GP.'