Shift away from face-to-face GP care after pandemic could be dangerous, warns RCGP chair

Face-to-face consultations are likely to be permanently reduced after the COVID-19 pandemic - but the change must not be allowed to erode the GP-patient relationship, the RCGP chair has warned.

RCGP chair Professor Martin Marshall (Photo: Pete Hill)
RCGP chair Professor Martin Marshall (Photo: Pete Hill)

Before the pandemic, the proportion of GP consultations delivered face-to-face was around 80% according to figures from NHS Digital, with most of the rest carried out by telephone.

The latest figures from the RCGP's surveillance programme show that just a quarter of consultations are now face-to-face - although RCGP chair Professor Martin Marshall says that in his experience 'it's even less than that'.

Face-to-face appointments will increase as the pandemic declines, he says, but probably not to pre-coronavirus levels. When the profession reaches a 'steady state', perhaps '50% of consultations need to be face-to-face and 50% can be done remotely', he predicts.

Face-to-face appointments

He admits this vision of a 50-50 split is no more than a guess, but warns that any permanent shift must be handled with caution to avoid undermining relationships and trust between GPs and patients that are built on face-to-face contact - and which are 'the heart of general practice'.

The east London GP says that along with the shift to near 100% triage of patient contacts, the move from face-to-face to remote consultations has been the 'biggest change we have seen in general practice'.

'It is a masssive change, and one that general practice has dealt with very well at the same time as keeping the non-COVID-19 service running - so I think it’s a remarkable achievement,' he told GPonline.

An increase in remote consultations is likely to stick because it is 'a direction of travel I think a lot of people thought was desirable and probably necessary', Professor Marshall says. But he adds: 'More for reasons of patient convenience than for reasons of efficiency or practice-based reasons, because I don’t think telephone or online consultations if done properly are any quicker.'

GP-patient relationship

Remote consultations, he argues 'are really good for transactional problems' - patients needing repeat prescriptions, advice on managing viral symptoms or antibiotics for a chest infection.

'But the most important part of general practice requires relationships, and it is more difficult to develop relationships remotely than when you are face-to-face,' he says.

'It is possible to have conversations and develop relationships on video, but you miss out on that kind of sixth sense, the non-verbal communications that are much easier when you are sitting with someone, you can see the whole person in the room.'

The RCGP chair says the significance of problems that can be picked up in facec-to-face consultations is 'massive'.

'Where I work in east London we have a lot of domestic abuse,' he says. 'It is not at all uncommon for women to present with recurrent sore throats. If they are seen by another member of the primary care team or a GP in a hurry, or seen digitally, it is very likely you will treat that sore throat as a simple straightforward problem and that will be it.

Trust

'It can take some time for the individual to build up the confidence in you - the sense of trust that you are there for them and to open up about being abused and then you can deal with the problem at hand. That’s really important.'

Losing the ability to 'lay on hands' through the erosion of face-to-face appointments could also be damaging, he warns. 'While examination is less important than it used to be it is still an important part of general practice - both in terms of making an accurate diagnosis and in terms of symbolism - that demonstration that you care, the rather traditional laying on of hands is really important.'

The RCGP chair tells a story about a patient - a keen runner - who came in to see him after online diagnostic tools failed to offer a satisfactory diagnosis for pain in his lower legs. After agreeing the patient probably had shin splints, Professor Marshall asked: 'Is there something else you're worried about?'

The patient then revealed that a friend had died recently from a rare bone tumour - admitting he 'knew it was irrational', but was worried he may have the same problem.

Professor Marshall says: 'I was able to examine him - laying on of hands - I was able to reassure him without the need to do any X-rays or scans because the chances of it being something dangerous were just about zero, and he went out happy in a way that he didn’t after the online consultations.'

The RCGP chair says any changes in future must 'have a sensitivity to the importance of face-to-face contact'. He explains: 'It is particularly important in general practice, in which the relationships we build with our patients are a fundamental part of our effectiveness - so to lose that I think would be really dangerous.

'There is something about that ability, that trust, ability to communicate that sense that you care, that you can convey face-to-face with someone you know and have a trusting relationship with that is really important.

'If we lose that in general practice, we have lost the heart of general practice, it seems to me.'

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