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Should GPs offer email consultations?

Dr Gurmit Mahay says email consultation will improve access, but Dr Trevor Stammers says the move will leave GPs at greater risk of legal action.

Dr Gurmit Mahay says email consultation will improve access, but Dr Trevor Stammers says the move will leave GPs at greater risk of legal action.


Email consultations will weed out non-urgent cases and increase flexibility of access for patients, says Dr Gurmit Mahay

The job of a GP is unique. It is to search for significant pathology among the vast number of concerns expressed by patients about their health. GPs must sift through all the unvetted raw information, looking for that red-flag symptom or sign that may indicate a medical problem that will not resolve without active medical intervention.

Patients report illness to doctors far more frequently and at an earlier stage than they used to. Access to healthcare is a problem for the public and the health system, and matching supply to demand remains a challenge. The safest way to practise medicine is to see all those patients who want to be seen, but it is also the slowest method and the most wasteful of human resources.

The fastest way to provide access to patients would be to consult with all of them by telephone or email alone. There is a carefully calculated line where safety and expediency meet and GPs must ensure they do not sacrifice the former for the latter.

My experience is that some patients will call to see the doctor after having vomited only once, or having a headache for which they have taken no analgesia. A triage system such as Connecting for Health's new Communicator function could siphon off these minor and self-limiting conditions so they don't block access where there is genuine need.

In my practice we already operate a telephone triage system by medical personnel so patients can get their symptoms checked wherever they are - at home, shopping or even abroad.

But patients need to accept they won't always physically see a GP if their symptoms, in the opinion of the doctor, do not warrant it. The GP in return must offer rapid access to direct face-to-face contact for patients exhibiting alarm symptoms.

A natural extension of this will be electronic consultation, ideally by way of webcam-based consultations that will allow some degree of face-to-face contact.

A natural appendage of that will be email consultations by which patients can post email queries to be answered by medical or even nursing personnel, and also request repeat prescriptions on email.

The downsides of email may include the prospect of a brimming inbox on Monday mornings or lengthy to and fro discussions with nerdy or overanxious patients. But the positive side would be an increase in the volume and flexibility of the contact that patients could have with their GP's team, since it does not have to always be the doctor who deals with all such queries.

Now that we have mobile email devices, access could be maintained outside normal working hours and even abroad, and could potentially be integrated into out-of-hours services so that footfall could be reduced in GP practices, hospital A&E departments and out-of-hours centres.

Patients would not need to wait around for non-urgent consultations and would not need to take time off work - leaving them more time to attend to whatever other matters they wished to deal with.

We can either increase access to a GP ad infinitum, restrict access or channel it into more flexible ways of working. Electronic communication would allow us the possibility to do the last of these.

Dr Gurmit Mahay is medical secretary of Wolverhampton LMC


Escalating our reliance on electronic communication lays us open to legal threats and will reduce face-to-face time with patients, counters Dr Trevor Stammers

Electronic communication has its place for booking appointments and requesting repeat prescriptions, but I am strongly sceptical about using the online system Communicator for GP consultations. It is at worst an inappropriate and, at best, an inadequate, medium for conducting the business of general practice.

As a teacher of general practice, I spend many hours improving medical students' communication skills, training them to pick up both obvious and more subtle clues of body language and facial expression, which tell the truth, even when the patient does not. All of this vital information is inevitably lost in email. Even in telephone consultations, the all-important elements of tone and pace of speech and paralanguage provide important diagnostic information in a way that is either impossible or laboriously slow by email.

Impersonation is, of course, possible by phone but I have never encountered it. By contrast, hoaxes and fraud by internet are daily experiences for most users and email consultations will be no exception, with all the medicolegal implications when GPs fall prey to it. Be prepared for defence subscriptions to rise yet again as claims of breaches of confidentiality rocket.

Confidentiality breaches will not be the only cause of increased claims, however. Email is a notoriously dangerous medium for letting off steam when the presence of a real person would otherwise diminish the likelihood of the doctor (or the patient) saying something they regret.

All of this is concerning enough before we mention the barn-door litigation risks that may come from the unopened email about headache and neck stiffness or the mass-forwarded inquiry about lack of penile stiffness.

Use of Communicator will also further the inequity of access that already exists.

Dr Gillian Braunold, clinical director for the Summary Care Record and Healthspace at the quango that is promoting Communicator, likens it to Facebook. But Facebook's users are largely made up of people in their teens and twenties - one of the age groups least likely to be in need of medical advice.

Most of my elderly and housebound or mentally impaired patients (especially those living in the poorer parts of the practice area) have no internet access, and never will. It is the worried well and hypochondriacs who will flood the inbox with ever more unnecessary work and consequently waste time and money.

How a practising GP could support the introduction of Communicator on the grounds that it will 'free up doctors to see patients face-to-face' completely eludes me. Rather than free us up, it will further clog us up and prevent face-to-face access for those patients who need it.

As it is, I spend hours every day clearing increasingly full email inboxes. As a respondent for an email answer service on sex and relationship issues, I know how demanding and difficult replying online can be. There are plenty of such services already out there for those who want medical email advice.

With every computerised takeover, such as with repeat prescribing, which has been such a helpful service, the computer will also tend to become our master and monitor. Dr Braunold's reported insistence that Communicator's use will be 'voluntary' makes me laugh. In order to stay competitive, once it's introduced, the costly Communicator will be as voluntary as polyclinics or Saturday surgeries.

And that's before PCTs produce incentives to use it. Once we've all volunteered, it will inevitably turn into yet another assessment tool. Minimum numbers to answer per week, maximum allowable response times and numerous other QOF points will ensue. The time we have to see the patients in front of us will proportionately disappear.

Dr Trevor Stammers is a GP and lecturer in healthcare ethics, St Mary's University College, Twickenham, west London

Should GPs offer email consultations to patients?

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