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RCGP chair defends remote GP consultations amid coroner patient deaths concerns


coroner remote consultations


The chair of the RCGP has defended GPs’ use of remote consultations during the pandemic, after a coroner’s report raised concerns over patient deaths.

According to a report from the senior coroner for Greater Manchester, widely covered in the media yesterday, seeing a GP face to face may have prevented five separate deaths.

The patients, who all received telephone GP consultations, might have received correct treatment more quickly if they had been examined in person, the coroner’s report had suggested.

But RCGP chair Professor Martin Marshall argued that the real issue in general practice is ‘not about face-to-face versus remote consultations, but about chronic GP shortages caused by more than a decade of under-investment’.

One patient highlighted in the coroner’s report, Maurice Leech, died in April 2020 after fracturing his femur. He was admitted to hospital after a fall, but the hospital did not carry out an X-ray of his femur and he was discharged. 

After still being in pain, Mr Leech was assessed by a GP over the phone. When the hospital finally found the fracture, he was no longer fit for surgery and died within two weeks. 

The coroner Alison Mutch found that a face-to-face GP appointment ‘would probably have resulted in Mr Leech being referred back to hospital at an earlier stage’, which may have prevented his death.

Another patient, Brian Mottram, died from Covid-19 pneumonitis in November 2020. After a phone consultation with his GP, he was prescribed antibiotics. He was found unconscious two days later.

Ms Mutch’s report deemed that a ‘face-to-face appointment and testing in such a scenario may well have led to identification of Covid-19 and different treatment’.

In two of the other cases, the coroner ruled that patients had not been able to effectively communicate the extent of their mental health issues, including anxiety and depression, in remote consultations.

But the RCGP’s Professor Marshall said media coverage of the coroner’s report was ‘contributing to a worrying narrative that has been gradually building up over the course of the pandemic: that remote consultations are substandard, harmful to patients and are being used by “lazy” GPs as an excuse for not seeing patents face to face in the surgery’.

He said: ‘As well as being inaccurate and untrue, this narrative in itself is harmful as it undermines public trust and confidence in remote consultations when thousands of patients are being assessed effectively and safely in this way in general practice every day – and have been since long before the pandemic. 

‘Patients are being led to believe that they haven’t had a “real” consultation unless they’ve seen their doctor in person and this can leave them feeling “fobbed off” or cause them unnecessary worry and distress that they haven’t been properly diagnosed.’

According to Professor Marshall, remote care ‘is not substandard, and GPs work incredibly hard to deliver the same high-quality, care for their patients, whether a consultation is remote or face to face’.

‘Another misconception is that remote consultations take less GP time, when many actually take longer.

‘The move to mainly remote consultations from the start of the pandemic was in line with government guidelines. It was necessary for infection control and to keep patients – and GP teams – as safe as possible. Face to face appointments and physical examinations have continued throughout, wherever clinically appropriate and safe to do so,’ he said.

‘Crucially, remote consultations have enabled GPs to carry on working, providing care and essential services to millions of patients at a time when other parts of the NHS had to shut down, and when many patients were reluctant to use the NHS for fear of catching the virus.’

Professor Marshall added that the ‘unexpected death of any patient receiving NHS care is always shocking and while we cannot comment on individual cases, our condolences go to anyone who has lost a loved one during the pandemic’.

It comes as a recent Pulse survey revealed that 50% of GPs say that a return to pre-pandemic numbers of face-to-face appointments would not be possible, and around 80% say that it is not necessary.

The survey also found that the majority of GPs – 57% – say that the flexibility afforded by doing remote consultations has benefited care overall.

However, some GPs expressed concern that remote consultations may be missing some diagnoses.

NHS Digital data for June shows that just over 15 million patients were seen face-to-face while 10.6 million had telephone appointments. 

There were also 161,689 home visits and 109,412 online consultations in June.

In March 2020, NHS England mandated a move to ‘total triage’ and, where possible, to remote instead of face-to-face consultations.

But in May 2021, NHS England issued guidance to practices which said GP patients must now be offered face-to-face appointments if that is their preference.

This led to widespread GP-bashing in the media, and headlines such as ‘GPs warned they must see patients face to face’ (The Daily Telegraph) and ‘GPs are ordered to see patients face-to-face amid fears vulnerable people are “having difficulty accessing doctors” during the pandemic’ (Mail Online).

READERS' COMMENTS [11]

Patrufini Duffy 10 September, 2021 5:44 pm

Whatever you do, it’ll never be good enough. You do your best, the patient and family don’t do the sensible thing, and everyone short changes your job in the gutter. That is a sad work environment to be in.

Slobber Dog 10 September, 2021 5:59 pm

The first case is an example of hospital negligence and the second should have been Covid tested and assessed at a hot site. Not sure if their GPs should be in the cross hairs for either.

Dr N 10 September, 2021 10:06 pm

FFS

Decorum Est 11 September, 2021 11:16 am

Put a sensible economic charge on a service and it will be provided. But patients and the government want quality services at a massive discount. Market Forces will eventually prevail!

David jenkins 11 September, 2021 11:28 am

the problem is – they want to pay a nickel for a dollar song !
melanie

C Ovid 11 September, 2021 1:51 pm

Whatever the circumstances (and I agree a missed #NOF, which we take on trust from DGH assmt is not our fault), it will come down to one thing: we are running out of GPs and unless people start being nice to us, there won’t be anyone left. I always felt that the BMA were more concerned about their gongs than those who fund their paycheques: a bit too quick to punch down and not up.
NHS primary care can become a totally ANP/ECP led service as far as I care. Those who really want a GP will find us, probably via continental blue chip insurers (no, NOT the Yanks) employer-based and self-pay schemes.
Why don’t we just tell them to get lost?

C Ovid 11 September, 2021 2:22 pm

.. and no, the NHS did not pay for my training. They worked me hard in the late 80s at 100h/week and £1.50 /h after hours (remember UMTs?). I don’t owe them a farthing in gratitude or money. My brother worked as a welder from aged 16y and his lifetime earnings at 38h/week are just ahead of mine at age 58y! Dreadful. I sound really negative but there is an institutional and institutionalised weakness in the medical profession which does us a great, collective disservice. Ultimately, it undermines patient care as a result.

Turn out The Lights 11 September, 2021 2:53 pm

Agreed C Ovid

Samir Shah 12 September, 2021 1:44 pm

Hopefully the coroner had enough sense to say that the fault lies with the hospital with not doing an xray.
Remote consultations are not convenient, time saving or a better way of practice ( in my opinion) . But a necessary tool to keep the population as safe as possible under the circumstances.

Samir Shah 12 September, 2021 1:45 pm

…. For clarification, I meant that it’s not convenient for GPs ( it can be for patients)

Vinci Ho 13 September, 2021 6:04 am

Interesting arguments.
I think there is certainly about the right decision , hence, policy, appropriate to the circumstances at one time during this tortuous journey of last 18 months :
(1) The timing of the two deaths mentioned in the article is essential; April and November 2020 . Am I right to say the global situation was substantially different those times as compared to present time ?
This is in the context of firstly , Covid vaccination was only commenced from late December 2020 and secondly , Covid 19 remained deadly with high mortalities before Covid vaccination was proven effective later in 2021.
(2) Hence , the purposes of remote consultation at those times ( should we call it pre-vaccination period?) essentially include minimising physical contacts to an extent that GP surgeries would not become a public health hazard in the community . The whole country was also going through multiple lockdowns and restrictions .It is pertinent to point out that GPs were still seeing patients face to face but understandably on highly selective basis .
(3) Moving to present day , I agree that the circumstance is different to take on different approach. The incidence of Covid 19 remains very high but with much less fatalities. Indeed , the overall number of face to face consultation has already been increasing.
However , it will be unreasonable to compare this current situation with the old ‘normal’ before there is any Covid 19 infection simply because significant proportion of the population with lesser immunity i.e. extremely vulnerable, still need to be protected in healthcare settings , as breakthrough infection in double-vaccinated subjects have become very common . A controlled fashion in providing GP appointments in a hybrid model mixing up remote and face to face consultations become necessary.
Clearly , one would expect independent consideration of all these points by the justice system before judging medico-legal accountabilities in individual cases .