Dr Katie Musgrave on how the rise in remote consultations could harm the patient-doctor relationship and health outcomes
One of my patients died in a tragic accident before Christmas. I had spoken to her on the phone just a few weeks earlier; this week I had a bereavement phone call with her husband.
Despite having had a recent telephone consultation, I didn’t know her. I wouldn’t have recognised her if I walked past her in the street. I am a stranger, akin to a friendly call handler from the bank.
This experience brought to the surface my misgivings about the direction of travel in general practice. What is happening to our relationships? How many of our patients know us? How can they trust us? And how can we reassure them, comfort them, or tend to them in their dying days?
As GP practices have merged and scaled up, many have already suffered a significant loss in continuity and personal relationships. And remote consultations will only exacerbate this trend – with relationships further weakening over time.
In 2020, I remember an experienced partner at my surgery expressing significant doubts about the rapid switch to remote consultations. ‘What’s the issue? We can always switch back,’ I naively thought.
But here we are. GP surgeries feel unable to switch back to face to face as default because they couldn’t cope with the demand. But I could speak to a patient a dozen times about a minor ailment over the phone and it would contribute less to a trusting relationship than one in-person meeting.
As our service has been allowed to become overwhelmed with a steadily increasing demand, GPs have felt powerless to resist the marches of progress. And I worry that we are marching to a place where we no longer know our patients, they don’t trust us, and levels of reconsultation and A&E attendance go through the roof.
A recent analysis of GP consultation trends between 2018 and 2022 has thrown up some troubling findings. Although the rates of consultation have increased overall during this period, the rates of face-to-face appointments remain significantly below previous levels.
Notably, pre-Covid the most deprived 20% had on average 0.36 more face-to-face appointments per year than the least deprived quintile. This difference has halved to a 0.18 difference in appointment numbers per year. Across our population, this will equate to millions of fewer in-person appointments for the most deprived.
Similarly, there has been a fall in the consultation rates in the over-75s and under 4s. Every other age group has seen an overall increase in the total number of appointments (remote and in-person combined). However, the over-75s now consult less often per year than they did pre-Covid; while every age group has seen a fall in the number of face-to-face appointments, the over-75s have seen a very dramatic fall when compared with other age groups (from 9.5 appointments per year to 6.6).
We know that the most deprived patients and the most elderly will, on average, be those with the greatest health needs. If – in response to the changes in consultation delivery – these groups are less able to access in-person GP appointments, then we should expect to see a widening of health inequalities and a consequent fall in overall life expectancy. I’ve written about such concerns for years, but NHS leaders seem determined to bury their heads in the sand.
Alongside these worrying changes, we are simultaneously witnessing a decline in patients’ ability to self-care. The recent strep A debacle saw parents of millions of children being encouraged to contact their GP urgently if they were concerned about their child’s fever, sore throat or rash – in the middle of December! This will of course have contributed to the meltdown we are seeing in hospitals.
If the British public can’t manage simple ailments such as a fever or sore throat, then the health service has a snowball’s chance in hell of surviving. GP time simply must be protected and valued, and we must prioritise our appointments to deal with significant medical problems. It cannot be impossible to design a system that better encourages patients to seek help in the most appropriate places. I don’t blame our patients – we have designed this system, and we have to do better.
Our healthcare system has been allowed to become perverse and deeply dysfunctional. My call list might have an appointment from a worried teenager about a single bruise that has been there for one day, while an 80-year-old with deteriorating heart failure is sat at home unable to get through. When will somebody tackle this? Does no one care?
Sometimes, I think I may as well give up and go into telesales.
Dr Katie Musgrave is a GP in Devon and quality improvement fellow for the South West
I do not feel remote consultations is the problem here, but a helpful partial solution.
Use of telephone and video consults and suchlike can save so much time, which we can then spend in getting to really know our patients, both in the surgery F2F and also in local events, meetings, co-op, post-office, market, cafe, etc
The problem is really two-fold :
1-A reduction in number of GPs
2-An increase in number of patients who need to have medical things done to them, of greater complexity, at increased frequency.
IE there is a lot more work and less staff. We also have to do more non-clinical admin work, audits, CME, etc
Unfortunately, as we continue to become cheaper and more efficient, they expect us to do even more, with even less. This is not sustainable any longer.
Some years ago I was locum in practice which had gone fully telephone “total triage”.
The GPs were happy, the system change had saved them drowning in appt requests…
But as a locum, I didnt know the patients, and found working in isolation much less enjoyable.
In my practice we went “back to normal” in Easter 2021, as soon as allowed. We now have a few extra accurx and telephone appointments, but face to face is the default as before, and I think it works well for us. We also don’t seem to have had the surge in demand reported by many other practices.
I wonder if triage systems actually reduce self care and encourage more trivial requests for advice, along with loss of knowing the patients and their health seeking behaviours?
I will answer in due course, but in the spirit of embracing change I asked Open AI if it could answer in the style of an 18th century Dandy – I thought it did quite well 😆
“I say, old chap, as a physician of some renown,
The topic of virtual consultations doth currently astound.
Gone are the days of in-person visits, tis true,
But I daresay, the change was necessary, there’s nought we could do.
Though some may decry the loss of the patient-doctor bond,
I assure you, the connection is not entirely gone.
We’ve adapted, and found new ways to connect,
To provide care and ease, is what we’ve aimed to effect.
True, it’s not the same as it was in days of old,
But progress marches on, and we must be bold.
So let us not despair, but embrace this change,
For virtual consultations shall help us rearrange
the way we practice medicine, for the betterment of all,
And that, my dear sirs and madams, is the heart of this call.”
Agree with you Katie. According to the Mehrabian communication model 93% of communication is non-verbal and 7% through words (ie we might be missing important stuff over the phone). Also was learning clinical examination at medical school superfluous?
https://worldofwork.io/2019/07/mehrabians-7-38-55-communication-model/
Also with phone consultations half the time is spent asking if they need/want a F2F appt, and also being a receptionist trying to book the F2F appt. What a waste of time. Now the patients are even confused what they need to come in for and think that abdominal pains can be assessed over the phone . The best model is default F2F with phone appointments only if requested by patients
” It cannot be impossible to design a system that better encourages patients to seek help in the most appropriate places. I don’t blame our patients – we have designed this system, and we have to do better.”
Heard of reinventing the wheel, Katie? There’s other systems existing today, and have existed before, that values GP time better than what the state does, it’s called the free market. And you do have to blame the patients, and everyone else. It is called civic responsibility. WE voted for this, maybe not me personally, but society, historically, etc. WE either contributed to the way it is today, or allowed it to become the way it is. And only WE can change it, INCLUDING patients.
Working in community dermatology in Garstang. The GP practice have abandoned all video and telephone consultants except in exceptional cases. Simply too inefficient and encouraged frivolous consultations. Patients apparently much happier. All patients F2F. Must admit I agree.
The f2f consult is the most efficient and safest patient interaction. I don’t understand why some colleagues think phone calls are better. Doctor-triage is also inefficient. By the time you’ve worked out what’s up, you’d have been better seeing the patient f2f. I’m sure there was a study whowingbthatbloweringbthe access inconvenience bar simply stoked demand. F2f demands commitment from the patient. Our “dna” rate for phone calls is 50%.
Christopher Ho – well said