Study highlights safety risks of remote GP consultations

While most remote GP consultations are safe, the Remote by Default study finds that GP consultations conducted remotely carry more risk for patients with some urgent conditions including new chest or abdominal pain, palliative care, physical injuries or diabetes. Safety risks include missed or inaccurate diagnoses, under-estimation of severity, delayed referral and treatment and inadequate follow-up.

The study recommends that general practice staff strongly consider a face-to-face consultation for patients who have had an initial remote consultation who are not improving, and patients with pre-existing complex illness. It also recommends that practices have protocols in place for clinical and nonclinical members of staff to ensure staff can escalate a patient’s care when needed.

The study, published in BMJ Quality and Safety, was conducted by Professor Trish Greenhalgh, Dr. Rebecca Payne and a research team from the Universities of Oxford and Plymouth and the Nuffield Trust. The researchers identified patient factors that may make remote consulting more risky, such as with very old or very young patients, patients in some care settings, communication challenges such as language, deafness or learning disability. Remote consulting can also be riskier for patients who struggle to understand how the health system works or if they lack technology such as a smartphone or are unable to use it.

The sudden switch to remote consulting at the start of the COVID-19 pandemic aimed to protect staff and patients, with the majority of patients receiving care via the telephone. As pandemic pressures have eased, more patients are being seen face to face, but telephone and online consultations using electronic forms remain an important way of delivering care.

The research team identified measures for clinical staff, practices, and patients to improve quality and safety of remote consultations:

• Communication skills are mission-critical. Putting the patient at ease, establishing good rapport, listening carefully to their story, clarifying points where needed, and taking careful note of the patient’s (or parent’s or carer’s) concerns can all contribute to a more accurate assessment of the nature, severity and urgency of the problem.
• At the end of a patient consultation, clinicians should ensure the patient knows what the next steps are in their care, and who to contact if things do not go to plan. Verbal advice should be backed up with a text or email and the clinician should get the patient to repeat back the instructions so that everyone is clear.
• Practices can improve the safety of remote consulting by enhancing processes such to ensure patients do not become “lost in the system” and working arrangements to minimise distractions for people taking incoming calls.
• Patients should ensure that the clinician is informed of all the key points about their condition, even if they have already told another member of the team, making it clear if things are deteriorating. Patients should feel able to ask for an in-person appointment if they have already had 2 remote appointments for a condition that isn’t improving, and to ask for written information to be sent via text message containing further instructions.

Dr. Rebecca Payne from the Nuffield Department of Primary Care Health Sciences, within the University of Oxford, said: “111 and GP out of hours services have been safely delivering remotely for two decades. This important research combines their wisdom with newer learning from in-hours settings. Implementing the lessons learned will provide safer care for all.”

Professor Greenhalgh, Chief Investigator for the study from Nuffield Department of Primary Care Health Sciences, within the University of Oxford, said: “The vast majority of remote clinical consultations in general practice are safe, in large part because staff are alert and err on the side of caution. When safety incidents happen, organisational pressures and poor communication often play a major role. This new research has identified more precisely where the risks lie and what measures we can take to reduce risks further.”

Dr. Rebecca Rosen from the Nuffield Trust said: “Remote consulting is here to stay and the study has identified ways in which to ensure quality and safety. Every clinician must be aware of high-risk symptoms for which it’s safer to see patients face to face; must listen and respond carefully to patients who say they need an in-person appointment and should consult face to face if a patient has not improved after previous remote consultations. We can also ensure that patients have the knowledge and tools to help them to get the best out of their consultations.”