Remote consultations (over the phone, via video link or online) are on the increase.
They can save doctors’ time, benefit patients and help meet public demand for faster access to medical advice.
But there are potential patient safety risks to consulting remotely. It’s important to identify and manage those risks, and to recognise that remote consultations are not always the right choice.
Innovations in medical practice
Charlie Massey - Chief Executive and Registrar of the General Medical Council
"We welcome innovations in medical practice that enable good care for patients, and support the use of remote prescribing that follows our clear prescribing guidance used in consultation with a patient in person or online."
Is a remote consultation appropriate?
Effective consultations allow you to establish a dialogue with your patient and make an adequate assessment of their condition.
There can be obstacles to this if you’re consulting by remote means. For example, if you’re speaking with a patient on the telephone, you can’t see their physical symptoms or demeanour. Or if you’re reviewing an online questionnaire you can’t ask the patient follow-up questions and the two-way dialogue is lacking.
So as a starting point, ask yourself:
- What do I know about the patient’s needs and wishes?
- What are limitations and risks of communicating with the patient by phone/video link/online?
- Will I need to carry out a physical examination or other assessment?
- Do I have access to the patient’s medical records and do I need them?
- Will the patient need follow up or ongoing management?
The answers should help you decide when a remote consultation is appropriate, and when a face-to-face consultation is required.
You must carry out a physical examination before prescribing injectable cosmetic products such as Botox, Dysport or Vistabel. Do not prescribe them on the basis of a telephone, video or online consultation.
Scroll through our case study below about a doctor who works for an online pharmacy receiving a questionnaire requesting painkillers for acute back pain.
Dr Best works for an online pharmacy, assessing patients’ requests for private prescriptions.
Dr Best reviews the questionnaire submitted by a 28 year old patient, Lauren, who has requested painkillers for acute back pain. Lauren has indicated that the pain was the result of an accident – she tripped and fell in the street.
Dr Best is concerned about the request since the painkillers Lauren has asked for are very strong. He also notes from the pharmacy’s records that Lauren has received the same medication for the same problem on three previous occasions. Dr Best is concerned that this may indicate an underlying issue – with the injury, Lauren’s pain management or possibly medicines misuse.
What should the doctor do?
- Prescribe the painkillers to help Lauren with her immediate pain, but tell her that next time she should see her own GP?
- Decline to prescribe and advise Lauren to seek face-to-face medical advice about her back problem?
- Contact Lauren asking for further information about her injury, current pain levels and previous prescription requests?
What the doctor did
As Lauren’s request was submitted online, Dr Best can’t discuss the request with her or carry out an examination. He also has limited opportunities for follow-up. As there is doubt about the cause of Lauren’s pain, which he isn’t able to resolve, Dr Best decides not to prescribe painkillers for her. He recommends that she make an appointment to see her GP or another doctor who can assess her condition and treatment needs appropriately.
What the doctor had to consider
- Remote consultations (online or via telephone or video link) can improve patient access to advice and treatment, but they are not always an appropriate alternative to seeing a patient face-to-face.
- When consulting remotely, it’s important to consider the limitations of the medium by which you are communicating with the patient. You should not prescribe unless you are satisfied that you have sufficient information to do so safely.
Good practice – key issues
The 3Cs - consent, capacity and continuity of care - are key issues to remember when you are advising or prescribing treatment for a patient via remote consultation.
- Give patients information about all the options available to them (including the option not treat) in a way they can understand
- Tailor the information you give, and the way you give it, to patients’ individual needs, and check that they’ve understood it.
- If you’re not sure a patient has all the information they want and need, or that they’ve understood it, consider whether it is safe to provide treatment
- Start from the presumption that an adult patient has capacity to make decisions for themselves.
- Be able to identify concerns about a patient’s capacity to make a particular decision.
- Maximise patients’ capacity to make decisions for themselves.
- If a patient lacks capacity to make a decision, consider whether remote consultation is appropriate, including whether you can meet the requirements of mental capacity law.
CONTINUITY OF CARE
- If you’re not the patient’s GP, ask the patient for consent to get information and a history from their GP and to send details of any treatment you’ve arranged
- If the patient refuses, explore their reasons and explain the potential impact of their decision on their continuing care.
- If the patient continues to refuse, consider whether it is safe to provide treatment.
- Make record of your decision and be prepared to explain and justify it if asked to do so.
Other points to remember
- Follow GMC guidance - the guidance on consent and good practice in prescribing
- Work within your competence
- Check you have adequate indemnity cover for your remote consultation activities
- Discuss this element of your practice with your RO at appraisal
Raising patient safety concerns
If you work with an organisation that provides remote advice and treatment services to patients, you should:
- follow our Raising and acting on concerns guidance
- take account of the organisation’s policies and procedures that support delivery of safe, effective care.
If you’re concerned that your organisation’s arrangements pose a risk to patients, you have a responsibility to raise your concerns with those in a position to put the matter right.
If you’re a doctor with leadership and management responsibilities in an organisation that provides remote services, you have a responsibility to ensure that patients can receive safe care and to act on any concerns brought to your attention.