One of the immediate impacts of coronavirus pandemic has been the rapid increase in the use of remote consultations and prescribing. This shift in practice was swift, with the profession moving quickly to ensure patient care was maintained.
Here, Mark Swindells, the GMC’s Assistant Director for Standard and Guidance, reflects on the implications of this development and on how General Medical Council (GMC) guidance ensures standards of good practice are maintained, whether a patient’s care is delivered face-to-face or virtually.
On Tuesday 18 February 2020, a month before the first lockdown, the UK had nine confirmed cases of coronavirus. It was also the day we closed our call for evidence on remote consultations and prescribing.
That evidence was to help us decide if our existing guidance, last updated in 2013, had kept pace with changes in practice and in the use of technology.
We will publish our updated guidance early next year. It has been informed by the evidence we asked for, and by what has happened in the months since, as back in February there was no way of predicting the transformation in digital healthcare that the pandemic would herald.
During the year, the number of patient consultations delivered remotely increased dramatically across all four UK nations:
- In England, between February and April GP appointments conducted by telephone more than trebled, from below 14% to almost half of all appointment types[i].
- In Northern Ireland, more than 14,000 video consultations were carried out between April and September 2020[ii].
- In Scotland, the ‘Near Me’ service expanded from 300 to 18,000 video consultations each week, and reached the half a million milestone by mid November[iii].
- In Wales, a new NHS Wales video consultation service is currently providing more than 1,000 consultations every week[iv].
There are many obvious benefits of remote consultations, not least the reduction in the potential transmission of COVID-19. But it is important that we also monitor the experience for doctors and for patients. As a regulator we want to enable innovation which can benefit patients, help doctors, and be safe. And updated GMC guidance will need to last beyond the current pandemic.
With remote consultations and prescribing now a fixture in health services, there’s a need to ask questions about how doctors can ensure ethical standards are maintained when delivering care remotely.
Can new technology make it easier for some to self-manage long term conditions? Does it improve the experience for patients with sensory disabilities, or risk creating barriers for them? Is it possible to properly demonstrate practical things, like using an inhaler correctly, without face-to-face interaction? Can a skin condition be properly assessed without a physical examination?
While our current guidance speaks to individual doctors about the standards of good medical practice, we recognise that decisions like whether to consult face-to-face or remotely will often be influenced by local protocols and the availability of technology. But one thing is clear – if a doctor can’t meet our standards using a remote consultation, they should switch to a face-to-face consultation instead.
Many doctors will also have roles in commissioning and influencing the design of these services. It is important they consider carefully how digital models can best support the two-way dialogue between doctor and patient, which goes to the heart of the traditional, trusted relationship.
For example, if online questionnaires are used to get information from a patient, it is crucial that that the doctor is able to discuss issues and check facts with the patient, and any other treating health professionals, in order to prescribe safely. Patients must also know who to contact afterwards if they have any questions. Doctors working in systems where this is not possible have a duty to raise a concern.
Doctors must also be able to access a patient’s medical history, especially when prescribing controlled drugs which present a risk of addiction, misuse or overuse. The pandemic has expedited system change to improve information sharing within the NHS and with the independent sector, but there are still gaps. We know doctors in both remote and face-to-face settings will sometimes find themselves in a position where they can’t easily access or verify the information they need to prescribe safely.
This raises serious questions. Should doctors be able to prescribe controlled drugs without access to medical records? In our view this is only appropriate in an emergency, such as, providing continuity of care until a patient can see their regular prescriber.
We will clarify our advice on information sharing, to be clear that if a patient objects to giving consent to share information with other treating health professionals, then it may be unsafe to prescribe. It is, sadly, a matter of public record that coroners’ inquests have found that when these steps are missed, the consequences can be tragic.
We see our regulatory role as enabling innovation that benefits patients – in a safe way – while being conscious that our updated guidance must remain relevant long after the current pandemic has passed.
That guidance, building on the 2013 version and taking account all that has happened since, including the rapid changes this year, will be published early in 2021. Until then, the principles in our current remote consultations guidance remain, and are hopefully helpful in what continues to be a challenging time for everyone in healthcare.
A version of this blog appeared in Independent Practitioner Today’s online magazine and weekly email to subscribers.
[i] NHS digital Appts in general practice series https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice/september-2020
[ii] Source: BMA Northern Ireland https://www.bma.org.uk/bma-media-centre/new-ways-of-working-but-gp-practices-still-open-protecting-and-caring