Post-COVID consultations should be a combination of remote and face to face, says RCGP

Face to face consulting is an essential element of general practice and remote consulting should be an option but not the ‘automatic default’ for GP care and services once things get back to normal after the pandemic, the Royal College of GPs says in a new report out today

Both options have their advantages and the decision about how care is delivered and accessed should be a shared one between GP practice staff, based on their knowledge of their patient population, and patients, based on their individual needs. The College’s new report is focused on consultations, post pandemic.

During the COVID-19 pandemic, the way in which general practice services were delivered had to rapidly change in line with the new NHS England guidance, informed by advice from Public Health England, to maintain infection control in GP practices, keep patients and staff safe, and allow general practice staff to continue delivering care should they need to self-isolate. This included the introduction of ‘total triage’ meaning that patients are remotely screened and directed to the most appropriate health service for their problem – and for consultations to be delivered remotely, by telephone, video or online, unless clinically appropriate.

Looking at the Future of remote consulting and patient ‘triage’, the College acknowledges the huge potential of remote consulting and other digital ways of working – and sees a significant role for them moving forward – but anticipates a ‘rebalancing’ between remote and in person care.

It says: “Face-to-face appointments will always remain a major element of general practice, and remote consultations will continue to be delivered where appropriate and useful. The mode of consultation should be determined through shared decision-making between a patient and practice staff.”

Currently around half of consultations in general practice are being delivered face to face. At the peak of the pandemic, the ways in which patients accessed their GP reversed from around 70% face to face and 30% by phone, video or online pre-pandemic to around 30% face to face and 70% remote.

However, a number of patient groups have recently highlighted a lack of satisfaction with remote access to general practice and the RCGP is calling on the Government to invest £1 billion in digital infrastructure and capabilities for general practice by 2024. This includes significant investment for ongoing upgrades to digital technology and supporting infrastructure.

The report distinguishes between remote consulting and patient triage and questions Government plans, currently in NHS planning guidance for 2021/22, to embed ‘total triage’ into general practice, saying “we are not convinced that the ‘total triage’ model or digital-first triage platforms should be the automatic default for all practices once the need for social distancing has lifted.” It says that digital triage systems must not present a barrier to care, for example by being overly complicated, and will never be appropriate for all patients at all times – traditional routes such as telephone and in person appointment booking must remain available.

The College is calling on government to conduct a comprehensive review of total triage platforms and processes following their unprecedented use during the COVID-19 pandemic. It wants to see the development of a new set of UK-wide principles for digital triage which do not make it the default but instead include a mechanism to ensure meaningful shared decision making between GPs and patients, as well as effective guidance on the safe use of such systems.

A ‘snap’ poll of RCGP members was conducted in September 2020, with 622 GPs responding.

It found that whilst GPs and their teams understood the reasons for the changes to GP consultations during the pandemic:

• 88% of GP respondents thought face to face consultations were important for building and maintaining trusting patient relationships;
• 90% felt they could be efficient in delivering the best health outcomes all or most of the time through face-to-face consultations, compared to 75% over the phone, 46% via video and 18% through online consultations;
• 81% said they felt able to deliver appointments without unnecessary follow-up with in person appointments, compared to 61% by telephone, 46% via video and 16% online;
• 63% said delivering all or mostly remote consultations reduced their job satisfaction and 61% said remote consultations were making the role more transactional;
• 94% said that to get the most out of remote consultations, they needed better broadband and better digital technology hardware, 92% said they needed better quality video consulting and 90% said they needed improved usability of remote appointment software.

Professor Martin Marshall, chair of the Royal College of GPs, said: “People choose to be GPs to care for patients – as a medical specialty one of our key tools is our ability to build doctor-patient relationships in order to deliver holistic care, and our members tell us face to face appointments are important for this. It is possible to build relationships via video or phone consultations, but it’s a very different skill to doing so in person, in a consultation room, which GPs have been trained for.

“GPs deserve credit for the remarkable way in which we swiftly transformed the way we deliver care in general practice once NHSE issued its pandemic guidance – both in terms of consulting remotely and implementing ‘total triage’ across the board. This was necessary so that we could continue delivering general practice services to patients whilst maintaining infection control in surgeries and keeping people safe.

“Remote consultations have advantages, particularly in terms of access and convenience for patients and making it easier for some hard to reach patient groups to access care. The pandemic has shown us that high quality care can be delivered remotely and many practices now have the appropriate means to do so effectively. There is certainly going to be a place for it in the future of general practice, and for this we need significant investment in the service, particularly in hardware and connectivity, so that GPs can deliver high quality remote care for patients where appropriate.

“But we know many patients prefer to see their GP face to face – and that many GPs prefer consulting in person, as well. Remote working has been challenging for many GPs, particularly when delivering care to patients with complex health needs. GPs have reported constant remote consulting to be exhausting in a different way to seeing patients in person – and that it can make it harder to pick up on ‘softer’ cues, which can be helpful for making diagnoses.

“Furthermore, these new ways of working do not reduce GP workload – in fact, there is evidence to suggest triage results in an increase in consultation numbers and remote consultations can take longer.

“Once we get out of the pandemic, and things return to a more normal way of living and working, we don’t want to see general practice become a totally, or even mostly, remote service. Face to face appointments have been facilitated throughout the pandemic and currently around half of consultations in general practice are being delivered in person – when you consider last month a record number of consultations were made in general practice, that’s a huge number of face to face appointments being made, all in line with current safety measures.

“As we move out of the pandemic, it needs to be down to individual GP practices to be able to decide how they deliver services, based on their knowledge of their patient population. Ultimately, we want to be able to offer patients the choice as to how they want to access GP services based on their health needs.”