In the past couple of years there has been a great deal of discussion about the relative advantages and disadvantages of remote consultations via video or phone calls as an alternative to face-to-face consultations, especially in primary care. This is a subject that precedes the pandemic, but it has come into sharper focus because of Covid-19, with claims and counter-claims about what works for patients and their doctors.
The arguments on both sides have often been simplistic, with an implicit assumption that some patients generally prefer remote appointments while others prefer to see a doctor or other healthcare professional in person.
At the same time, to varying degrees in different places, protocols have been developed that define the kinds of condition that are best dealt with face-to-face or otherwise. For example, GP practices may have a rule that they will always see babies and young children in person, or that patients with abdominal pain require face-to-face appointments. We welcome this development, but there is a lack of transparency about what protocols are in place, and where protocols do exist, they are rarely communicated to patients or co-produced with them.
But there is another issue at the heart of this debate. At present, it is usually the doctor’s decision (often mediated through a receptionist applying a simple triage procedure) as to who will be seen in person and who will be seen remotely. In many instances, the rule is that a phone consultation must come first and will only lead to a face-to-face consultation on the doctor’s say-so.
We propose a different paradigm from the outset. We suggest that the initial discussion when a patient first seeks an appointment should be geared towards negotiating the best way forward, rather than unilaterally applying blanket policies about telephone consultations first or conforming to a rigid set of pre-determined criteria. We expect that most patients will be content to be seen remotely if they are part of that decision and if it is made clear that it is the first stage of a consultation which may, if necessary, be followed up with a face-to-face appointment. Many patients will, indeed, prefer to conduct their appointment remotely, but others will have a variety of individual reasons for wanting to see their doctor in person, and their views should be taken seriously. In fact, the current draft of the General Medical Council’s Good Medical Practice which sets the standards to which doctors should work to says, ‘Where possible, you should agree with the patient which mode of consultation is most suitable to their individual needs and circumstances.’ It will be interesting to see if this sentence makes the final edit when the final guidance is published next year, but it is encouraging that the medical regulator clearly sees this as the direction of travel.
Shared decision making should not be an optional extra that only applies when major decisions are being taken about treatment options. It is of equal value in defining the relationship between patients and healthcare professionals from the outset and it may result in more appropriate joint decisions about appointments, with better outcomes and greater patient satisfaction. It is also critical in resetting the contract between general practice and the population, which has suffered a trial by media over the last year or so.
Of course, there will be those who claim the insertion of this additional decision point will only add to the burden on our already hard-pressed medical workforce. However, we believe that as with so much in health and care, the opposite can be true. It would potentially save time and potential duplication further down the track by increasing patient satisfaction and giving patients a sense of ownership not just of their health, but also of the way they receive care.
3 May 2022
This represents the views of the authors and not those of the Academy Council.
© 2022 Academy of Medical Royal Colleges.