The NHS Long Term Plan states by 2023/24 every patient in England will be able to access a digital first primary care offer. Online consultations will be a key part of this.
Digital first is an approach to providing for the needs of a local population. It enables redesign of care pathways with digital tools. It aims to ensure people can access appropriate health and care services. Access should be consistent, as and when patients require and in a way that meets their needs. The coronavirus (COVID-19) pandemic increased online and video consultations in core clinical practice. This helps with social distancing, reducing travel and protecting the most vulnerable. Consultations may include a mixture of telephone, photographs and video consultation. This depends on the patient’s condition, the clinician’s relationship with the patient and their preferences.
It may not always be possible or appropriate to assess a patient’s condition online or by video call. The General Medical Council’s flowchart helps clinicians decide if a face to face consultation is necessary. If not, to signpost to other services where appropriate.
NHS England and Improvement published principles with The Royal College of GPs for supporting high quality consultations by video in general practice during COVID-19. These principles cover video examinations, safety netting, documentation and further resources.
The General Medical Council (GMC) published guidance on providing appropriate patient care in a video consultation. It contains key points for clinicians to consider including:
- Appropriate identification of the right patient.
- An awareness that telephone consultations can lead to inadvertently disclosing patient information to other people. This can include family members.
- Making sure the patient is ready for their consultation to begin. Allowing time for them to make sure they have a private space for the discussion.
- Using approved secure systems for clinical video consultations.
Online and video consultations enable people to contact their GP practice without waiting on the phone or coming to the practice.
Patients can use online consultations to:
- ask questions
- report symptoms
- submit an administrative request
- discuss other information
- review a known problem or condition
- upload photos where appropriate.
NHS England produced an online consultations in primary care toolkit. It sets out the key aims of online consultations. This includes the need to focus on people, not technology and sharing good practice.
Safeguards for patients accessing online and video healthcare
There are potential patient safety risks with phone, video and online consultations. Patients should expect effective safeguards in place to protect them. This includes when they receive advice and treatment by video and online.
Responsible providers of these services will have systems to identify patients with safeguarding flags or alerts on their records. Providers would also check patients’ identity. They would identify patterns of behaviours which may indicate serious concerns. Appropriate steps can then be taken to protect patients. Particularly vulnerable patients may include:
- those at risk of self-harm, substance or drug use disorders
- those with long term conditions
- children attempting to access services intended for adults.
Healthcare professionals who lead a team or service offering online and video care are expected to make sure staff are clear about:
- their roles
- their personal and collective responsibilities for individual patients
- the quality and safety of care provided by the team or service.
They have a responsibility to set up and maintain effective systems to identify and manage risk. Act quickly where patients may be at risk of harm.
Providers should ask and record who is in the room with the patient during consultations. They should ask more questions than normal about how the patient is doing generally. If the consultation is with a child, they should try to speak with the child if appropriate. If this is not possible, ask to see the child on the video.
After consultation, record everything carefully in the notes. If a safeguarding referral is made the appropriate read code should be recorded.
Communication
Effective communication between doctors and children and young people is essential to good care. The GMC have produced ethical guidance on communication.
Receiving, storing and handling clinical images
During an online or video consultation it may be appropriate to consider using photographs and video consultations. This may help assess or diagnose a patient, and support clinical decision making.
The Medical Defence Union have produced guidance and advice on receiving and storing patient images from online consultations. GMC guidance on making and using visual and audio recordings of patients applies to photographs as well as other recordings.
The clinician should agree with the patient how the image will be sent. If this is by email, it should be by secure NHS encrypted email accounts. This is in accordance with the providers policy. The image would be uploaded to the patient's records. The email and image would be deleted from the email account. Some practices and NHS organisations use specific software to allow receipt of an image by text. The same principles would apply.
Storing and handling intimate images
An intimate examination carried out online may support clinical decision-making. Clinicians should carefully consider whether this is clinically necessary to provide a diagnosis, or appropriate to examine the patient in person if this is possible. If the decision is to proceed online, a chaperone should be offered wherever possible. GP Mythbuster 15: Chaperones contains more information.
GMC guidance states when carrying out intimate examinations by video, it is important to consider:
- whether clinicians can see well enough to assess the patient
- that patients may find it more embarrassing to present themselves to a camera/screen than to a physical examination
- that patients may have concerns about the security of the line. That the video might be recorded or otherwise be stored somewhere allowing future access.
GMC guidance, Intimate examinations and chaperones, provides further information about issues to consider when carrying out intimate examinations.
The Royal College of Nursing produced a publication on genital examination. It includes useful information on chaperoning regardless of gender.
NHS England produced some key principles for intimate clinical assessments carried out by video or online in response to COVID-19. They include how to conduct intimate examinations by video and use of chaperones.
Consent and capacity
Specific consent to receive and store a patient's photograph is necessary. This is irrespective of whether it is the clinician’s idea or the patients. Getting and documenting consent should include why a photograph will help provide clinical care.
Patients should be told how clinical records, including photographs, will be securely stored. They won't be used for any other purpose without their express permission. These discussions and decisions would then be coded and/or recorded in the clinical records.
If a patient lacks capacity to make a decision about sharing a photograph of them, the decision taken on their behalf must be in their best interests. This is in line with the Mental Capacity Act 2005. GP mythbuster 10: Mental Capacity Act 2005 contains more information. It is important to remember that there may be someone who has legal authority to act on the patient's behalf in healthcare decisions. Their agreement should be sought.
GP mythbusters
SNIPPET GP mythbusters RH
Clearing up some common myths about our inspections of GP and out-of-hours services and sharing agreed guidance to best practice.