For many patients up and down the country the chance of a face-to-face appointment with a GP is a distant dream.
Whereas it was thought — indeed, hoped — by many that phone, video or email consultations would be a largely temporary measure, adopted as a response to the pandemic, shocking new figures revealed by this newspaper yesterday showed it has become the norm.
More than half of patients still don’t see their GP face-to-face in a quarter of areas, according to the data from the Commons Library, which looked at GP appointments from the start of January to the middle of last month.
Even in the best-performing districts, this rises to just 71 per cent — well below pre-Covid levels, when 80 per cent were face-to-face.
For many patients up and down the country the chance of a face-to-face appointment with a GP is a distant dream
Of course, in some cases a quick phone or video consultation may be beneficial — more convenient even — but there are concerns that in some instances, important diagnoses may be missed as a result.
So when is it appropriate to ‘see’ your GP virtually and when should you insist on going into the surgery?
Dr Clare Gerada, a GP in South London and former chair of the Royal College of GPs (RCGP), says up to 75 per cent of patient requests in general practice do not require a GP and can be handled effectively by another healthcare professional, such as a nurse or pharmacist.
‘If a patient asks for a repeat prescription, you look at their notes and if they need a review of their medication, that can be done by a pharmacist and they don’t need to see the GP,’ says Dr Gerada, who is also the founder of eConsult, an online platform which allows patients to contact their GP by filling in an online form, sent digitally.
‘Equally, blood pressure checks to monitor conditions such as type 2 diabetes can be done by a nurse.’
Other conditions such as repeat urinary tract infections (UTIs) can be taken care of virtually, either by email or video consultation, she says.
‘If a young woman who has had a UTI before accurately describes symptoms of a UTI again, a GP doesn’t need to see her but can prescribe antibiotics, which she can pick up at her local pharmacy, and next time she attends the surgery we would make a note to check everything is OK,’ says Dr Gerada.
It is when you have these symptoms for the first time, or UTI symptoms don’t clear up with treatment, that patients should push for a face-to-face consultation, as this may suggest GPs need to take a sample to check which antibiotic to give, she adds.
Of course, in some cases a quick phone or video consultation may be beneficial — more convenient even — but there are concerns that in some instances, important diagnoses may be missed as a result
In her experience, other red flag symptoms which require actually seeing the GP include severe headaches, any condition that the patient has presented with more than three times without improvemenT such as back pain, severe skin rashes and a fever in children under one.
A face-to-face appointment is also essential when a physical examination is needed, such as checking a suspicious breast or testicular lump.
‘Most doctors and patients believe virtual consultations cannot be an adequate replacement for face-to-face consultations especially when a clinical examination is required in patients with breast symptoms,’ says Professor Kefah Mokbel, a consultant breast surgeon at the Princess Grace Hospital in London.
‘Furthermore, even breast cancer can present with symptoms less obvious than a lump — dimpling of the skin, for example. With other cancers it may be even more subtle, hence the need for a face-to-face consultation.’
However, virtual appointments are adequate for follow-up to ‘discuss results of tests, side-effects of treatment, management of chronic cancer symptoms and genetic counselling’, he adds.
Dr Gerada says: ‘We will invariably see an elderly patient face-to-face at least once a year for a routine check-up, the over-50s for a general health check (for cholesterol and blood pressure) and do cervical smears.’
A report earlier this year by the Royal College of GPs, called The Future Role of Remote Consultations a nd Patient Triage, admits there can be problems diagnosing patients remotely.
‘Remote consultations are better suited for more straightforward conditions or queries, where a physical examination isn’t clinically required, with those more complex, multifaceted or sensitive being likely to need a face-to-face assessment,’ it said.
‘In some cases, non-verbal or “soft” cues such as signs of anxiety, self-harm, or smelling alcohol on a patient’s breath, may be more easily missed remotely.’
Indeed, 60 per cent of GPs in an RCGP survey conducted last year said remote consultations are more effective for monitoring and following up with existing patients rather than new patients.
But Dr Gerada says, with experience, GPs can identify warning signs from the information patients give online. ‘When patients describe their condition in their own words via an online consultation form, this reveals a lot to the doctor.’
She admits online consultations are more popular with the under-50s and more challenging for older patients, especially those with dementia and people with learning difficulties.
‘For example, if someone requests a GP consultation for acne and describes it as disgusting, you would call them in, as this suggests they may also be feeling depressed. Likewise, total body pain may actually be describing depression.’
Virtual appointments can be a helpful first step to seeking medical care for people with sensitive conditions such as infertility or mental health problems, or embarrassing conditions such as sexually transmitted diseases, she adds.
‘Sexual health clinics were carrying out virtual appointments pre-pandemic and found it really encouraged people to come forward,’ she says. ‘It can really help improve access.’
Dr Gerada estimates 30 per cent of GP appointments should be carried out face-to-face (former Health Secretary Matt Hancock suggested it should be 55 per cent), with the rest done through a combination of email, phone or video consultations.
The Government has already signalled its intention to move towards ‘digital first’ primary care in its NHS Long Term Plan, published in 2019. This states every patient should be able to use online tools to access all primary care services, such as having a consultation with a healthcare professional, receiving a referral and obtaining a prescription.
However, the huge swing towards online consultations during the pandemic led to NHS England reminding GPs earlier this year that they must make ‘a clear offer of appointments in person’ (even though they are not contractually obliged to do so) — a move welcomed by patient groups.
‘Patients have made clear how difficult they have been finding access to GP services, and that they clearly prefer to see their GP in person,’ said Rachel Power, chief executive of the Patients Association.
Its research, mainly of older people with long-term conditions, found 48 per cent felt remote GP appointments offered a worse experience.
But around 70 per cent of GPs say telephone, video or online consultations increase efficiency, and 88 per cent say their surgery is now equipped to deliver video or e-consultations — up from 5 per cent before the pandemic, according to a RCGP survey of 829 GPs last year.
Yet GPs also admit that face-to-face appointments still play a vital role. ‘They will always be an essential element of general practice, but remote consulting should also be an option as things get back to normal because there are advantages to both,’ Professor Martin Marshall, Chair of the Royal College of GPs, told Good Health.
‘However, we have a huge shortage of GPs. The Government made a manifesto pledge of an additional 6,000 GPs by 2024 and we urgently need to see progress so that we can safely deliver the care and services that our patients need, now and in the future.’
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