Some weeks ago one of my former patients, a man in his mid-70s, asked if I would meet him. As we made our way to a coffee outlet near his office, I noticed he’d developed a shuffling gait, though what he actually wanted to discuss was how he suddenly felt old.
While I could see no evidence of tremor, I was convinced that he might have Parkinson’s disease and urged him to see a neurologist.
Within days he’d undergone a brain scan and a lumbar puncture to collect cerebral spinal fluid, and was diagnosed with a brain condition I’d never come across, caused by a dangerous build-up of fluid.
He underwent urgent neurosurgery to drain the fluid – and within 24 hours he was cured, back to his old self.
This story highlights just why face-to-face consultations matter so much. ‘Doctoring’ isn’t simply about patients telling you their symptoms – the vital skill is in observing the unspoken signs, their demeanour, how they move, even the way their skin looks, the non-verbal communication.
It’s about spotting the symptoms the patient themselves might not have noticed – such as this man’s change in gait.
The fact is, without seeing a doctor in person, he would probably have died after months of deteriorating health and senility. And I have little doubt an online consultation would not have led to the brain scan that diagnosed this man in time.
The fact is, without seeing a doctor in person, he would probably have died after months of deteriorating health and senility. And I have little doubt an online consultation would not have led to the brain scan that diagnosed this man in time (stock image)
But that is where we are at this point, with alarming figures showing that in parts of England, less than half of patients see their GP face to face. As a result, illnesses are being missed.
The Mail recently reported the desperately tragic story of 27-year-old Jessica Brady, from Stevenage in Hertfordshire, who died of liver cancer after a series of virtual appointments over five months failed to spot her tumour.
And while I fear the elderly and vulnerable are particularly at risk from the inadequacies of remote medicine, her story demonstrates that no one of any age is immune.
One of the key things you miss with online or phone consultations is physically examining a patient. At medical school we were taught: ‘If you don’t put your finger in it you will put your foot in it.’
There is no doubt actually examining patients saves lives, and without the return of more face-to-face consultations, I predict more tragedies – and increasing litigation.
I no longer want to have friends tell me of terrible stories, such as the accountant I know who suffered a fall at home and was only permitted a telephone consultation. Painkillers were prescribed ‘to help the pain of the bruising’ but that was the only care offered.
After two days bedridden at home he eventually rang an ambulance, and went to hospital where he was diagnosed with a fractured thigh – a serious injury, and potentially lethal. He was lucky: he survived. But it shouldn’t have been a life and death situation.
The pendulum has swung too far. I fully support the Mail’s campaign to get more patients in front of their GPs, but we need to think where the solution lies – and that’s not in the hands of the individual GP, or even edicts from government ‘requiring’ more face-to-face appointments.
For while I suspect there are some individual GPs who would prefer the new status quo, because it’s simpler, saves time and helps cut waiting lists, it is too simplistic to say ‘it’s the doctors’ fault’ – or worse, ‘they’re lazy’.
For the fact is this was a juggernaut of governments’ making: we just don’t have enough GPs.
Well before the pandemic, patients were finding it difficult to see a GP, with too many having to wait days or even weeks.
I remember my heart sinking last year when then health secretary Matt Hancock said all GP appointments should be done remotely by default, unless a patient needed to be seen in person (stock image)
The blame for this – and now, the online mess – lies at the door of successive governments who are guilty of gross failures of forward planning. Put simply: they’ve failed to ensure there are enough GPs.
For instance, it was obvious that allocating more medical school places, quite rightly, to women, from 10 per cent in the 1960s, to 50 per cent, would eventually create manpower difficulties as women needed time out to have families.
At the same time more GPs began retiring early – the demands of an ageing population, and escalating obesity and diabetes, hugely increased workloads, while red tape spiralled out of control – dealing another crushing blow.
The shortage of GPs along with the workload had already compelled doctors to devise additional ways of providing at least some sort of service, which led to telephone consultations.
The fact is, online and phone consultations do have their use – for instance, a brief assessment before sending a patient to the right place for minor problems, or for then shifting the case to the practice nurse.
Remote consultations are particularly suitable and safe when the GP and patient know each other.
I remember my heart sinking last year when then health secretary Matt Hancock said all GP appointments should be done remotely by default, unless a patient needed to be seen in person.
Well before the pandemic, patients were finding it difficult to see a GP, with too many having to wait days or even weeks (stock image)
This would be disastrous. While there is no doubt remote consultations are here to stay, it’s time the default is for patients to be back in front of their GPs.
It can be done: just look at secondary care – treatment in hospitals – which is functioning well, with consultants clearing the waiting list backlog, doors wide open, and skilled personnel getting on with the job. Face to face.
So how can we get out of this mess? One of things we need is a campaign to bring back retired GPs to assist with triage, patient workloads, and the continued winter vax programmes. Hitherto this has been blocked by impossible and frustrating bureaucracy.
When the pandemic emerged I was reinstated by the General Medical Council within 24 hours and by my insurer the Medical Defence Union the following day.
All that happened quite spontaneously and without asking, and I readily complied.
Yet NHS England, despite that acknowledgement by the GMC of my suitability, required a copy of my passport, a utility bill, and 29 pages of questions to be answered. I did all of this but never heard any more.
And I know from frustrated peers, I was not the only one. Slash red tape to ensure this can’t happen.
What about setting up pop-up GP centres at A&E units or other venues to ease the backlog, with staffing from healthcare assistants and other nursing staff for non-critical care – and some of those retired GPs!
We also need a strong advertising campaign to encourage greater use of pharmacists – and clear guidelines about when a ‘e-consultation’ is appropriate.
Last but not least in the longer term, we need more GPs.
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