WHAT NEXT FOR YOUR GP APPOINTMENT?
With more telephone consultations and fewer in person, Dr Sarah Jarvis explains the pros and cons for patients
Dr Sarah Jarvis explains what the future looks like for patients
It’s 11.30am and I am on my 16th consultation of the day. A year ago, I’d have gone into the waiting room and called my next patient down the corridor. Instead, Fiona is booked for a phone consultation. Earlier, I had a patient with a skin lump – I sent him a text allowing him to upload a photo and was able to reassure him confidently that it was a seborrheic keratosis (a harmless warty spot) that needed no further action. Had I not been so confident, I’d have asked for more pictures and, if I were still concerned, organised a referral.
The patient before that had a breast lump, which definitely needs full examination, so I’ve arranged for her to see me at the practice at midday. When I told her, I could sense her relief.
I was taught that 80% of diagnosis comes from the history (the symptoms), 10% from the clinical examination and only 10% from investigations. Over 30 years as a GP I’ve learned how true this is, but I understand the concern of patients who have always been examined. It requires a major mindshift, and not just for patients.
A WORKFORCE IN CRISIS
When I first became a GP in 1990, the vast majority of my work involved seeing sick patients, making a diagnosis and then providing treatment. This work hasn’t actually gone away, but these days, more of my time is taken up with ‘preventive’ medicine – identifying risk factors and trying to help keep people healthy.
All this work on prevention has undoubtedly borne fruit – for instance, death rates from heart disease in the UK have fallen by more than 60% in the past 20 years. But it has led to an inexorable rise in the number of yearly appointments for the average patient. Factor in the reduction in the number of ‘whole time equivalent’ GPS (numbers of permanent GPS dropped by more than 1,000 between 2015 and 2018) and it’s hardly surprising that waiting times to see a GP continue to rise.
THE MOVE TO ONLINE
In 2017, the NHS launched the GP online consultations system fund to support a shift to online consultations, with patients pre-submitting details of their issues online.
Take-up was slow at first, with only one in five practices offering any sort of digital consultation by 2018. In January 2020, the NHS plan was for all patients to have access to a ‘digital first’ service by 2023/4. But after the NHS England mandate to screen all patients before any physical contact at the outset of the pandemic, change sped up.
While more practices did adopt online consultations for all, the biggest change was from in-person consultations to ones by phone. Contrary to media reports, practices never closed. After a downward blip in spring, by autumn 2020, GPS offered more consultations than before the pandemic and, in the year to March, did 134m in-person appointments.
Face-to-face appointments also increased after the first lockdown, (to about 44% of all consultations by March 2021) but it is unlikely we will ever go back to pre-pandemic levels.
GOVERNMENT U-TURN
In April 2021, the Government added online consultation for all into its NHS annual planning guidance to GPS. But after a GP and patient backlash, NHS guidance to GPS has changed to make it clear that patient request is a valid reason for seeing patients in person, even if the GP doesn’t believe it’s clinically needed. But local arrangements will enforce this.
UPSIDE OF THE DIGITAL REVOLUTION
There’s no question that for some, online consultations are welcome. No waiting on the phone. Never again the words ‘I’m sorry, no appointments left, try tomorrow’. For the time-poor working patient, phone and video consultations also provide greater convenience.
In addition, freeing up time by dealing with certain issues online allows the increasing number of patients with complex medical problems to be offered longer appointments, in which GPS can look at all their issues together. As the pandemic eases, practices are gradually setting up more of these ‘vulnerable patient’ appointments.
STAYING SAFE
But there are some downsides, too, and one of the major questions is whether remote consultations are as safe as face-to-face. Part of the skill of being a GP is learning when someone just doesn’t look right. GPS are every bit as worried as their patients about patient safety. There are strict guidelines in place from the General Medical Council about GPS having capacity to call a patient in for a face-to-face consultation if clinically necessary. But as a doctor, it’s not always straightforward to make that call.
If your GP says they don’t need to see you but you think they should, start by asking why they feel they can safely make a diagnosis and treatment plan online. If you still think they need to see you, you have a right to say you want a face-to-face appointment.
BY THE WAY, DOCTOR
Then there’s the ‘hidden agenda’ consultation, driven by embarrassment or anxiety. Every GP has seen patients who spent 10 minutes talking about back pain, only to ask as they leave, ‘By the way, doctor, is it normal to bleed after I make love?’ While some patients may prefer outlining issues on a screen to in person, every GP I know worries about losing the chance to find out what the patient really came for. Even if you’re anxious, it’s best to come straight out with your concern. Try writing it down so you can practise what you want to say. Your GP will have heard it all before.
GETTING TO KNOW YOU
When I qualified as a GP, we almost all joined partnerships for life. But as the proportion of female GPS has shifted (more likely than males to work part-time, take breaks or switch practices), that has changed. The number of GPS joining partnerships continues to fall, with half now salaried doctors or locums.
These shifts have reduced the chance of building those all-important long-term relationships with patients. In a November 2020 survey, 40% of GPS worried their relationship with patients had worsened in the shift to digital and phone working.
To ask Sarah a question
Email ghask.sarah@hearst.co.uk or write to Ask Sarah, Good Housekeeping, House of Hearst, 30 Panton Street, London SW1Y 4AJ. We regret we are unable to respond to letters individually.