“Online consultations in general practice: the questions to ask” RCGP Report.

RCGP Online Consultations in General Practice the questions to ask

The Royal College of General Practitioners has been “working with a group of Patients, GPs, health service managers and academics to develop a set of questions that you might want to consider if you are a patient, clinician, practice or commissioner” interested in using these online consulting services.

Download the “Online consultations in general practice: the questions to ask” report (PDF).

mHealth Insight

At times the RCGP seems fixated on efforts to detract from efforts to evolve general practice beyond the office visit only model but I think this is a fascinating document and it will provide a great launchpad for discussions about how services should be designed.

“Online services provide a new way of consulting in general practice. Use of text based or video digital technologies has some advantages over established ways of consulting such as face-to-face meetings or the use of the telephone. It also carries risks.”

While I agree that booking an appointment is an online service it’s disappointing that the paper refers to “consulting with a Doctor” as just an “online service”. Similarly to how Video Consults with Doctors shouldn’t be described as ‘Virtual Consults’, I think there is a distinction that the report would benefit from making clear that becomes particularly obvious when you realise most internet access comes via the mobile phones that most of us carry and never switch off (which makes it unclear when a Patient using a mHealth service or a GP or Nurse who shares their mobile number with a Patient would consider themselves to be online or off-line).

I also find it a bit of dangerous presumption that documented mobile video consults are accepted to be inherently more risky than a conventional face to face meeting in a clinic or a plain old telephone voice call when surely we all know Patients are more honest with their Mobiles than their Doctors, surely we all know there are Patients having consults with overworked GPs that are little more than stranger encounters and the college is aware of the great work being done by RCGP members who are providing online tools to their Patients that are helping them to work at the top of their licence. (Related: “The biggest “disruption” in healthcare is honest, direct, accessible communication” (2012)

“We present some questions that you might want to ask if you are a patient, clinician, practice or commissioner, to help you to get the most out of the potential of these new services. The questions have been developed by a small group of patients, clinicians, health service managers and academics working with the RCGP and are currently being tested more widely, prior to be being published on the RCGP website”

I would’ve loved to have helped contribute to this work as it really does seem to be missing the most valuable potential contributors eg. how could the questions that “Practice Nurses” and “Carers” might want to ask have been overlooked?

I personally think Carers make the strongest solid use case for GPs to start offering mobile video consultation services because these invaluable volunteers deliver some +80% of total healthcare and they are all too often unpaid (and missing out on the opportunity to work/get paid) and medically untrained. In my experience the value of having a Video Consult with a Doctor on your mobile is probably most significant for Carers.

“Questions to ensure that the service is safe: Has the service been inspected by the health regulator, the Care Quality Commission (www.cqc.org.uk) (or its equivalent outside England), and am I satisfied with the report?”

It’s a bit odd that the RCGP has become a big fan of the CQC’s ability to protect the safety of Patinets. Perhaps everyone’s forgotten that the organisation (that gets by on a measly £262Million a year) published a banding system that wrongly labelled 60 GP practices as “potentially putting patients at risk” when they weren’t.

I think it’s important to appreciate that a Doctor video consulting service becomes safe when it’s properly documented for Patients and is provided by registered Doctors. Fail to document or let Patients even access records and we just continue to support the growth of pointless bureaucracy and clipboard-wielding parasites who ultimately take funding that we really need to be allocating to those who are actually providing care.

“Will the online provider have access to my GP records so that they know about my medical history?”

I think this is something that’s rapidly changing. As Patients get access to their records (something that the paper doesn’t refer to) mobile health apps like Apple’s new Health Record service are going to flip this question on it’s head eg. it will soon be more sensible to ask “will the service let me securely share my Healthcare Records with the remote Doctor”.

I think this is very interesting because we know Patients are more honest with their mobiles than their GPs so it’s likely that these Patient accessible records are going to be much more useful for GPs.

“Is it clear whether my personal information is being kept safe and confidential? Will it be shared with other parties (including my registered GP if appropriate) or used for purposes other than the direct provision of care? If the online provider wants to record my consultation, will I be asked for my permission to do so?”

I think these are great questions but they’re not going to be realistically solved by us hoping that Patients will remember to ask it at a time when they are all too often stressed and in urgent search of health advice.

I think the RCGP could have impact if members were to draw up an approved T&Cs and Privacy Policy that their members should work with when advertising their services online. By doing this RCGP members won’t be seen with their mugshots plastered all over the scammy websites that advertise free* or cheap subscription services directly to the public but hide behind protracted T&C’s and Privacy Policies that state they aren’t Healthcare Professionals and are nothing more than “providers of a website” and not responsible for healthcare or advice given while informing the 1% who bother to read the small print that they have (automatically because they visited the website) granted permission for the website owner (or the liquidators when it’s VC debt funding runs out) to share/sell everything with third parties who can use it unaccountably for whatever purposes they want.

“Does the online provider offer services for people who are not able to consult in English?”

It’s interesting to note that this report from the RCGP is only made available in English.

“Questions about how the service is provided: Is a free NHS service being offered or will I have to pay for it? If I have to pay, how much and what payment schemes are available?”

I think this is going to be one of the biggest challenges facing Patients. Already we’ve seen free* video consults with Doctors offered by a range of website owners including some of the biggest corporations in the world and I think this paper could’ve done more to help educate Patients and Carers to this major issue and perhaps even offered suggestions to regulators (like the GMC, advertising standards agency, etc).

It should be made obvious to our Patients that their personal health data is worth more money than a few minutes of a Doctors time and that there are unscrupulous business people who know this and see it as an opportunity to get rich quick. I think it would be very sensible if the RCGP lobbied for legislation to be put in place to force corporations that market “Doctor consults” to not be using that statement as just a marketing headline to masquerade their real business model (which is to profit from the selling on of Patient information that they get from giving away or subsidising Patients so that they have an easy to use inexpensive opportunity to chat with a Doctor).

It’s interesting to note that in countries like the USA you would be sent to jail for involvement in this type of activity (yet it’s still commonplace in the UK).

“How much do I know about the qualifications, background and interests of the doctor who is advising me?”

I think this is an interesting question because it presumes that the best model is the one we have today with office visits where the Patient selects the Doctor. I think it’s becoming increasingly obvious that as we use and share information more productively we should flip this model and have Doctors selecting Patients based on their own particular strengths, personality and experiences.

“Am I able to get a follow up appointment with the same doctor who saw me first time?”

I’m surprised the RCGP isn’t maintaining the line that we have used here at 3GDoctor for the last 10 years that states “the best place to get care is with your Family Doctor”. I don’t think it’s particularly healthy to be encouraging Patients to become dependent on a particular remote Doctor and through the use of modern medical record documentation tools it should be possible for Patients to find continuity with a different remote Doctor or to get follow on support and advice from their Family Doctor.

“Am I confident that I will be able to provide as safe clinical care online as face-to-face? If not, how will the risk be managed?”

I don’t think there will be any Doctors who are going to be able to confidently say they can provide clinical care remotely as safely as they can provide it in an office because there are clearly practical things you can do in an office to ensure the safety of a Patient (obvious things like lock the door and call for assistance) that won’t be possible in a remote setting over a video call, but this should never be a reason to not make it more convenient for Patients to connect with Doctors because the reality is you’re naive if you think alternatives won’t be sought by Patients or that marketeers working for quacks won’t reach these Patients online. In 2018 by making registered Doctors harder to access we’re just making the services of unregulated services more attractive (remember the global sham ‘alternative’ medicine market is already generating sales of $200Billion a year and it’s a lot harder to dispel misinformation than to create it).

“Can I be confident about the identity of the patient I am providing online care for?”

I think we should also provide the capacity for Patients to anonymously obtain the independent impartial advice of a registered Doctor. The BMA offer this to all Doctors in the UK so I wonder why many Doctors don’t think that Patients might also value this same type of anonymity.

We should appreciate that anonymous services can be a great opportunity to start helping Patients who are putting off seeking help because they are too nervous or uncomfortable about a concern to initially share it with their family Doctor.

“Am I confident that the consultation is confidential, for example that no one else is listening in without the patient’s permission?”

I think the much more significant threat comes from the websites offering video consults with Doctors that have business models that are all about selling information and recordings of video consults onto third parties.

“Will there be any changes to my current indemnity costs?”

It absolutely amazes me that Doctors who prescribe medicines to strangers via websites pay the same medical indemnity costs as those who only see registered Patients in their office where they have access to their health record and a familiarity with their family and social background.

With huge year on year increases in costs it’s time more Doctors starting asking their professional medical indemnity provider if they are providing cover for Doctors who are working for these websites with scammy T&Cs and Privacy Policies because if they are you as another member are subsidising their massively increased risk profiles.

“Will I be part of a peer network so that I can seek help or support and avoid any risk of professional isolation?”

A bit of an odd one that as I think the RCGP is incredibly well placed to help with this and is really failing it’s membership on this front eg. wouldn’t it be great if the RCGP offered a community service like Doctors.net.uk for members?

Related Posts:

Can a quick phone call substitute for a doctor visit?

The doctor will see you now: NHS starts outsourcing mobile video consultations

“So, exactly why would one need to video call a doctor vs. just talking to them?”

If Patients see you uncomfortable using a mobile they may doubt how current your medical knowledge is

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