Patients at risk from virtual GP appointments

Doctor video call
Doctor video call - Kiwis/iStockphoto

GP appointments over the phone or online risk harming patients, a new study published in the BMJ Quality & Safety journal has found.

An analysis of remote NHS doctor consultations between 2020 and 2023 found that “deaths and serious harms” had occurred because of wrong or missed diagnoses and delayed referrals.

Distracted receptionists were also found to be responsible for deaths after they failed to call patients back.

The report, led by the University of Oxford, suggested doctors should stop giving phone appointments to the elderly, people who are deaf, or technophobes.

As many as a third of GP appointments are now virtual after face-to-face appointments slumped to less than half during the pandemic.

Restoring access to face-to-face appointments has been a priority of multiple health secretaries, with Steve Barclay last year promising to name and shame GPs who did not see patients in person.

Patient groups said the study was likely to be “just the tip of the iceberg” given the “potential for tragic misdiagnoses because of the limitations of online or telephone consultations”.

Researchers said incidents involving death or serious harm were “rare” and that the “vast majority of remote clinical consultations in general practice” were safe.

Experts from the University of Oxford examined 95 serious safety incidents in Britain since 2020 in which patients came to harm.

Errors made over the phone included missed diagnoses or an underestimation of the severity of a range of serious conditions including sepsis, cancer, congenital heart disease and diabetic foot complications.

They said they “would likely have been readily diagnosed with an in-person examination”, and found there was more risk of patients coming to harm if they had urgent conditions including new chest or abdominal pain, palliative care, physical injuries or diabetes, or if they were particularly young or old.

In one case, a 16-year-old girl was diagnosed with glandular fever by a GP over the phone, but died of sepsis shortly afterwards.

In another, a new mother died from a missed pulmonary embolism, while NHS 111 staff diagnosed a pregnant woman with “urinary problems” rather than the premature rupture she was having.

Communication problems with GP receptionists also caused deaths, the study revealed, with one woman in her 70s who was suffering from sudden breathlessness being told she would be called back, only for the receptionist to be distracted by a patient in the waiting room. The patient died at home that afternoon.

Researchers also revealed that remote consultations were more likely to lead to family doctors being swayed by what had been said to the patient before and repeating a previous diagnosis. They said less qualified staff may be less likely to act on signs of illness.

The report recommends that doctors are not distracted while conducting phone calls and go over treatment plans and next steps with patients at the end of a consultation, giving them opportunity to ask questions.

It says patients should be seen in person if they are not improving after previous remote appointments.

The Telegraph has previously revealed that more than half of GP appointments no longer involve a doctor following an influx of pharmacists, physician associates and other roles into surgeries.

In October, three in 10 appointments were delivered remotely, down slightly on August but considerably more than pre-pandemic, when more than 80 per cent were delivered face-to-face.

The number of video consultations has also boomed in the last two years, rising fourfold from around 150,000 per month to 600,000.

During the pandemic, some GPs were allowed to work remotely, up to 250 miles from their practices.

The study, published in the BMJ Quality and Safety, cited challenges around communicating effectively with patients remotely, claiming “poor rapport-building” was a problem as well as “inadequate information-gathering”, “limited clinical assessment” and “inadequate attention to social circumstances”.

Dennis Reed, the director of Silver Voices, an over-60s campaign group, said the “sobering and hard-hitting study justifies our long campaign to increase the number of face-to-face appointments back to pre-pandemic levels”.

He added: “We have constantly referred to the potential for tragic misdiagnoses because of the limitations of online or telephone consultations, and we fear that the examples quoted in this study are just the tip of the iceberg.

“The Government  has waxed and waned in its bid to get practices to increase the number of face-to-face appointments, and this research should stiffen ministers’ resolve to make immediate progress on the issue”.

A similar study by BMJ Quality and Safety in 2010, when phone appointments were far less common, concluded that they “may compromise patient safety”.

In some cases, GPs admitted there were limitations in remote consultations. One recalled how a father “underplayed” his child’s illness on the phone, saying:  “[He] really didn’t seem to be too concerned, and was very much underplaying it and then when I did a video call, this child had intercostal recession [and] looked really, really poorly.

“It was quite scary actually – you’d had the conversation, and if you’d just listened to what dad was saying, actually you probably wouldn’t be concerned.”

Prof Trish Greenhalgh, the chief investigator, from the University of Oxford, said: “The vast majority of remote clinical consultations in general practice are safe, in large part because staff are alert and err on the side of caution.

“When safety incidents happen, organisational pressures and poor communication often play a major role. This new research has identified more precisely where the risks lie and what measures we can take to reduce risks further.”

Dr Rebecca Rosen, of the Nuffield Trust said: “Every clinician must be aware of high-risk symptoms for which it’s safer to see patients face to face; must listen and respond carefully to patients who say they need an in-person appointment and should consult face to face if a patient has not improved after previous remote consultations.

“We can also ensure that patients have the knowledge and tools to help them to get the best out of their consultations.”

An NHS spokesman said: “Every GP practice must offer face-to-face as well as telephone and online appointments, and almost seven in 10 appointments are being delivered face-to-face. Patient preference must be considered alongside clinical needs, and remote appointments are only provided when clinically appropriate.”