Remote consultations

Remote consultations have become more commonplace in primary care since the COVID-19 pandemic. They present multiple challenges, as well as benefits, for health professionals and patients to navigate. Emerging evidence indicates that certain patient groups may face additional or more complex barriers to communicating concerning symptoms to their GP via telephone or video.

As the shift from in-person to remote consultation at the start of the pandemic in early 2020 has been sustained to some extent, it is important that GPs and GP practices take steps to harness the benefits, mitigate risks, and adapt the consultation type to patients’ needs. The following information aims to support GP efforts to ensure equitable access to primary care and the timely recognition of suspected cancer signs and symptoms.

  • The proportion of GP appointments that take place remotely has slowly decreased since mid-2020. In the first few months of lockdown, nearly 50% of appointments in England took place via telephone or video1.

remote_consultation_graph.png

Graph showing proportion of GP appointments by mode of appointment, England

  • Remote consultations may provide a more convenient route to accessing healthcare for some people. However, primary care professionals should be aware that it might not be suitable for everyone, and therefore try to ensure equitable access to care by offering patients a choice of appointment type.
  • Much of the evidence and data around who remote consultations are most suitable for is situation-specific. Even within groups that typically benefit from remote consultations, this may vary depending on individual factors and preferences. The evidence- base should be used as a guide and health professionals should take an individualised approach when organising appointments.
  • Evidence and insight suggests that remote consultations may be more appropriate for specific groups, including: younger people, women, those having a follow-up appointment, patients with simple concerns, those living rurally and those with long-term stable conditions. Please see the 'Inequalities in access' accordion for more information about these specific groups.
  • In a CRUK Public Poll (December 2022), 54% of respondents were not provided with a choice between face-to-face and remote when arranging an appointment2. Qualitative data highlight a strong desire from patients and clinicians to provide or receive a choice of consultation type (face-to-face, video or telephone3). It is important not to take a ‘one-size-fits-all’ approach to consultations, but to recognise that remote consultations are more suitable for certain patient groups.
  • More research is required to understand the impact of remote consultations in primary care on clinical outcomes.

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There are potential benefits to remote consultations, such as facilitating regular and effective use of safety netting tools by health professionals4. Furthermore, the results from CRUK's Cancer Awareness Measure (CAM) surveys - run in March 2021 and September 2022 - showed a 5% increase (from 53% to 58%) in patients who reported that their concerns were adequately addressed using remote consultations5.


The following section highlights the potential benefits and challenges GPs and patients face around remote consultations, which were identified through an evidence review.

Access

Benefits

  • Improved access for:
    • Patients requiring translation or support services
    • Those living in rural areas
    • People who are housebound
  • GPs may have easier access to patient groups who find it challenging to access care in-person
  • More convenient for patients

Challenges

  • Variation in access to internet, devices and email​

Time/workload

Benefits

  • No travel time required
  • No need for patients to take time off work
  • Some GPs reported no impact on workload17

Challenges

  • Some GP concern around potentially increased workload7
  • Remote appointment considered futile if a face-to-face appointment is still necessary​

Confidentiality

Benefits

  • Video consultations considered superior to telephone and face-to-face consultations in some studies​14

Challenges

  • Challenges with technology, such as concerns over security of software
  • Concerns around privacy when people use video consultations at home

Technology

Benefits

  • Able to provide images or audio files for patient record​

Challenges

  • Wi-Fi connections
  • Limited image quality
  • Cost for patients and practices
  • Difficulty integrating new systems and software into current or older IT processes

Quality of care

Benefits

  • More timely communication of test results22
  • At home could be considered a better environment to receive serious news
  • Generally perceived as safe and effective​ by the public

Challenges

  • Diagnostic accuracy may be impaired5
  • Loss of body language cues
  • Unable to carry out a physical examination
  • Can be less information rich from both clinicians and patients13
  • Patients potentially raise fewer health concerns13
  • Limits educational opportunities for both patient and GP​

 

Main concerns from patients:

  • Disengaged in own care: patients may not feel able to ask questions or raise concerns as easily as when in-person6
  • Quality of follow-up: issues receiving supplementary information may occur (e.g., leaflets or emails not coming through)7
  • Privacy concerns: patients may be concerned by the security and confidentiality of online systems8
  • Access: there may be general confusion around how to get an appointment or the type of appointment they want, and uncertainty over the types of appointment available (e.g., video appointments are very rarely utilised)9
  • Technological concerns: interruption to the flow of conversation has been shown to impact consultation9

Main concerns from clinicians:

  • Lack of continuity of care: lack of communication and continuity of care in an already complex health system may impact health professionals’ ability to safety-net patients effectively and increase the risk of patients slipping through the net. This is referred to as the ‘Swiss Cheese Effect’4
  • Poor integration of technology into current ways of working: very quick initial uptake of remote consultations means practices may need to redevelop workflows, due to lack of training, lack of organisation and availability of technology10,11
  • Impacted clinical intuition: evidence suggests clinician gut feeling, as well as ‘doorknob disclosures’ from patients, are reduced in remote consultations, which are especially important when identifying non-specific cancer symptoms12,20
  • Concern for patient groups with less access12
  • Impact on health professionals: Research has shown that the shift to remote consultations can have a negative impact on health professionals’ mental health. This is due to the potential increase in workload via duplication6, anxiety around mistakes and liability without sufficient training for new ways of working and negative press about remote consultations13. For health professionals experiencing this, you can find access to help and support here.

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The following table presents the key groups that may be at a disadvantage by having a remote consultation.

Disadvantaged groups

Older patients 14-19

  • Research has shown that older patients can find it difficult to access online systems due to decreased health literacy or limited online access (e.g., no smartphone) and may therefore require support
  • Limited trust with online systems may be a barrier to disclosing all relevant information in an appointment
  • May have difficulty understanding or recalling advice provided online
  • Unable to rely on body language cues and lip reading if the person has a hearing impairment

Poor health literacy8

  • Research has shown patients are less likely to receive supplementary information (e.g., leaflets via email) compared to in person, which could have a greater impact on those with lower health literacy
  • Research has also shown that some patients may feel less confident asking questions or taking an active role in their care in a remote consultation, potentially reducing health literacy

Less affluent / lower socioeconomic position9,15

  • May not be able to afford the technology required for remote consultations (e.g., smart phones and laptops)
  • May encounter issues with phone credit and Wi-Fi connection

Men16,19

  • Research suggests that women use remote consultations more than men. The reason for this is unknown but may be influenced by gender preferences and patterns of disease

Refugees / Asylum Seekers21

  • Barriers identified in research include language barriers, access to professional interpreters, confidentiality fears, mobility of populations and lack of continuity, unwillingness to divulge information (for fear of legal repercussions, such as failed asylum seekers), and lack of knowledge about health service structure and how to access services

Learning disabilities9

  • Research has shown that communication issues can occur via remote consultations

Poor IT literacy15

  • For those who find technology more challenging to navigate, they can be put at a disadvantage when trying to access remote consultations and utilise the service effectively

Complex social situation (e.g., abuse)7

  • Unwillingness to divulge address or other personal information (for personal safety)
  • Privacy conerns when accessing remote consultations e.g., being overheard, lack of safe space to divulge about potential abuse
 

The table below highlights groups that can be advantaged or disadvantaged by remote consultations, depending on specific situations and this should be kept in mind by health professionals.

Groups that can be disadvantaged or advantaged (situation-specific)

Those with mental health issues13,15,20

  • Can find remote appointments helpful if the person finds in social situations challenging
  • Can find remote appointments distant and unsupportive 

Those whose first language is not English12,15,18,19

  • Internet connection and lack of body language cues can be a disadvantage
  • Research suggests the patient is more likely to communicate openly if the translator is remote rather than in person

Excluded groups e.g., travelling communities, homeless7

  • Can improve continuity of care, as GP can access patient wherever they are
  • Unlikely to keep up to date with changes in protocol in primary care

Visually, verbally, hearing impaired12,20,21

  • Written communicating e.g., e-consult and emails can be an easier way for this group to express themselves, but should not be used instead of providing support where a face-to-face or remote appointment is required
  • Internet connection and lack of body language cues can be a barrier

Rural communities  

  • Easier access as no need to travel12
  • Research shows concern around the risk that a two-tiered system could develop in rural areas if only online consultations are offered. This could potentially disadvantage those who already face barriers to access even further (e.g., those who are less affluent)12

Top tips on how to get the most out of remote consultations6,20

For clinicians

Improve communication with patients on how to access online services and help them make informed choices with open discussion of the potential advantages and disadvantages of the different consultation methods available.

Ensure people's support needs and appointment preferences are recorded, to allow appropriate appointment allocation in the future.

Book a follow-up face-to-face appointment if examination is required.

Actively enquire about non-specific but concerning symptoms with groups known to be less willing or able to come forward with information (e.g., those with language barriers, lower health literacy)

Adopt a proactive approach to safety netting, including booking in follow-up telephone calls and appointments where necessary and ensuring that people understand your safety netting advice.

 

For practices
Provide training to help staff identify people's ability to engage with remote consultations, build remote clinical skills and manage safeguarding concerns.

Include patients as co-designers of pathways to identify and address challenges, from booking to attending an appointment.

Invest in digital infrastructure.

Develop robust quality assurance processes. For example, monitor patient and staff satisfaction metrics regarding consultations, and check the quality of communication software.
Review information available to patients about the different consultation options, formats, location and equipment required.
 
Save our prompt sheet for your next remote consultation to ensure any potential barriers have been addressed.

  1. NHS Digital. Appointments in General Practice. [online] NHS Digital. January 2023 and January 2022 summaries. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice/ [Accessed 27 February 2023]
  2. Cancer Research UK’s Public Polling Survey. Unpublished findings.  Data collected online via YouGov Plc.  Total sample size was 2,052 adults. Fieldwork was undertaken between 16th - 19th December 2022. The figures have been weighted and are representative of UK adults (aged 18+). Please note that as of April 2023, the CRUK Public Poll is referred to as the CRUK Public Omnibus.
  3. HealthWatch. Locked out: Digitally excluded people’s experiences of remote GP appointments | Healthwatch [Internet]. www.healthwatch.co.uk. 2021 [cited 2022 Nov 4]. Available from: https://www.healthwatch.co.uk/report/2021-06-16/locked-out-digitally-excluded-peoples-experiences-remote-gp-appointments?mc_cid=fc67fe561c&mc_eid=08eb89404d
  4. Friedemann Smith C, Nicholson BD, Hirst Y, Fleming S, Bankhead C. Cancer in the time of COVID: Qualitative study of primary care practice and cancer suspicion during the first three UK lockdowns of the COVID-19 pandemic. British Journal of General Practice. 2022 Jul 22;BJGP.2021.0719. 
  5. CRUK’s Cancer Awareness Measure (CAM) September 2022. All figures, unless otherwise stated, are from YouGov Plc. Total sample size was 2387 adults. Fieldwork was undertaken between 20th September - 30th September 2022. The survey was carried out online. The figures have been weighted and are representative of all UK adults (aged 18+)
  6. Rosen, R., Wieringa, S., Greenhalgh, T., Leone, C., Rybczynska-Bunt, S., Hughes, G., Moore, L., Shaw, S., Wherton, J. and Byng, R. (2022). Clinical risk in remote consultations in general practice: findings from in-Covid-19 pandemic qualitative research. BJGP Open. [online] doi:10.3399/BJGPO.2021.0204.
  7. Leszczynski. R, et al. Remote consultations: experiences of UK patients with prostate cancer during the COVID-19 pandemic. Future oncology (London, England) [Internet]. 2022 Oct 17 [cited 2022 Nov 4]; Available from: https://pubmed.ncbi.nlm.nih.gov/36250591/
  8. HealthWatch. Locked out: Digitally excluded people’s experiences of remote GP appointments | Healthwatch [Internet]. www.healthwatch.co.uk. 2021 [cited 2022 Nov 4]. Available from: https://www.healthwatch.co.uk/report/2021-06-16/locked-out-digitally-excluded-peoples-experiences-remote-gp-appointments?mc_cid=fc67fe561c&mc_eid=08eb89404d
  9. Shaw SE, Seuren LM, Wherton J, Cameron D, A’Court C, Vijayaraghavan S, et al. Video Consultations Between Patients and Clinicians in Diabetes, Cancer, and Heart Failure Services: Linguistic Ethnographic Study of Video-Mediated Interaction. Journal of Medical Internet Research. 2020 May 11;22(5):e18378.
  10. James HM, Papoutsi C, Wherton J, Greenhalgh T, Shaw SE. Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework. Journal of Medical Internet Research. 2021 Jan 26;23(1):e23775.
  11. Greenhalgh T, Ladds E, Hughes G, Moore L, Wherton J, Shaw SE, et al. Why do GPs rarely do video consultations? qualitative study in UK general practice. British Journal of General Practice. 2022 Feb 16;BJGP.2021.0658.
  12. Greenhalgh T, Rosen R. Remote by default general practice: must we, should we, dare we? British Journal of General Practice. 2021 Mar 26;71(705):149–50.
  13. BMA. The impact of the pandemic on the medical profession BMA Covid Review 2. [online] Available at: https://www.bma.org.uk/media/5620/20220141-bma-covid-review-report-2-the-impact-of-the-pandemic-on-the-medical-profession-final.pdf.
  14. Randhawa, Ratan S et al. “An exploration of the attitudes and views of general practitioners on the use of video consultations in a primary healthcare setting: a qualitative pilot study.” Primary health care research & development vol. 20 (2019): e5. doi:10.1017/S1463423618000361
  15. Edwards HB et al. “Use of a primary care online consultation system, by whom, when and why: evaluation of a pilot observational study in 36 general practices in South West England” BMJ Open 2017;7:e016901. doi: 10.1136/bmjopen-2017-016901
  16. Mold, Freda et al. “Electronic Consultation in Primary Care Between Providers and Patients: Systematic Review.” JMIR medical informatics vol. 7,4 e13042. 3 Dec. 2019, doi:10.2196/13042
  17. Atherton et al. “Alternatives to the face-to-face consultation in general practice: focused ethnographic case study” British Journal of General Practice 2018; 68 (669): e293-e300. DOI: 10.3399/bjgp18X694853
  18. Parker RF, Figures EL, Paddison CA, Matheson JI, Blane DN, Ford JA. Inequalities in General Practice Remote consultations: A Systematic Review. BJGP Open. 2021 Mar 12;5(3):BJGPO.2021.0040.
  19. Turner A, Morris R, Rakhra D, Stevenson F, McDonagh L, Hamilton F, et al. Unintended consequences of online consultations: a qualitative study in UK primary care. British Journal of General Practice. 2021 Oct 20;BJGP.2021.0426.
  20. Archer, S., Calanzani, N., Honey, S., Johnson, M., Neal, R., Scott, S.E. and Walter, F.M. (2021). Impact of the COVID-19 pandemic on cancer assessment in primary care: a qualitative study of GP views. BJGP Open, 5(4), p.BJGPO.2021.0056. doi:10.3399/bjgpo.2021.0056.
  21. Powell, R.E., Henstenburg, J.M., Cooper, G., Hollander, J.E. and Rising, K.L. (2017). Patient Perceptions of Telehealth Primary Care Video Visits. The Annals of Family Medicine, [online] 15(3), pp.225–229. doi:https://doi.org/10.1370/afm.2095