‘Pulling complex patients out from under the sofa' - considerations for remote consultations with those who have additional needs’

Dr Pia Martinez, Dr Daniel Korn and Dr Carmel Boyhan Irvine belong to the Deepend group in Plymouth; a network of GPs working in Plymouth’s most deprived communities. GPs from three different primary care practices, they took part in a discussion, facilitated by researchers from the Remote-by-Default study about the shift to a remote primary care model in the wake of the Covid- 19 pandemic.

Digital healthcare and complexity need particular scrutiny

Complexity refers to patients who experience multi-morbidities and a range of psychosocial problems (i.e. drug and alcohol misuse, mental health problems, homelessness). They are the highest users of services but are also more likely to be digitally excluded.

‘It comes back to our attitude towards these patients and whether we have a willingness to deal with them or whether we would rather they fell under the sofa’

– a concerned GP on potential inequities in access to healthcare following the shift to remote consulting during the Covid-19 pandemic.

As part of the discussion the following 7 considerations for remote consulting with patients with complex health and social care needs were identified:

1. Ensuring Everyone Counts: clear communication about different access routes

Remote access to primary care may seem to be a problem for a few outliers, yet digital platforms are sometimes a preferred means of contact for some patients with complex social anxiety. However, the so-called outliers exist within the number tens of millions in the UK. The three GP’s were quick to identify a number of access barriers for their patient cohort during the pandemic that ranged from problems with: being unable to wait on phone lines because of low phone credit, poor connectivity, limited mobile data and Wi-Fi, low quality devices or no access to a device, and low digital literacy. Access barriers were not limited to an initial problem of getting an appointment but also whether patients were able to receive a call back from their GP. This was particularly problematic when devices are lost, stolen or pawned.

Although most primary care practices provided multiple access routes these were not always clearly signposted or widely communicated to patients. Online platforms appear to be the default means of access in some practices with contact telephone numbers less visible on primary care webpages. Clear and transparent communication about access routes needs to comply with equality legislation and be in keeping with NHS core principles and Everyone Counts values. Dr Carmel Boyhan Irvine warns that where patients experience barriers to access, NHS services may be in breach of General Medical Council quality, safety and communication standards.

2. The role of Digital Care Navigators:

GP’s were positive about the potential role digital care navigators could have in supporting patients with complex health and social care needs. They saw opportunities to work alongside existing community support services that could provide devices and digital literacy training including how to use online primary care assessment platforms. GPs were however sceptical about the logistical and infrastructural supports needed for successful implementation. For instance, a digital care navigator may offer useful support for planned appointments but what happens when a patient needs urgent access.

3. You may not want to talk about your mental health problems outside Aldi or with a load of people you don’t feel safe with

Lack of private spaces is particularly problematic for remote consultations for people living in insecure or multiple occupancy housing. If a patient appears distracted it can be difficult to tell whether it is because of the environment or whether poor communication is a health risk indicator. GPs reflected on the importance of rapidly following-up with patients and offering the choice for an in-person or a remote consultation. Simply being alert to this and asking whether people are able to talk freely is a potentially helpful opening question.

4. One Size Fits All is derogatory: the importance of patient choice and continuity

Getting to know your patients was seen as the best way to be responsive to complex patient needs. GPs were wary of blanket recommendations for remote consulting for patients with additional needs, and suggested that attempts to establish different procedures around specific patient groups was potentially demeaning.

Being responsive meant communicating with patients through whatever modality they preferred, even if it is may not appear clinically necessary to see someone face to face or might not seem time efficient if they prefer back and forth text messages. Dr Daniel Korn did point out the tension between demand and capacity but also questioned how much workload was being potentially duplicated with the number of telephone appointments changed to in-person appointments. Regardless of a clinical need, Dr Daniel Korn warns that little progress can be made if the patient is not comfortable or confident in the process of clinical assessment.

5. Don’t Forget the Hidden Cues

Dr Carmel Boyhan Irvine pointed out the findings from the Hammersley et al. (2019) study that suggest that remote consultations (video and telephone) are limited when trying to determine the problem in the patients psychosocial context. Practices situated in areas of high deprivation disproportionately care for patients who have complex psychosocial needs, which may be missed through remote consulting. GPs recognised the benefits of managing minor patient problems remotely but caution that hidden agendas cannot be picked up through online pre-assessment forms. Dr Daniel Korn recommends that when consulting remotely clinicians need to take time to facilitate a free flowing dialogue and notice the intonations in the patient’s voice.

6. Knowing your Boundaries

GP’s sometimes change remote consultations for in-person appointments if there is a potential clinical or safeguarding risk or if they cannot get a coherent sense of the problem. Dr Daniel Korn warns that GPs ought not to feel pressured to pursue a remote consultation just because that is how the appointment was booked in. Individual clinicians need to be free to establish their own boundaries, though thresholds will vary depending on their level of experience. For patients with drug and alcohol issues remote appointments are sometimes stopped because the patient is too sedated to engage in the consultation. Although, Dr Pia Martinez explains that as clinician’s become more experienced working with this population, they are more comfortable to continue a consultation with a patient who is under the influence of drugs and alcohol. To insist otherwise would mean that these patients would be unable to access healthcare.

7. Giving the Impression of Ample Time

There was a concern that the efficiency associated with remote consultations may have a negative impact on building rapport with patients. There is potential for remote consultations to become a tick-list speed exercise. Dr Martinez explained the clinician doesn’t necessarily spend any extra time with a patient, but should provide quality attention, avoiding appearing rushed and giving the patient the opportunity to talk longer if required. Most important, is the attitudes towards patients with complex problems. Dr Martinez advises clinicians with less experience of patients with drug and alcohol issues to make the parallel with other patients needing a compassionate response (i.e. patients needing palliative care or a complex diabetic). The patient needs time to articulate their problems and the clinician should be happy to give that time.

Listen to the full discussion in these two podcasts:

Part 1: What Covid-19 has taught us about remote consulting with complex patient groups

Part 2: What Covid 19 has taught us about remote consulting with complex patient groups