Patient and staff concerns over GP online consultation tools

Patient safety risks

The investigation that underpins the report identified that online tools were not always accessible and easy to use, and did not always allow general practices to collect the necessary information they needed to make decisions about a patient’s care. These issues can put the safety of patients at risk. In the context of this report, online consultation refers to those where the patient and GP are not speaking to each other in real time.

Early on in the investigation process, patients and staff shared their concerns about patient safety incidents and online consultation tools when HSSIB was exploring the overall topic of the digital environment in primary and community care. This led to the investigation focusing specifically on online tools and we collected evidence from patients and staff across four focus groups and engagement with 16 general practices across England.

Less likely to seek consultation

Some patients said they or people they knew were less likely to seek a consultation with general practice about a medical problem if they had to use an online tool, whether through choice or because they were unable to.

Later patient conversations expanded on the reasons that people were unable to use the tools. The report states ‘HSSIB heard that patients are not always able to access and use online tools due to their personal circumstances, social exclusion or deprivation.’

During the focus groups, patients described feeling “frustrated”, “humiliated” and “embarrassed” when trying to use online tools; they said this made them less likely to want to use them. They also described a loss of “trust” that their general practice could provide for their needs. GP staff echoed these concerns, with some telling us that online tools disadvantaged some patients, reduced continuity in patient care, and had changed the value of consultations.

The issue of accessing online tools was repeatedly flagged during the investigation. For several patients engaged with, the increasing use of online tools to access care and for consultation led them to believe that they could no longer have telephone or face-to-face consultations. These beliefs coupled with difficulties in using online tools meant that some had not sought medical advice when they needed it.

Patient harm

Staff across general practices visited by HSSIB gave examples of where the use of online tools had contributed to harm or had the potential to harm patients. The harm resulted from missed or delayed care.

An example set out in the report was the case of delayed cancer diagnosis for a patient who was told by her general practice that they ‘had to’ use an online tool to request a consultation with a healthcare professional. The patient had a more aggressive form of skin cancer than first thought and as a result the delay may have contributed to needing more complex surgery.

Under-reporting of incidents

GP staff acknowledged that these examples were not always reported as incidents and this is a wider issue identified by HSSIB – that there is under-reporting of incidents in general practice overall and in relation to online consultation tools.

When undertaking searches of national reporting systems for serious incidents, the investigation identified a limited numbers of reported incidents. The finding of limited harm conflicted with what GPs, patients and academics had described to the investigation.

Our report says ‘..that conflict was heard to potentially be due to a lack of recognition and reporting of incidents, because the use of online tools in some practices was still in its infancy, and because GPs will “err on the side of caution” to maintain patient safety.’

Users not involved in design process

GPs also highlighted concerns about the design of online tools, the potential impact on workload and the different skill set and training needed to ensure online consultations were effective.

When we examined the design, procurement and implementation of online tools, we found limited evidence of users (patients and staff) being involved in the design process.

General practices also told the investigation they had limited oversight and support from their former clinical commissioning groups and current integrated care boards when procuring and implementing online consultation tools. This has contributed to variation in how tools have been implemented.

The report recognises that the introduction of online consultation tools into general practice is part of the national vision for a ‘modern general practice model’. Where general practices have transformed their ways of working to align with this model there are examples of the positive impact this has had.

We reference the benefits of the tools in the report and the national work undertaken to support implementation, although have not examined them more widely. Some patients who attended the focus groups were positive about online tools, particularly where it did not matter to them which healthcare professional responded to a request. They described getting quicker diagnoses and advice for some problems.