The Doctor May Not See You: A Lack of Face-to-Face GP Appointments and Significant Delays Harming Patients

Despite the Government declaring that all remaining Covid-restrictions were dropped on 16 August, some GPs and dentists are among primary healthcare providers which remain under lockdown conditions with face to face appointments being significantly reduced and thousands of appointments being cancelled.

Recent data from NHS Digital showed that in July 2021 only 57.2 per cent of GP appointments in England were conducted face-to-face i.e. 14.6 million patients had a face to face appointment. Although this figure is higher than the 46.8 per cent in April 2020, as the first Covid wave swept across the UK, it is much lower than the 80 per cent figure before the pandemic.

Covid and the impact on care provided by GPs

Any treatment, however complex, usually begins with a trip to the local GP surgery. While this system had some inconveniences, the importance and value placed on the GP and patient relationship meant the system has remained largely unchanged to the present day.

However, Covid-19 changed everything. A system that had revolved around face-to-face appointments transformed almost overnight, and remote appointments, once something of a rarity, became the norm. For many, this was an improvement, remote appointments can be more convenient and easier to manage, but for others, the lack of face-to-face contact meant significantly worse health outcomes.

Two core issues impacting patient care:

  1. Remote consultations could increase the chance of misdiagnosis

  2. Some GPs still not offering enough face to face appointments, despite recommendations from the Government to ease Covid restrictions post-lockdown. This has led to serious delays in obtaining an appointment.

In a HealthWatch report “GP access during COVID-19 A review of our evidence: April 2019 – December 2020”, Sir Robert Francis QC, Chair of Healthwatch England noted:

“For some people the rapid digitalisation of care has worked. Our previous report The Doctor will Zoom you now highlighted how for many, remote consultations were more convenient, making access to care quicker, more efficient and easier to fit around their lives. Therefore, it is important that where people’s experiences of accessing care have improved, that we acknowledge this and make the improvement a permanent feature of the system. On the other side of the coin, it is clear many people are now struggling to access care from their GP, often simply because they do not know how.

This is leading to people feeling that GP practices are not ‘open for business’ or that they should not seek care for their health issue because of the pressures the pandemic has placed on the NHS. This puts people’s health and wellbeing at risk and increases demand on overstretched hospitals – both from those who cannot get a GP appointment so seek care at A&E, and from people who now need more advanced care and treatment because they were unable to get help sooner.”

The Healthwatch report involved a thematic analysis of 10,089 people who have shared their experience of GP services via local Healthwatch or directly with Healthwatch England between April 2019 and December 2020 – and highlighted 4 key issues they have faced when trying to access care and treatment:

  • Communication: Communicating information about changes to services because of COVID-19
  • Difficulties booking an appointment: Problems getting through over the phone and “problems booking appointments because of triage systems and not being sure when their GP or other healthcare professional will call back, leaving people feeling anxious.”
  • Appointments not meeting people’s needs: “These problems were exacerbated for disabled people, people with long-term health conditions, people without access to the internet and for anyone whose first language is not English”
  • Access to regular treatment and medication: “People also struggled to get appointments for regular health check-ups, treatments and medication reviews. As a result, they were unable to get the medication and treatment that they need to manage their condition.”

The report also noted that Routinely offering remote appointments before face-to-face appointments disadvantaged some groups, particularly:

  •  People on persistent low incomes
  • Some older people
  • People with learning disabilities
  • Autistic people
  • People with Dementia
  • People whose first language isn’t English.
  • Homeless people
  • People with sensory and communication impairments
  • People who cannot access technology (e.g. no internet access, a laptop or smartphone or because they find it difficult to use technology)

Remote GP appointments and the risk of misdiagnosis and mistakes

There are several factors that affect the quality of phone and remote appointments. When the pandemic started, GPs were advised to use remote appointments wherever possible. While some GPs had been using remote appointments successfully for many years, most GPs were forced to adapt to new ways of working almost overnight and with next to no training on how to best conduct remote consultations. This, undoubtedly, affected the quality of care offered to patients.

There are also some fundamental problems that mean remote appointments are not always suitable.

  • The most obvious is that a GP cannot perform an examination on a patient. While some attempts to overcome this can be made using pictures and video, these rarely meet the same standard as a direct examination in a well-lit surgery, and the GP is totally unable to touch or manipulate anything. Nor can they conduct simple tests since few people have even basic medical equipment in their homes.
  • There are also communication difficulties. Even excluding those for whom language barriers make non-face-to-face communication difficult, those with fluent English may still lack the specialist vocabulary to adequately describe their symptoms. While the GP should take steps to ensure full understanding, it can still mean that misdiagnoses are made.

Coroner highlights five cases in which remote appointments a factor in deaths

Alison Mutch, the Senior Coroner for Greater Manchester South, recently highlighted five cases where, she believed, remote appointments were a factor in the deaths. In each case, the use of remote appointments, whether by telephone or video, meant that opportunities to spot problems were missed.

Alison Mutch wrote five prevention of future deaths reports highlighting concerns that doctors were missing details in telephone appointments which may have been spotted, had the patient been seen in person. Prevention of future death reports are created by coroners and are then sent to people or organisations that are in a position to reduce the risk of a person dying under the same circumstances in the future. Ms Mutch sent five reports to health authorities – including local trusts, Health Secretary Sajid Javid and NHS England – asking them to take action to deal with the risks associated with remote appointments.

Five cases noted by the coroner as being associated with a lack of face to face GP appointments:

  1. Maurice Leech: Broken femur missed

Maurice Leech died in April 2020 after breaking his femur. The hospital did not X-ray this part of his leg and discharged him to his care home. The broken femur was missed in both a previous hospital visit and a virtual appointment. Mr Leech had told the GP of his pain but could not be given an examination. By the time the problem was discovered, Mr Leech’s condition had deteriorated and following complications he died in hospital.

The coroner noted that, had a GP physically examined Mr Leech, he would have been sent back to hospital earlier.

  • Brian Mottram: Covid misdiagnosis of a high risk patient

Brain Mottram died in November 2020 from covid-19 pneumonitis.

Mr Mottram had previously had surgery for lung cancer and also had diabetes, so was at high risk from Covid-19. He called his doctor after feeling unwell for a week and, in the telephone appointment, described his symptoms which included a temperature, shortness of breath, and a cough. His doctor prescribed him with antibiotics. However, two days later he was found unresponsive and subsequently died. It was discovered that he had, in fact, contracted Covid-19.

The coroner’s report questioned whether he may have been diagnosed with covid-19 before his death had his GP appointment been face-to-face.

  • Fadhia Seguleh: Impact on patients with mental health issues

The lack of face-to-face appointments are not just an issue for physical health conditions. Ms Mutch also highlighted cases involving mental health issues, suggesting that case management suffered because of the lack of in-person appointments.

Fadhia Seguleh, who was being treated for anxiety and depression, died by hanging in February 2021.

The coroner concluded that appointments to help manage Ms Seguleh’s mental health conditions would have been face-to-face before the pandemic, and her care would have been better. The result was that, although her GP was aware of her condition, they may have missed warning signs that indicated a deterioration which could have resulted in a life-saving intervention. However, Ms Seguleh took her own life.

Among the coroner’s concerns were that her GP assessments were over telephone due to covid and the inquest “accepted that assessments of mental health risk and understanding of need was far easier to assess face to face”.

  • Stanislaw Zielinski : Mental health referral lost

The coroner reached a similar conclusion with Stanislaw Zielinski. Mr Zielinski died in died in November 2020 after he was hospitalised when he fell from an upstairs window.

His wife reported that he believed he was being chased by people and was trying to escape when he fell. He had previously suffered from anxiety and insomnia and had alerted his GP that his mental health was deteriorating but had only had telephone appointments for a year. Although he had been prescribed medication, this had little effect, and a referral to a mental health service was lost.

The coroner’s report said “he and his family struggled to communicate with the GP to explain his deteriorating health position as a result of how his GP practice was delivering healthcare” and “as a consequence his deteriorating picture was not fully understood by his GP”.

5.Steven Allen: Monitoring of medication did not occur

Steven Allen died October 2020 and a toxicology report found a fatal level of prescribed medication in his system.

Finally, the coroner highlighted Steven Allen, who had a history of drug addiction. Despite this, he was prescribed oxycodone, an opioid-based painkiller that is frequently used recreationally and, therefore, not usually suitable for people with addiction problems. Despite this, the coroner reported, he was able to obtain the drug and get repeat prescriptions with little challenge in phone appointments. Mr Allen died following an overdose of the medication he had been prescribed.

The coroner’s report noted the pandemic meant his medication was being prescribed through telephone consultations and, on occasion, he was being provided with replacement prescriptions with little challenge.

A lack of GP appointments also affecting cancer diagnosis

Jessica Brady, 27, from Stevenage in Hertfordshire, passed away from liver cancer in December 2020 after GPs failed to spot a tumour for five months during remote appointments and refused to see her in-person. Even after seeing a GP in-person, it was not until she went to a private doctor that she was diagnosed with stage four cancer of the lungs, bones, spine and liver.

Her mother, Andrea Brady, spoke to the Health and Social Care Committee  on September 17 2021. She advised that Jessica was repeatedly denied an in-person appointment after first complaining of abdominal pain last year.

Mrs Brady commented:

‘I think the most important thing is we feel, and Jess felt that no one listened, no one took it seriously and more than anything, she needed a permitted face-to-face appointment really early on, with people making notes. 

‘And also, during all that time, she wasn’t seen by one designated doctor, four different doctors spoke to Jess and prescribed her medication. And we think that was really key. 

‘No one person was looking at the whole picture and putting the pieces of the jigsaw together. That didn’t happen until two days before Jess received her diagnosis, when I think there was an element of panic, because she was receiving quite a lot of phone calls at that stage, and saying you probably need a gastroscopy.

‘In fairness, if that had happened three months earlier, obviously her cancer would not have spread – well we think it wouldn’t have spread so aggressively by then – so I think it’s fair to say that Jess was a very gentle, sweet person, but she really did attribute her late diagnosis to the slow reaction of her GP surgery.’

A lack of face to face appointments contributing to a rise in still births

A lack of in-person appointments during the pandemic may have led to a surge in stillbirths, a report has warned.

According to a The Healthcare Safety Investigation Branch (HSIB) report, stillbirths were up 88 per cent in 2020 compared to pre-Covid levels. Its investigation into 37 cases found the move to remote appointments (particularly by midwives and obstetricians) ‘impeded’ medics’ ability to carry out vital checks. 

The HSIB said there were 45  ‘intrapartum stillbirths’ in England from April to June last year – 88 per cent more than the 24 during the same period in 2019. These are deaths where a baby was thought to be alive at the start of labour but was born, beyond 37 weeks of gestation, with no signs of life. The majority of the stillbirth deaths occurred due to problems with the placenta and compromised blood flow to the baby. 

The HSIB report says: ‘The proportion of consultations undertaken remotely is not known and the impact of remote consultations is not clear… However, there was evidence that remote consultations impeded certain activities.

‘Specifically, there were fewer opportunities for physical examinations to be carried out, limiting the opportunity to establish trends for [growth] measurements.’

Some GPs cancelling or significantly delaying appointments

Some GPs and dentists are turning away patients in order to continue with continue with Covid-19 infection control measures (eg. self-isolating, social distancing) despite the Government relaxing self-isolation guidance last month. This means that patients are having their appointments cancelled if they or a family member has tested positive for Covid.

Dr Richard Vautrey, chairman of the BMA’s GP committee, said: “Managing this risk is especially important as Covid-19 infection levels remain high in the community, with average daily hospitalisations and deaths also rising. Many people coming in to GP practices are already very unwell, and should not be exposed to what is still a deadly virus if it is avoidable.”

Professor Martin Marshall, chairman of the Royal College of GPs, added: “Although Covid restrictions are now easing, this pandemic is still far from over and decisions on appointments need to be based on a number of factors, primarily on the needs of the patient but also on the capacity of the practice and the potential risk of infection to other patients and practice staff.

“GPs will make every effort to fulfil appointments, where clinically appropriate and safe, but we also need to make important judgements to ensure that practices can continue to run safely and effectively for all patients.”

For some, it’s possible that their conditions have worsened because of the delay, leading to poorer outcomes and complications.

The public is demanding more face to face GP appointments and faster care

Campaign group Silver Voices, which represents the over-60s, has launched a petition calling for a legal right to in-person appointments. Dennis Reed, the director of Silver Voices, is calling for patients to be given a legal right to ‘timely face-to-face GP appointments’

Mr Reed said: ‘If you can get through to your GP surgery on the phone you’ll be interrogated by a receptionist and have to jump through so many hoops to get an appointment. Many elderly people find this so daunting that they have just given up trying and are suffering at home. It’s very worrying and stressful for them.’

Mr Reed added: ‘We are worried that serious conditions are going undiagnosed, people are getting sicker and dying as a result. Ministers must get a grip on this now.’

Have GP delays and mistakes affected your care?

If your diagnosis and treatment was delayed by your GP or your GP made mistakes in your diagnosis or failing to refer you for further tests, you could be entitled to claim compensation for the harm caused to your health and well being.

Trained medical professionals can be held accountable for mistakes and negligence. Serious negligence can lead to life-threatening situations in the case of a dangerous progressive illnesses such as cancer, or ongoing disability and long-term poor health.

If you are considering suing your GP and need help with a negligence claim, don’t hesitate to contact us right away. We can help you determine whether you have a valid claim and take the steps to ensure that you get the maximum compensation you deserve.

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There can be time constraints for filing a claim, so if you suspect that you may be entitled to compensation, get in touch today. Call us on 0333 900 8787, email or complete our online contact form.

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