Online consultations in general practice:
the questions to ask
Online services provide a new way of consulting in general practice. Use of text based or video digital technologies has some advantages over established ways of consulting such as face-to-face meetings or the use of the telephone. It also carries risks.
A growing number of services are available online in addition to consultations, including booking appointments, ordering repeat prescriptions and checking symptoms. Some of these new services are offered by established general practices (and funding is currently available in England to help practices to develop such services) and some by new providers.
The focus of this paper is online services which support planned or actual consultations between patients and GPs.
Below are a series of questions that patients, clinicians, practice staff or commissioners might wish to ask to get the most out of the potential of these new services. The questions have been developed by a group of people who use GP services, clinicians, health service managers and academics. They have been agreed by the RCGP Council and are now being disseminated for wider use on the RCGP website.
The content of these questions has been influenced by research that is being carried out by academic teams based in Bristol, Warwick and London. Full references to this work can be found at www.bmj.com/content/360/bmj.k1195
If you are a patient using online services to get care:
Questions to ensure that the service is safe
- Has the service been inspected by the health regulator, the Care Quality Commission (www.cqc.org.uk) or its equivalent outside England, and am I satisfied with the report?
- Does the online provider offer access to UK-based GPs who are registered with the regulator of the medical profession, the General Medical Council?
- Will the online provider have access to my GP records so that they know about my medical history?
- Is it clear whether my personal information is being kept safe and confidential? Will it be shared with other parties (including my registered GP if appropriate) or used for purposes other than the direct provision of care?
- If the online provider wants to record my consultation, will I be asked for my permission to do so?
- If you require a prescription, will your medication meet UK quality standards?
Questions about the services available
- Does the online provider offer a full range of GP services, or a limited set of services? Is it easy to find out what services are available?
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- Will the online provider accept me as a patient whatever health problems I have, or will they exclude me if I have complicated problems?
- Is it possible to get a physical examination if I need or want one? How far will I have to travel in order to be examined?
- Does the online provider offer services for people who are not able to consult in English?
- Is it clear what will happen if I require a home visit?
Questions about how the service is provided
- Is a free NHS service being offered or will I have to pay for it? If I have to pay, how much and what payment schemes are available?
- Is the online service provided by my current GP practice or separate from it? If the latter, will I have to move my registration from my current practice to the online provider?
- Am I confident about how the system works, for example when I can expect to receive a response to a text-based query, or how the doctor will respond to my query?
- How much do I know about the qualifications, background and interests of the doctor who is advising me?
- Is information, support or training available to help me to use the system effectively?
- Am I able to get a follow up appointment with the same doctor who saw me first time?
- Is it clear how I can provide feedback on the service?
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If you are a GP considering working for an online provider:
Questions to ensure that I am able to provide safe care
- Has the service been inspected by the health regulator, the Care Quality Commission or its equivalent outside England and am I satisfied with the report?
- Am I confident that I will be able to provide as safe clinical care online as face-to-face? If not, how will the risk be managed?
- Is there a good system of clinical governance in place to ensure that the online service is safe and that any concerns that I might want to raise are acted upon?
- Will I have access to all or part of the patient’s regular NHS GP records?
- If the patient is registered elsewhere, will I be able to communicate effectively with the patient’s own GP?
- Will I be able to refer for further care, carry out appropriate investigations and access emergency specialist advice where necessary?
- Can I be confident about the identity of the patient I am providing online care for?
- Am I confident that the consultation is confidential, for example that no one else is listening in without the patient’s permission?
- Is it clear how I should deal with any safeguarding issues if they arise?
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Questions about the technology
- Am I confident that I know how to use the online system?
- Is it clear what I should do if the technology fails?
Questions about my professional standards and professional development
- What are the implications of working for an online provider for my annual appraisals and revalidation?
- Will the online provider support me to fulfill my appraisal and revalidation requirements?
- Are my prescribing and referring rates different when providing online care from face-to-face care? Are any differences justifiable?
- Is it clear who pays for my indemnity cover and the extent of the cover? Will there be any changes to my current indemnity costs?
- Is specific training made available by the online provider to help me to use the technology effectively and to improve my online clinical practice?
- Will I be part of a peer network so that I can seek help or support and avoid any risk of professional isolation?
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If you are a practice considering purchasing an online system:
Questions to ensure that the system is safe
- Has the online system been used elsewhere? If so has it been subject to CQC inspection or its equivalent outside England and evaluation? If so, what was the outcome and what learning do we need to take on board?
- Are our administrative and clinical staff fully trained to use the technology safely and effectively? Are we confident that staff can differentiate between presentations that may be dealt with effectively online and those that might require face-to-face contact?
- Is the system fully compliant with data governance regulations? For example, is it secure and are we clear about how information may be used beyond the direct provision of clinical care?
Questions to ensure that patients will be happy with the service
- Is the online system easy to use for patients? Are we confident that patients can differentiate between problems that can be dealt with online and those that require face-to-face contact?
- Is the online service available to all patient groups or is there a risk of exacerbating inequalities?
- Does the online system sell products to patients? If so, is this transparent and acceptable?
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Questions relating to strategic and operational planning
- Do we want an online system which is integrated into our current model of service provision with the service provided by our team, or do we want the service provided by an external organisation?
- Is there high quality and reproducible data on the likely impact of the online system on our total workload, taking into account possible increases in demand?
- Are we clear how we will monitor the benefits and risks of using the online consulting system?
- If we are, or plan to become, an undergraduate teaching or postgraduate training practice, what are the implications of the online services for our trainees, trainers and practice training requirements?
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If you are an STP, Health Board, CCG or practice network considering commissioning an online system for your locality:
Questions to ensure that the system is safe
- Has the online system been used elsewhere? If so has it been subject to CQC inspection (or its equivalent outside England) and evaluation? If so, what was the outcome and what learning do we need to take on board?
- Are we confident that the online system is compatible with data governance regulations?
Questions about the wider impact of a new online service
- What impact will online services have on access? Is it likely to address current demand or generate new demand? If the latter, are resources available to meet that demand?
- What impact will a new online service have on the scope and sustainability of current services?
- What impact will the online system have on health inequalities?
- What impact will a new online service have on the wider health system, including A&E attendances, hospital admissions and prescribing rates?
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Questions relating to commissioning responsibilities
- Do we want online services to be provided directly by current contracts holders or do we want to introduce new providers in a way that promotes competition?
- How will we evaluate the benefits and risks of the new service?
- What are the training needs of staff using the new service and how will they be met?
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