What is your name?
Dr Selena Stellman
What do you do?
I am a member of Nuffield Council of Bioethics and a GP.
What are your symptoms?
Ethical issues arising from the use of virtual consultations (VCs) in primary care. Virtual consultations include video consultations, online triage where a patient enters their symptoms into a computer programme/app and receives algorithmically-generated advice, or e-consultations where a patient completes an online questionnaire about their symptoms, which is reviewed and GP/administrator contacts patient with plan.
What worries you most about your symptoms?
My greatest ethical concerns regarding the increased use of VCs in primary care are widening health inequalities due to their potential impact on access to healthcare, and fundamental changes to the doctor-patient relationship.
As an inner city GP, I look after deprived patients already experiencing poor health, for whom VCs may not always meet their complex needs or be easily accessible. Our health system is already complex to navigate, and whilst the shift to VCs may benefit many, the most vulnerable risk being left behind.
When did your symptoms start?
The pandemic necessitated a shift toward alternative consultation modes, from face-to-face to more telephone and video consultations. This is an acceleration of an existing trend as VCs were already gaining popularity before the pandemic.
How often do you get symptoms?
The number of VCs conducted each month is estimated to be around 0.6 percent of primary care consultations. Anecdotally, their use is increasing, which is likely to continue with the NHS Long Term Plan aiming to ensure every patient in England can access digital primary care by 2023/24.
Please describe your main symptom.
Arguably the most significant ethical issue arising from VCs surrounds accessibility and widening of health inequalities.
VCs are accessible and easy to use for many, but not all. Many patients I look after do not speak English, are refugees or asylum seekers, have significant mental health problems, or are elderly. Others have learning disabilities or visual impairments, making it difficult to use VCs. Thirteen percent of UK adults do not have internet - predominantly older people and those from the most deprived socio-economic group.
These patients are not excluded from accessing healthcare entirely, but may be inadvertently disadvantaged. Practices increasingly request patients to first consult virtually and have long phone queues for booking ‘traditional’ appointments. Many practices have contractual obligations to respond to e-consultations within 24-48 hours, which is often quicker than the wait for a routine telephone or face-to-face consultation.
The same patients struggling to use VCs in the first place may therefore be further disadvantaged. There are already significant health inequalities within society, and the move towards greater use of VCs raises significant ethical concern around the widening of such disparities.
Do you have any other symptoms?
VCs significantly alter the nature of the interaction between doctor and patient. During face-to-face consultations, a human interaction takes place between doctor and patient which is fundamental for the therapeutic relationship. For example, GPs may notice a patient’s subtle body language, make an empathetic expression after disclosure of a sensitive issue, or offer a tissue to a tearful patient. These small gestures are fundamental parts of being a caring and compassionate doctor and human-being.
VCs (with the exception of video consultations) lack real-time doctor-patient interaction. Whilst this is not essential for all issues, it may be crucially important for others. A patient who is suicidal may complete an e-consultation, only to receive an automated message advising them to contact their urgent care centre or A&E. Whilst this may be safe management (and may be what is recommended after a face-to-face consultation), as a GP something feels morally uncomfortable about the void of human interaction and compassion occurring from this transactional and automated consultation.
Have your symptoms impacted your job?
GPs have had to adapt to new systems to monitor, triage and respond to VCs in a timely manner, and develop safety-netting measures to ensure patients do not experience harm. This significant change has inevitably placed strain on primary care.
Additionally, whilst VCs can save time and resources, they may have the unintended consequence of making GPs too accessible. In some practices e-consultations can be completed anytime, and for problems which are trivial or might have resolved by the time they had accessed a GP through traditional means (e.g. waiting for a phone appointment). Whilst I certainly do not advocate unnecessary barriers to accessing healthcare, primary care has finite resources. Offering almost unlimited access through VCs is unsustainable, placing stress upon GPs and diverting resources away from exactly the patients who need their GP most.
Do you consent to sharing of this information with others?
Data protection is another potential concern regarding VCs. VC tools are developed and sold by private companies, and clear regulation about the use of patient data collected through them is lacking. GPs and patients are often unaware how such data is processed and stored.
Confidentiality may be an ethical issue of concern. People’s phones and computers may not be secure, and so family members may be able to access messages or VCs without the patient’s consent. Additionally, in contrast to face-to-face appointments where only the GP and patient are present, some patients may find it difficult to a private space within their home to conduct a video consultation. This may lead to certain patients feeling reluctant to openly disclose their concerns, particularly those experiencing sensitive problems such as mental health difficulties or domestic violence. These challenges with regard to potential breaches of confidentiality may place those who are already vulnerable at risk of further ill health and exacerbate health inequalities.
Is there anything else you would like to tell us about your symptoms?
VCs have many advantages - quick, efficient and convenient access to GPs, and the potential for issues to be dealt with by other team members, saving GP time and using the healthcare team more efficiently. Video consultations may be particularly useful for patients unable physically attend the surgery, also saving the GP a time-intensive home visit. Ethically, there is significant benefit in freeing up scarce resources to enable GPs to spend time with patients who need it most.
VCs may also be helpful for patients lacking confidence to call their GP, for example due to anxiety or if they consider the issue embarrassing or difficult to talk about. Patients may find it easier to articulate their problem in writing with time to think it through, rather than on the spot under pressure.
Are there any treatments you think might help?
VCs have the potential to benefit GPs, patients, and the wider healthcare system, particularly taking into consideration the potential to use resources and time more effectively. However, it is essential that ethical considerations around access, widening inequalities, the impact on workload, and confidentiality are taken into consideration, and that the technology is not rushed out at the expense of some of the most vulnerable in our society.
Thank you for submitting your e-consultation. Your answers will be reviewed and you will be contacted with a plan in due course.
Totally agree with you Selena - great interview ! Econsultation etc makes working as a GP like being in a soulless call centre!
This is indeed disconcerting. The ethical questions raised all seem very pertinent. Hailing from India, I can completely relate to some of the points highlighted, especially the one on the digital divide.