Newsletter June 2021 – Ian McDermott

When the COVID crisis first struck last year, back in late March 2020, most private practitioners were hit with an abrupt and somewhat brutal termination of almost all private practice. When the NHS took over most of the private hospitals, many private doctors were effectively thrown out on the streets with almost zero care or regard for us or our patients.

As you will all recall only too well, there then followed a period of months where only “emergency” private patients were ‘allowed’ to be seen, and then only with the permission of the local NHS leads. During this terrible time, the one thing that did help us all maintain at least some small degree of momentum, and that allowed us to be there for those of our patients that still needed us, was our ability to offer remote tele-consults from home.

Over the last 12+ months now, most of us have become used to and quite adept at delivering remote consultations via a variety of means, ranging from simple phone-calls to internet-based video consults using tools such as Microsoft Teams and Zoom that allow face-to-face conversation and a very limited degree of ‘examination’ (through just basic observation). These systems do, however, also allow us to go through results (such as imaging) with patients, which makes them particularly useful for some follow-up appointments.

It is important to recognise and acknowledge some of the distinct limitations of remote video consults. Whilst there are situations where a remote consult may be ideal, such as reassuring patients about negative results or simply checking on a patient’s progress after previous treatments, there are many times when a remote consultation can be a poor substitute for a proper face-to-face assessment and an actual hands-on clinical examination.

The negatives of remote consultations include:

• It is harder to guide or direct a conversation when speaking remotely, particularly on some systems such as Zoom that only allow one person to speak at a time.
• Remote consultations can often be slower, more tiring and more stressful than an equivalent face-to-face appointment, and there is a greater propensity for miscommunication and potential errors in interpretation.
• I.T. issues, such as slow internet speeds (at either the doctor’s end or the patient’s end) can render video consults extremely stilted and difficult.
• Clearly, it is impossible for most specialities to perform a proper clinic examination via just video link.
• Finally, some patients seem to not take their consultations seriously enough, in terms of ensuring that they are in an appropriately private and quiet environment. I had one video consult where a patient was a passenger in a moving car, with the rest of her family in the car with her. I also had one video consult with a doctor who was walking around outside their hospital yelling their personal details at me down their phone, with a poor signal and with a lot of background noise. I’ve also heard of colleagues who’ve had video consults where the patient has been speaking to them from their laptop whilst lying in bed! (In these kinds of circumstances, it is generally best to terminate the consult as quickly as reasonably possible, and to explain to the patient that the situation is not ideal and that they should re-book for some time when they can actually commit to the consult properly.)

Importantly, it is the responsibility of all doctors in practice in the private sector offering remote consults to their patients to ensure that their medical negligence insurance policy or indemnification organisation fully covered them for work of this specific nature.

Despite the negatives, remote tele-consults provided an absolute lifeline for many of us and for our patients during a time that for many of us was probably the most stressful and difficult of our careers, to-date.

If any good things can potentially come of the crisis of the last year, it is that it has prompted many of us to reflect properly on issues such as work / life balance, and ways of working: things that, ironically, many of us simply felt too busy to acknowledge or address. In terms of remote tele-consults, it feels like these are most probably here to stay with us for good now, to at least some degree: particularly for some of the more routine follow-ups and especially for patients that live long distances away, or even abroad.

Disappointingly, some insurance companies issued diktats last year that they were only going to offer reduced reimbursements for tele-consults, with some of the worst offenders reducing reimbursements by as much as 50%! This showed a crashing disregard for private consultants and for their patients.

On the other hand, BUPA, for example, took a far more professional and constructive approach, and they, instead, issued a new contract / agreement listing their expectations of what should be in place for a safe, appropriate and effective tele-consultation. BUPA’s first version of their contract contained a number of clauses that raised some concern within The LCA and within the Federation of Independent Practitioners Organisations (FIPO). Representatives of FIPO therefore engaged with members of the management team at BUPA, and entered into useful and constructive dialogue and discussion. The result of this was that BUPA duly amended their agreement, so that the latest version that we have seen is, we believe, a sensible, reasonable and appropriate contract that fully recognises and addresses the many various issues that remote consults can throw up.

Unfortunately, however, just at a time when things were beginning to feel more settled and stable, the CQC, in their wisdom, have now just issued fresh guidance that appears to state that private doctors can only undertake remote tele-consults from a CQC-registered facility, such as a registered private hospital or clinic. Their latest guidance, dated 10^th May, suggests that any doctor wishing to undertake remote tele-consults outside of a registered private hospital or clinic would themselves need to seek CQC registration as an individual! (https://www.cqc.org.uk/news/providers/exemptions-registration-independent-doctors) CQC registration is a complex and deeply onerous, time-consuming and expensive undertaking that is simply not practical for the very large majority of private doctors, as individuals. FIPO and the LCA believe that if the CQC does seek to impose and enforce this measure, it would be a pointless restriction of trade for many private doctors and it would cause direct and completely unnecessary damage to patients’ access to care.

Formal guidance already exists from both the GMC (https://www.gmc-uk.org/ethical-guidance/ethical-hub/remote-consultations) and the BMA (https://www.bma.org.uk/advice-and-support/covid-19/adapting-to-covid/covid-19-video-consultations-and-homeworking) relating to remote tele-consults. What we don’t now need is another entity sticking their oar in and further complicating matters unduly, and needlessly making doctors and patients’ lives even more difficult in these already horrendously difficult times. It does, sadly, make one question just how ‘in touch’ some of these organisations might really be with the realities of frontline healthcare?

At the time of writing, FIPO (the Federation of Independent Practitioners Organisations) and the LCA (the London Consultants Association) have written to Mr Ian Trenholm, the Chief Executive of the CQC, to raise our concerns and to request an opportunity to discuss the situation further. Hopefully, by the time of this going to print (or otherwise, hopefully soon after), there will be a further update on this, hopefully with some much-need good news!