The doctor won’t see you now: online consulting and prescribingBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e7238 (Published 30 October 2012) Cite this as: BMJ 2012;345:e7238
- Margaret McCartney, general practitioner, Glasgow
Telephone consultations are second nature to most general practices, but what about online consultations? Some NHS doctors offer email contact with patients, interspersed with face to face consultations. However, many private companies now offer the whole consultation and prescription process online, claiming this to be efficient and popular.
Tony Steele, a general practitioner, set up online medical services through his website, DrFox (www.doctorfox.co.uk), two years ago. He told the BMJ that many routine face to face consultations with GPs could be done safely online. He said, “It should be possible to do the necessary safety checks without interfering with primary care’s function. We are aware that some treatment areas are complex, and we don’t get involved in that. Hay fever or malaria medication would normally involve an appointment with the doctor, whereas online it may actually be better.” The site also provides copious written information for patients.
Steele told the BMJ, “We know that in ED [erectile dysfunction], the NHS will fund only small quantities [of drugs], and most men don’t qualify for a supply on the NHS, so it will likely be a private prescription anyway. Many people with busy lives might need a stopgap when they can’t get it from their GP, they are busy at work, or have travel commitments. We would only do this if there is the mechanism for making sure it was safe and by doing the necessary checks.”
Steele is aware that his service doesn’t have access to notes on medical history. He said, “We are more conservative than any other clinic we know.” He also said that a GP’s contact details are required when women request repeat supplies of contraceptive pills or cystitis treatment. However, for other treatments between 20% and 30% of patients ask for details not to be sent to their GP. The DrFox website has 2500 visitors a day, with 5% making an order. Half these orders are repeat prescriptions, especially for erectile dysfunction drugs, travel drugs, and cystitis. The site has issued 70 000 prescriptions to date, with no reported adverse effects (personal communication).
There are many other clinics competing online. Tom Van Every set up his private online clinic, www.DrThom.com, in 2002, when working in a genitourinary clinic in London. “It was obvious that patients were embarrassed,” he told the BMJ, as well as inconvenienced. “The idea was to mimic a visit to the clinic by putting it all online, with information, advice, and postal diagnosis.” By about 2006 he decided that adding treatment would be useful. “At that time, and it still exists today, there was a bad perception of online medicine.” The site became registered with the Care Quality Commission, with the aim that it could substitute for patients’ visits to their regular GP. Last year the business was bought by Lloyds Pharmacy, where Van Every is now medical director, and now the service also offers to manage chronic asthma. The Lloyds website says, “Join over 250 000 patients who’ve used our online doctor service to obtain prescription only medicines and postal testing kits without the need to see a doctor face to face” (https://onlinedoctor.lloydspharmacy.com).
Van Every thinks that many conditions can be managed safely without the need to see a patient in person. “There is a lot of dogma, and we are taught that patients have to be seen. In most cases there is no evidence that underpins this belief. In fact, with the right sort of targeting of remote care, it can work very well.” The business audits its doctors’ work and collects feedback from patients. If there is doubt about a patient’s suitability for treatment, the patient is telephoned for a discussion.
Van Every described a situation in which a woman could attend a pharmacy for a blood pressure reading, fill in a questionnaire online on a handheld computer in the shop, and get the contraceptive pill dispensed to her within a few minutes. DrThom has issued half a million prescriptions since the site began, although most of the workload remains in sexual health.
But could patients answer questions minimally or miss out important information to get a prescription more quickly or easily? “The range of services is not so catastrophically risky that patients would come to grief,” Van Every said. “We have processes in place that minimise that risk, but ultimately, like any part of medicine and history taking, a great deal relies on trust.” He said that the company ensured that patients understood the risks of taking drugs through its service. He described the system as “hyperefficient” and said that a doctor was able to safely oversee 100 patients an hour.
Currently, many NHS GPs manage prescriptions online for patients but without rafts of dedicated support. If some conditions can be managed online at some points for the benefit of patients, then surely this shouldn’t be limited only to those people able to pay? Otherwise the risks produced by inequality and fragmentation of care may deepen. But clear evaluations of the limitations of entire consultations moving online are needed: GPs are trained in the value of face to face consultation, of cues, the facility of silence, open questions, and the “door handle moment” (when a patient voices concerns when seemingly also about to leave).
Moving more consultations into the realm of the tickbox based protocol has the potential to dehumanise medical interactions. On the DrThom website, for example, in treatment for depression, patients are asked to give “informed consent,” pledging that “I understand that in an emergency or if I feel a risk to myself or others I will contact my GP or voluntary service such as the Samaritans.” The site does not prescribe antidepressants, but in mental illness this hardly seems like fair sharing of risk between doctor and patient. Additionally, the value of personal relationships and interaction is lost. Any advantage of online healthcare has to be carefully balanced against what could be lost.
Cite this as: BMJ 2012;345:e7238
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.