Medical Negligence Expert answers common questions you may have about seeing your GP.

Sophie McGarry, Solicitor at Patient Claim Line, has shared what your legal rights are to an in-person GP appointment and what you can do if you have been misdiagnosed as a result of a telephone or video GP appointment.

Do patients have the legal right to an in-person GP appointment?

GP patients must now be offered face-to-face appointments if that is their preference.

NHS GP states: “According to new NHS guidance, practices in England must offer face-to-face appointments if requested. GPs who fail to make the necessary arrangements for patients to make an appointment without having to spend hours on the phone or who are not available for face-to-face appointments are, in the strictest terms, breaking the law.”

NHS England has issued guidance to practices which says that GP practices must all ensure they are offering face to face appointments and practices should respect preferences for face-to-face care unless there are good clinical reasons to the contrary, such as the patient is displaying COVID symptoms.

NHS England states: “While the expanded use of video, online and telephone consultations can be maintained where patients find benefit from them, this should be done alongside a clear offer of appointments in person”.

If someone feels they need an in-person GP appointment but aren’t offered one, what steps can they take to request one?

In their letter to GP Practices, dated 13 May 2021, NHS England states, at a minimum, that clear advice should be provided and maintained on all practice websites regarding:

How to contact the GP and ask for help
How face-to-face or walk-in services can be accessed

Firstly, you could check your practice’s website to see if there is any information about how face-to-face or walk-in services can be accessed. If you are unable to locate this on the practice’s website, you could ask the practice to provide you with this information. If you come up against resistance from the practice, you could refer them to NHS England’s letter which states that this information should be available on their website, as a minimum.

Ask your GP Practice to arrange an in-person appointment for an assessment, examination or testing and explain why you feel a face-to-face appointment is necessary. Explain that it is your preference to have a face-to-face appointment and you can quote from the NHS England guidance that GP Practices must all ensure they are offering face to face appointments and practices should respect preferences for face-to-face care.

If the GPs or receptionists continue to refuse to examine you in person, you could ask for the matter to be escalated to the Practice Manager and ask them to explain why your wish and request for a face-to-face examination is being refused.

Are in-person appointments safer/are you less likely to be misdiagnosed?

Telephone and remote assessments have their place for certain, minor issues but, overall, I believe in-person appointments are safer and you are less likely to be misdiagnosed than if you had a remote assessment.

If a GP is assessing someone by telephone, there is no opportunity for them to conduct any tests or examinations. If a GP is assessing someone in person, even if they just want to perform the examinations as a precautionary measure, this is more likely to identify an abnormality than a telephone appointment. An in-person appointment also lends itself to any incidental findings which would not be spotted during a telephone assessment.

During a remote assessment, a GP is completely reliant on asking the right questions and the patient providing the right answers.

People are also discussing difficult and sensitive, personal issues. It may be easier for them to open up to a GP in an in-person appointment, where they are receiving face-to-face, hands on, human care which is much more personable, rather than speaking to a voice asking questions on the phone. Remote appointments can leave patients feeling like there is a disconnect between them and their GP and like there is less ‘care’. In stressful and emotional situations, patients will find comfort in the GPs physical presence and human touch.

During an in-person appointment, patients are in the room with their GP, solely focusing on the consultation and discussing their symptoms. Telephone GP appointments can catch patients whilst they are at work, driving, or doing the shopping so the patient may not be able to give the appointment their full, undivided attention.

What are the potential pitfalls of remote assessments?

As outlined by NHS England, without adequate training, support, and process development, staff may struggle to optimise patient care through remote means. In these circumstances remote consulting could result in:

delayed or missed diagnoses
over or under investigation of patients
increasing the burden on clinicians to make judgements remotely
reduction in the therapeutic relationship between patients and clinicians
increase in the transactional aspect of care over personalisation, where patients experience limited interactions remotely or feel they are unable to see their doctor face-to-face
missed opportunities to pick up on subtle cues during a face-to-face consultation
digital exclusion of certain patient groups
increasing complexity for reception staff when booking in patients to different consultation types
Barriers to technology or simple blockers, such as a poor phone signal, can become problematic for patients being asked to consult remotely.

Are there any demographics which are more difficult to assess remotely?

Generally speaking, children, elderly and those with mental health issues or communication difficulties, can be more difficult to assess remotely.

Children can have difficulties expressing themselves and their symptoms so this may require more careful assessment.

The elderly may be hard of hearing and struggle to hear on the phone and therefore may be less likely or able to give a full account of their symptoms. They may also be less technologically skilled and be unable to share photographs to evidence issues. I believe older people value the face-to-face and human touch more. GPs may be more likely to find incidental findings, conditions and symptoms in older people, during an in-person appointment.

Some people do not feel comfortable speaking on the phone and may find it difficult to express themselves or may benefit from an in-person appointment to feel able to open up about their mental health symptoms.

However, it’s important to remember that every demographic is vulnerable to health issues which can be difficult to assess remotely.

Are there certain conditions which are more difficult to assess and diagnose correctly, when appointments are carried out remotely?

Any condition which requires visual assessment or physical touch, is more difficult to assess and diagnose correctly when an appointment is carried out remotely. This can include:

Infections
Chest pain / abdominal pain

It is important for a patient to be able to show the GP exactly where the pain is and for a GP to palpate the area to establish exactly where the pain is.

Assessment of a lump / changes to skin in order to suspect cancer

It is important to visualise and feel the lump to ascertain where the lump is located, the size of the lump, whether the lump is hard or soft, whether the lump is painful when touched, to compare the visualisation and feel the affected side of the body with the unaffected side of the body. All guidance for early detection of cancers revolves around knowing your body, feeling your body and noticing changes – not to look at photographs. The GPs need to see and feel a lump to decipher whether or not it is suspicious and requires further investigation / onward referral and on what basis that referral should be made, either routine or an urgent 2 week suspected cancer pathway.

Visual / physical internal assessments

An example is a digital rectal examination to assist in diagnosing prostate cancer, or vaginal examinations with a speculum to visualise cervical abnormalities, assisting in the diagnosis of cervical cancer. GPs need to see and feel the prostate or cervix to decipher whether or not there are suspicious features which require further investigation / onward referral. They need to consider on what basis the referral should be made, either routine or an urgent 2 week suspected cancer pathway.

Any conditions requiring intimate examinations

NHS England says “It is not advisable to encourage patients to send clinical images of intimate regions or reveal or self-examine intimate areas during a remote consultation. The GMC is clear that all patients should be offered a chaperone. Patients who require an intimate examination should, therefore, be encouraged to attend for a face-to-face assessment.”

Limb ischaemia

This requires assessment of peripheral pulses to assess whether they are weak or absent.

Any condition requiring the assessment of temperature or blood pressure
Visual assessment of eyes, ears or mouth
Assessment of any orifice or skin abnormalities

What can I do if I believe I have been misdiagnosed over the telephone, or in a video consultation?

If you believe that you have been misdiagnosed over the telephone or in a video consultation at the time of your assessment, you can ask your GP to arrange an in-person appointment for further assessment, examination or testing and explain why you feel a face-to-face appointment is necessary.

If that particular GP will not arrange an in-person appointment with you, you can call the surgery to make a further appointment and request an in-person appointment for a second opinion and further assessment, examination or testing and explain why you feel a face-to-face appointment is necessary.

For example, you could advise that you are very concerned that the lump you have located is suspicious and you feel a physical appointment is necessary so that the GP can see and feel a lump to decipher whether or not it is suspicious and requires further investigation / onward referral and on what basis that referral should be made. If the GPs continue to refuse to examine you in person, you could ask for the matter to be escalated to the Practice Manager.

If your condition is urgent or deteriorating after a telephone or video consultation, you should take appropriate action by attending a walk-in centre, urgent care centre or A&E, depending on the severity of your condition and your level of concern.

CASE STUDY 1: Delay in diagnosing prostate cancer

Our client was an over 50’s male with a history of rectal bleeding and had previously undergone a colonoscopy to investigate.

Our client was suffering with further rectal bleeding. Our client consulted his GP and a telephone appointment took place. Our client told his GP of his recurring and more frequent rectal bleeding and requested a further referral to the Colorectal team. His GP arranged some blood tests and made a routine referred to the Colorectal team. Our client’s GP failed to arrange a face-to-face appointment and failed to perform a digital rectal examination.

Had the GP examined our client in person and performed a digital rectal examination, as he ought to have done, the examination would have revealed a suspicious lesion in the prostate indicative of cancer and an urgent referral to the Colorectal team should have been made.

Overall, there was a delay in diagnosing our client’s prostate cancer. This failure was not admitted by the GP Defendant and the claim is ongoing.

CASE STUDY 2: Delay in diagnosing cervical cancer

Our client contacted her GP with complaints of ongoing heavy and irregular vaginal bleeding. She had a string of telephone GP appointments. Her GPs failed to arrange a face-to-face appointment and failed to undertake a pelvic examination including a speculum examination with visualisation of the cervix.

Had an in-person examination been undertaken, as it ought to have been, the pelvic examination including visualisation of the cervix would have revealed a suspicious cervix and an urgent referral to the Gynaecology team should have been made.

Overall, there was a delay in diagnosing our client’s cervical cancer. Liability has not yet been established and the claim is ongoing.

CASE STUDY 3: Delay in diagnosing limb ischaemia

Our client was a 67-year-old type 2 diabetic, with a history of peripheral vascular disease.

He had 5 telephone GP appointments over a 4 week period. He complained of painful toes, warm to touch with swelling. He reported that his symptoms were getting worse. He sent photographs to his GP which were reviewed and he was diagnosed with gout.

With photographs indicating poor peripheral circulation and limb ischaemia, with reports of pain and swelling and with a history of vascular disease and diabetes, our client required a face-to-face examination, assessment of his peripheral pulses and an urgent referral to vascular surgery.

There was a failure to arrange and conduct an in-person examination of our client’s foot, a failure to assess his peripheral pulses and a failure to refer him for urgent vascular surgery review. Overall, there was a failure to identify and manage our client’s limb ischaemia. These failures were admitted by the GP Defendants and the claim is ongoing.

If you feel you have been misdiagnosed due to a telephone or video appointment, Patient Claim Line can help. For more information, visit the GP Negligence Claims page here or call for free advice regarding a potential clinical negligence claim on 0330 107 5317.

What are my legal rights to an in-person GP appointment?