GP remote consultations with marginalised patients and the importance of place during care: a qualitative study of the role of place in GP consultations

Unpredictable appointment times limit the ability to create privacy

The issue of privacy during remote consultations was a key concern of respondents. The extent to which privacy was a problem was tied to the reason for consulting, as well as the space available and time in which to take a call from the GP.

Respondents reported that owing to wide appointment windows, they may end up taking consultations in places that are not fully private, which can limit willingness to disclose information:

'I’ve had to do it [consultation] in my car driving like whereas normally obviously they ask you quite personal questions about how you’re feeling and I felt like I couldn’t quite answer properly because I didn’t want people to look at me like a lunatic while I’m driving down and sitting in traffic tears streaming down me eyes, and, you know, I mean, I think I felt like I really couldn’t answer properly and honestly.' (9, Female, 40s, White British, foodbank)

The reason for the consultation can impact how important privacy was, and patients spoke about privacy being particularly important when discussing sexual or mental health concerns. The unpredictability of the timing of remote consultations was spoken about as a key barrier to care, and patients reported feeling paralysed into inactivity, taking half days off work to wait at home for a phone call from their GP. This differs from in-person appointments during which patients go to a physical location for a set time and can make more precise plans.

GPs spoke about the inbuilt unpredictability in remote consultations, arguing that giving exact call times would not be feasible:

'So again, assumption, when we talk about assumptions, you know, we can’t presume that people can pick up a phone all the time, just like, I feel that it is unfair to say, "I’m definitely going to call you at 10 past eight", because actually, the person that you’re speaking to before, has a problem that takes longer than the 10 minutes, you have to deal with that.' (20, GP, Newham)

This unpredictability was reported as being a matter of clinical safety, allowing for previous consultations to overrun if necessary. Notably, the reasons why the call windows were longer than the appointment slots for in-person consultations was not clear.

However, GPs did give examples of trying to work around patients’ schedules and agree on specific call times in order to ensure they had access to an appropriate space in which to take a call:

'A lot of our service users didn’t have private spaces and we would have to be very flexible about when we call people to try and allow that opportunity. I remember we had one particular case of a lady who lived ... she was asylum seeker who was living in a shared house […] and had paper-thin walls. You know, she had no privacy in her home at all, and she had lots of very difficult medical issues to talk about. We had to try and coordinate a time when all of her … everyone else in the house was out so that she could take the call and be comfortable to you know, to talk fully.' (26, GP, Lewisham)

This illustrates how individuals’ physical circumstances can limit their capacity to secure privacy without planning. Other examples were given by GPs of fitting call times around patients’ work breaks as they were unable to take a telephone call without asking permission from a manager.

While there was some awareness from GPs that marginalised patients may struggle to create private spaces for care, there was also surprise at the public spaces in which these patients might take calls from, indicating an assumption that privacy was both an obvious precondition to care, as well as accessible:

'The number of times I remember doing NHS remote calls and someone’s clearly in an office and probably like an open plan office, so it sounds very noisy, or they’re in a shopping centre or something.' (26, GP, Tower Hamlets)

'I’m very surprised about, you know, the number of patients who will just take a call on the Tube [London Underground public transport network].' (23, GP, Tower Hamlets)

Phone borrowing and privacy

Another reason why patients may take telephone consultations in non-private spaces is the need to borrow a phone. Many respondents reported unstable access to a phone because of a lost or broken handset, or a lack of funds to buy phone minutes. This can lead to people borrowing or renting devices from others. This was particularly true for respondents who were experiencing street homelessness. Borrowing a phone may lead to the patient taking a call in a shared space with the phone owner or, in more extreme examples, speaking via the phone owner:

'I have [had to borrow my mum’s phone to contact the doctor] I’ve had to shout, they put like the doctors and stuff, she puts them on loudspeaker and I have to shout like I give permission for her to speak on my behalf.' (5, Female, 30s, White British, foodbank)

On top of privacy during a call, patients were concerned about borrowing a phone to speak to their doctor being a burden as they needed phone access for an extended period owing to the unpredictability of appointment time. It could also lead to them needing to disclose their reason for calling the doctor to the person lending them the phone:

'Having to say to someone "can I phone the doctor", and immediately when I say to my mum obviously she’s my mum so she’s worried and first thing she says is "what’s wrong" … and you know I have to disclose my medical history to her and I know she’s only worried so obviously I do because she’s my mum you know but urm yeah like I don’t really want to disclose things.' (5, Female, 30s, White British, foodbank)

GPs expressed concerns about the impact of phone borrowing on privacy and spoke about how they look out for verbal cues that a patient may not be alone, which would be a reason to transition to a face-to-face appointment, demonstrating GP awareness of the issue of privacy and potential need to adapt:

'Yeah. “Oh, I can’t talk right now”, or if they’ve given you someone else’s mobile, then that might be a red flag, and saying, “Can you call this”, and what we tend to do, what I always do is if the patient’s husband answers. I always say, “where is she?” unless the patient’s there and she’s given consent, or I know them both. I would insist that I speak to the woman on her own if not, I say, “okay, I’ll book you a face-to-face appointment.”' (25, GP, Tower Hamlets)

As well as unplanned lack of privacy, that is, difficulty securing a private space, GPs expressed concern that a lack of privacy can also be a result of coercion whereby a patient’s partner or family member deliberately wants to limit what they are able to speak about with their GP. This was a particular concern regarding domestic violence.

The problem of being unable to follow-up with patients was also mentioned as a complication of phone borrowing during telephone consultations:

'We did see that [phone sharing] a lot … And we’d often have the difficult situation of trying to follow people up and then realising that the number they’ve given us was not actually theirs.' (26, GP, Lewisham)

Concerns over the GP's location and privacy

As well as struggling to secure privacy, patients also expressed concern that their GP may be somewhere not private, where they can be overheard:

'The doctor could be doing the same thing. Think "oh it’s just my husband or wife [listening] or whatever, it don’t matter" ... so you feel a bit. Well with face-to-face you know that conversation is just between me and them. Do you know what I mean? Obviously like they wrote down it down and they might discuss it with another doctor. But yeah, if they want to go home and discuss it then fair enough, but I’d rather not feel like someone sitting there listening to what I’m saying.' (9, Female, 40s, White British, foodbank)

This fear was spoken about by several respondents, who felt particularly nervous about speaking to an unknown GP over the phone. GPs also reported being asked by patients where they were consulting from (remotely). While all GPs included in this study spoke about the importance of privacy, and pointed out their own duty to confidentiality, they also discussed holding remote consultations from shared spaces:

'I do one remote surgery a week. And so, I usually do that, from my breakfast table at home, trying to get my son and my wife to sort of be quiet. You know, I haven’t had any sort of negative feedback about that. And I’ve been, I think, you know, most of the people I know, know that I work here [GP surgery], and I guess they’re sort of, you know, in their heads I’m sort of just working from, you know, my office.' (23, GP, Tower Hamlets)

The above quote highlights how remote consultations lead to unknowns on both ends of a call, and that both patients and GPs consider where the other is located.

Healthcare spaces as emotional places of care

The importance of the GP consultation room as a specific sort of place, beyond simply offering physical privacy was also mentioned as a container for difficult conversations:

'I think there is something very special about the physical healthcare space, for so long it’s been recognised as this confidential space, which allows people not just to talk about health, but to talk about things that they feel that they can’t talk to anyone else about, because they don’t have anywhere else that’s confidential.' (26, GP, Lewisham)

The effort to recreate the emotional conditions of the physical consulting space during remote consultations was also mentioned:

'If you’re a skilled practitioner, you can still create that space in the way that you are, and the way that you ask questions, you can still create that in that space. And that’s what I hope, virtually, with a really skilled practitioner, you can do the same thing over the phone. But that takes a lot of time and experience to do that.' (26, GP, Lewisham)

The account reflects a perceived need to reproduce the in-person consultation experience during remote consultations, suggesting a perception that the emotional container of a physical consultation room should be replicated regardless of consultation modality.

The findings indicate multiple barriers that may emerge for patients when trying to create effective conditions for remote consultations, which can have knock-on effects on their consultation experience. An effective remote consultation requires certain conditions, which include access to digital technology and connection, and a private space. The ability to secure these conditions within a relatively unpredictable window of time requires predictable access to these resources, which may be more challenging for patients from socioeconomically marginalised groups.