Analysis reveals how GPs weighed up the potential losses and gains that occurred from initial contact, through the consultation, and after its completion. Findings have been grouped into the following stages: contact (gaining access to and beginning conversations with the GP); consultations; and after the consultation (the impacts of safeguarding remotely on GPs and their practice).
Contact (gaining access to and beginning conversations with the GP)
Several GPs described how COVID-19 had necessitated the use of shared ‘triage’ lists, where appointment and advice requests were pooled and collectively managed by doctors working that day. While remote working reduced continuity of care and made safeguarding more difficult, some GPs noted that initial remote consultations could allow them to flexibly create space for safeguarding conversations. They suggested that rapid response through pooled triage combined with the invisibility of the virtual ‘waiting room’ could encourage some conversations:
‘A telephone call feels less to the patient like an appointment, so I think in some ways although you do have all the barrier of not having someone in front of you, it sort of facilitates sometimes going, “Oh and just while I’ve got you on the line”, or it doesn’t feel so much like they’ve got that appointment to talk about one thing. They phone the doctor to ask the doctor to call them, so I think, in some ways there might be a bit more freedom … because if you think about it, not having that list, that thing in the corner of your screen of “Two patients waiting, three patients waiting, four patients waiting”, is actually quite nice.’
(GP11)
Working through a telephone list could allow more time for conversations with vulnerable patients, as well as the chance to offer remote or face-to-face appointments. GPs reported that this allowed them to negotiate safe times to consult with women affected by domestic violence, or to arrange a rapid assessment for adults with learning difficulties. They suggested that the possibility of a hybrid model of care, which built on the greater autonomy and flexibility facilitated by remote consulting and telephone triage, might promote a more equitable delivery of care:
‘I think that doing more and more telephone triage you can actually clear a lot of it by phone and email which actually gives you the time to actually put to the people who need it … So actually in terms of access you are actually using for the people who need it.’
(GP7)
However, GPs remained concerned that triage approaches that required patients to state in advance the reason for contact could deter patients and GPs from exploring any other reasons for consultation, reducing safeguarding opportunities:
‘That’s not how consultations work. It starts off with a headache and you end up talking about alcohol and DV [domestic violence] , that’s the bread and butter of the conversations that we have; bullying at work or whatever the thing is, because there are things that are legitimate to go to your doctor with and there are things that really aren’t.’
(GP3)
GPs identified some groups, such as teenagers or those with mobility needs, for whom remote consulting improved access. One GP recounted supporting a woman who was in an abusive and controlling relationship who was able to use working from home to justify locking her door for a private telephone call ‘for work’. But GPs remained concerned about vulnerable patients whose access to care was impeded by remote access. Digital exclusion due to lack of access to (or ability to use) devices or the internet, as well as barriers of language, literacy, cognitive impairment, and those with unsafe (or no) accommodation were cited:
‘… an issue with using video is it’s dependent on, people having the right kind of phones and having data that they can use for doing video or submitting photographs, and a lot of our families don’t — you know a lot of them will have smartphones, but they don’t necessarily have the budget to use a large part of their data on video consulting.’
(GP1)
Consultations
GP reflections on remote consulting conveyed their powerful sense of loss of the familiarity and boundaries of their consulting rooms. Consulting rooms were seen as ‘safe spaces’ (GP3) where GPs felt comfortable interacting with patients, and both GPs and patients welcomed the privacy and confidentiality offered. Remote consultations threatened this; GPs were concerned that they did not know who was listening in, watching, or monitoring video, online, or telephone communication. As one noted:
‘When everyone’s locked into the house, the privacy is gone and it’s really difficult having open and honest conversations.’
(GP10)
Some GPs attempted to mitigate this by routinely asking every contact if ‘it was safe and comfortable to speak’ (GP6). One or two noted that an advantage of not having fixed appointments was that this allowed flexibility to re-arrange calls. This was easier if vulnerabilities were known, or anticipated, but much harder to introduce unexpectedly:
‘You ask them, “Is it OK to talk now? Are you in a private space? Can anybody hear you? Is now a good moment, would you rather I rang you back?” […] but I think if you’re just in a what you were thinking is a routine consultation, and you start to get little prickles it’s a little bit harder to then start to introduce that [concerns about privacy] . It’s harder to frame it as part of the dialogue really, suddenly to say to somebody, “Are you on your own there?” You know it’s not very subtle.’
(GP18)
A further challenge of navigating consultations remotely was knowing how to ensure safe closure of the conversation, especially for vulnerable patients:
‘… you want them to open up and tell you everything and then you’re kind of leaving them in their own room where they sleep and hang out.’
(GP2)
GPs worried about what might be missed. Echoing the aforementioned concerns about access and disclosure, some reported:
‘I think that’s where the challenge lies, because […] just asking isn’t necessarily going to get you the answers or uncover the problems.’
(GP10)
‘… that’s what worries me. The one time when I’ve really picked up horrendous domestic violence the patient rang up, her opening gambit was a physical symptom. Which was not, which was related to the violence, but the only way I realised there was violence was because I examined her. I sat her down and I said, “How did this happen?” And then she told me. But she didn’t want to tell me, the first ten minutes of the consultation she’d just focused on that physical symptom, and if I’d managed that on the phone, I would have managed it in a completely different way.’
(GP17)
GPs wanted face-to-face visual and verbal cues and argued that ‘open communication’ (GP12) was a vital part of their safeguarding conversations. Non-verbal communication could also convey empathy, support, and ‘presence’ (GP2) in the consultation. While video consulting might restore some of these features, GPs recognised that many vulnerable people were reluctant or unable to use this technology. This sensory deprivation was felt in the context of the consultation. GPs noted that observation of the waiting room or family interactions could also inform safeguarding and care of vulnerable people, and this was also missing:
‘You miss so much — you know concealed pregnancy, track marks on arms, poor dentition, signs of liver disease. Patients don’t phone up and say I’ve got palmar erythema and if you watch me carefully you’ll see I’m a bit trembly and you’ll see I’m drinking too much do they? So you’ll miss all of that.’
(GP14)
‘You don’t get the body language or the eye contact and the interaction between parents and children that you see — and not just the child that’s brought in but how the other siblings are behaving — or not — when they’re in your consulting room. That kind of information isn’t there.’
(GP1)
One strategy GPs adopted was to use concerns about vulnerability or potential safeguarding needs as a reason to offer a face-to-face appointment. However, in the early stages of the pandemic this could be harder to negotiate, as this GP explained:
‘Normally if I was worried about someone I would make up some sort of reason why I needed them to come and see me, like if they needed an urgent [blood pressure] check that I think would sound sufficiently serious and plausible that I could get them in my room so we could have a proper chat but I wouldn’t — given that we haven’t been seeing anyone besides those who we feel it is medically urgent to see I wouldn’t feel I could do that plausibly at the moment.’
(GP5)
A particularly powerful challenge of remote consulting and adult safeguarding was when GPs needed to evaluate capacity, a task they considered virtually impossible by telephone or video:
‘How you get someone to be their best and give their best account in the most dignified way. I’ve only ever done this face-to-face and I can’t imagine doing it in a different way.’
(GP2)
GPs also mentioned red flags or incidents of concern, such as children who were not brought to GP or hospital appointments, who were not attending school, or where there was a delayed presentation following an injury. Such incidents were harder to appraise for relevance to safeguarding in the lockdown phases of the pandemic:
‘We know that children were not coming in, and we were asking people not to come in, there were late presenters to A&E [accident and emergency] […] people fearful of the hospital and staying away, but also I guess potentially NAI [non-accidental injury] going missed because it’s an easy way of saying well, you know we didn’t come because we didn’t want to bother A&E during COVID.’
(GP10)
These kinds of concerns were also more difficult to manage because of the loss of routine encounters and interactions with members of the wider primary care health team such as midwives or health visitors, or community services.
Against these largely negative concerns, GPs felt that some remote encounters created safeguarding opportunities. Video consulting allowed a view into homes of patients who would normally have ‘always’ come to the practice, and this might reveal new information about a patient’s domestic situation that could prompt further exploration. GPs also said that some patients appeared to welcome the easy access to support and advice via telephone calls. However, GPs noted that approaching safeguarding concerns in a remote consultation was even harder with patients not previously known to them. It was especially challenging to support patients in new or evolving situations, including safeguarding needs arising because of societal responses to the pandemic:
‘Trying to demonstrate that you care which again is very hard to do on the phone particularly if you don’t know the person, I think if you do know that patient and you already have a relationship with them you might stand a chance on the phone.’
(GP5)
GPs worried about vulnerable adults and children losing regular contact with family members, losing access to respite care, day centres, and schools, increased alcohol consumption, increased domestic violence, and impacts on young carers, including those newly created by COVID-19. Yet they also felt that the pandemic had created opportunities for proactive care and support for patients. GPs described working with social prescribers and using the shielding programme as a valid reason to contact vulnerable patients. They also proactively established networks and groups to support new families. Some aspects of multi-agency communication for safeguarding, such as liaising with community health workers, health visitors, and social care, also evolved rapidly during the pandemic and was welcomed. Working remotely removed the necessity to travel and made it easier to join safeguarding meetings and case conferences, as explained here:
‘I have taken part of a strategy meeting that I perhaps otherwise wouldn’t have been able to […] I could attend for the amount of time that I could spare, whereas previously I would have said that I can’t attend but because I was doing it remotely from my consulting room, I did it for the length of time that I was able to allocate. So, I think actually, that was a good change in practice.’
(GP1)
Figure 1 summarises the gains and losses for safeguarding experienced by interviewees.
Figure 1. Balance of losses and gains for safeguarding utilising remote consultations during the COVID-19 pandemic.
After the consultation (the impacts of safeguarding remotely on GPs and their practice)
GPs described emotional and personal impacts of the transition to remote assessment and consultations. While these were brought to the fore in complex areas of their jobs, including safeguarding and end-of-life care, they were apparent in other consultations. GPs reported a range of potential stressors, including worrying about missed or delayed diagnoses and missed opportunities for being physically present with patients at pivotal moments of care, for example, conveying a life-changing diagnosis or sharing a positive event such as a patient being granted asylum status. For some GPs, their role had become stressful and ‘lonely’ (GP8), ‘isolated’ (GP13), or ‘anxiety provoking’ (GP17), resulting in ‘more sleepless nights’ (GP16) and worry. Remote working was ‘less rewarding’ (GP5) and concerns were raised about a lost ability to make an ‘intuitive’ (GP9) assessment of situations, with potential impacts for training and learning in primary care. The net effect was that primary care had become more ‘transactional’ (GP18), and what was enjoyable and valuable within GPs’ roles was reduced:
‘I enjoy seeing patients, losing that face-to-face impact interaction, I think has made a massive impact. To be honest, I don’t really enjoy the job at the moment.’
(GP11)
‘I feel as a doctor that quite a lot of the joy and the reason why I still want to get up and go to work as a GP has been taken away from me, because of the fact that I’m not doing much face-to-face stuff now. And I just rely so much, I’m so much better face-to-face, than on the phone.’
(GP12)
‘A big part of what we do as GPs is risk assessment […] So you are making risk assessments in situations where you don’t have as much experience, and that I think has been a source of stress. And particularly for potential high-risk situations like safeguarding. Those are stressful ones anyway without the added challenges of remote consulting.’
(GP1)
Critically, some, including both newly qualified and more experienced GPs, reported remote consulting was changing how they felt about staying in general practice:
‘Right at the beginning of all this COVID crisis — I became the doctor I needed to be but it wasn’t the doctor I wanted to be […] I want to go back to being the doctor I want to be. And not lose some of the good stuff but I don’t think the doctor I want to be is on video, that might be me being set in my ways. That would be my personal challenge not to lose my emotional connection with patients.’
(GP2)
To address these kinds of challenges a number of GPs told of how they had made positive changes to adapt to remote working, including innovative and proactive group consulting, developing team meetings and peer support, and of personal skillset development to optimise remote consulting. These are summarised in Figure 2.
Figure 2. GP innovations and adaptations to support safeguarding care.
