An expert’s experiences

I think there’s a lot of risk factors. And it does depend a lot on the patient. I think there are similar risk factors when you’re, say, triaging face-to-face or performing a consultation face-to-face, but you would have a lower threshold for those. So I think the main ones which come to mind are elderly patients. They would definitely be higher risk patients who live alone and maybe don’t have a support network. So they don’t have anybody maybe to kind of look after them, or to keep an eye on them. Housebound patients, that falls kind of into a similar category. Anyone describing or showing any red flags relating to whichever system we’re discussing.

So for example, if it’s kind of a shortness of breath. If the patient was at home by themselves and housebound and elderly, then that would be really kind of concerning to me. Comorbidities plays a big part as well. One which comes to mind in particular is dementia. So a patient suffers from dementia. The advice and the guidance and the safety netting that you discuss with the patient, will they remember that? Are they going to forget that? And then what happens if the situation develops? I take into account, as well, the frailty score of the patient. And you know on our system here in the practise, all of the patients, healthy patient, we calculate the frailty score.

And depending on that score, again, that would mean they’d have a higher risk factor.

Communication impairments, and particularly, say, impaired vision, or if they had any other form of communication concerns. Because then if the condition deteriorated, would they be able to effectively communicate to another health care professional? Would they know who to contact, say, for example, if it was the evening, surgery was closed or on weekends? Mental health as well. So look at the mental health of the patient. If they have an a long-term mental health condition. Do they have capacity to be able to decide for themselves, for example, when to seek further medical attention. Social factors as well. Kind of consider that when I’m deciding about risk factors. And also things, say, for example, look at diabetes.

If they’ve got, say, a history of low blood sugars, or they’re on insulin, for example, it’s a big risk there of, say, hypoglycemia and falls. So lots and lots of risk factors. Some are kind of disease and condition specific. But I think, in general, I’m more cautious when performing telephone calls and video calls. And I think definitely I’m learning now not to kind of be so I say afraid about actually asking the patient, you need to be seen. We actually do need to see you. So I think that’s kind of the key underlying point. Don’t be afraid to say, no, this isn’t appropriate. And we need to see you.

Or I need to refer you on to secondary care, for example.

I think it depends on the presenting complaint as to what you might use. In general, I found on the GMC website, there’s quite a nice general risk assessment framework. And it looks to ask questions about, for example, is the patient able to consent to having this consultation? Do they have capacity to be able to consent to offering a telephone consultation or to a video consultation? And if they don’t, do they need to be brought in? Do you need to examine the patient? Does the patient understand what you’re discussing with them? And do you have access to all of the patient’s medical notes? So that’s, I think, a general framework, which I try to work from.

In terms of kind of condition specific, then things which bring to mind, the things like we have a template to highlight totals of a potential risk of, say, sepsis, for example. So on our system, we have a built-in framework. And if we ask those particular questions, then if depending on what the patient answers, then there’s potential that that could show that the patient may be septic. We use the NEWS2 score quite often as well. And that helps, particularly in recent times, to try and assess how ill we feel the patient is. And it’s a good framework. Some of it can be quite difficult to complete remotely.

But I know in my local area, during the past recent months, we’ve had nice kind of procedures in place where we’ve been able to send some of the equipment out in a taxi. So like, say, an oxygen saturation probe out to the patient. And then they can ring us back with the results. And that helps us complete that template. In terms of mental health, there’s quite a few risk assessment tools, which are useful in deciding, say, for example, if the patient needs to be urgently referred, if there is a feeling suicidal, for example. And at the start of kind of the COVID pandemic, we were using the ROC score quite a lot as well.

I know this kind of debate going on about the evidence behind it, but it was a tool which we did use on a regular basis, particularly at the start of the COVID pandemic as well.

So trying to manage the risk, I think safety netting is one of the key things. And making sure that there’s an adequate follow-up in place. So if I’ve completed a consultation with a patient, I always try and book a follow-up myself so I know that that’s booked in. Because if you just advise the patient to book a follow-up, they forget. They may think that it’s not needed. So I’ll always try and follow the patient up, whether it’s back into one of my clinics or with one of the GPs. Understanding of the patient at the end to make sure they’re aware of the risk. Do they understand what the risks are? And are they aware what to do?

Signposting to other services as well. Making the patient aware of the services, like 111 or crisis line, for example. Discussing with the patient’s relatives as well. So a particularly elderly patient or patients that, say, again, communication problems or memory impairment, discuss it with the carers. Discuss it with the relatives. So they’re aware and informed of what’s going on with the patient. That helps. And try and include any social care packages as well. So again, inform any social care providers. And kind of approach the consultation holistically. So rather than just focusing on the condition and the medication, think about does this patient need, say, a social care package or a referral to another organisation?