One of the features of the COVID-19 pandemic was the increasing use of remote consultation methods. Paragraph 9 of the GMC's 'Good medical practice' (2024) says that you must provide safe and effective clinical care however you assess a patient and, "if you can’t provide safe care through the mode of consultation you’re using, you should offer an alternative if available, or signpost to other services."
Many remote consultations reach a satisfactory conclusion through dialogue and (if in video mode) the patient illustrating their medical history – for example, by pointing to the site of pain. The summary of the consultation along with any treatment plan is then recorded in the clinical records in the usual way.
However, sometimes an image can be useful, such as with a frail patient with a leg ulcer or someone who has noticed a new, pigmented lesion on their arm. But there can be pitfalls, and here are some of the factors you should keep in mind if you're doing remote consultations.
GMC guidance
Ensure you have read and are thoroughly familiar with the GMC guidance on making and using visual and audio recordings of patients. The guidance applies to photographs as well as other audio and visual recordings. If you work in an NHS trust you should also familiarise yourself with, and follow, any relevant information governance policies.
Necessity
First, ask yourself if a remote consultation is the most appropriate method of arriving at a safe diagnosis and treatment plan in circumstances where you or the patient think a photograph is necessary. Will an image be enough, or do you need to undertake a more extensive examination of the patient? Addressing this question at the start may help prevent problems later.
Consent
The GMC's advice is that specific consent to receive and store the patient's photograph is necessary, irrespective of whether it is your idea or the patient's. The process of obtaining and documenting consent should include explaining why a photograph will help in providing clinical care.
Explain to the patient how the clinical records, including photographs, will be securely stored and that they won't be used for any other purpose without their express permission. Document these discussions and decisions in the clinical records.
Capacity
Where the patient is a child who lacks capacity to make a decision about a photograph of them being shared with you, you will need the permission of someone with parental responsibility. If the patient is an adult who lacks capacity you must be satisfied that the photograph is necessary, will be of benefit to them and in their best interests.
In this situation, it is important to remember that there may be someone who has legal authority to act on the patient's behalf in healthcare decisions and their agreement should be sought.
Receipt and storage
Agree with the patient how the image will be sent to you. If this is by email, it should be to your secure, NHS encrypted email account (usually nhs.net email) used in accordance with your organisation's policy. Upload the image to the patient's records and delete the email and image from your account. Some practices and NHS organisations use specific software to allow receipt of an image by text and the same principles apply.
If the patient does not agree to the retention of the photograph on their clinical records, it may make it retrospectively more difficult to understand the advice you gave and the treatment recommended. In such circumstances you may wish to carefully consider whether a remote consultation method is the safest way to proceed.
Intimate images
Intimate images (genitalia, anus and breasts) create particular medico-legal risks. In a normal clinical consultation where an intimate examination is needed a chaperone would be offered to the patient, which you cannot easily replicate in a remote consultation. It's also possible that an image alone is insufficient to reach a safe clinical diagnosis; palpation and samples might be needed.
A further consideration is that taking, sending and receiving intimate images of children under 18 may potentially lead to a criminal investigation. Frail patients and those lacking capacity may need assistance from others in trying to obtain an intimate photograph, and this could seriously impact their dignity and be an unreasonable burden on family or carers.
Consequently, where the need to obtain an intimate image arises in a clinical setting, and it is not possible to safely defer the consultation, the question arises as to whether a remote consultation is appropriate. You may wish, in those circumstances, to consider whether you should see the patient in person or make a referral to a specialist colleague where this is appropriate and necessary.
For more information, watch our video on remote consultations.
This page was correct at publication on 30/01/2024. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.