Should we consider a “three strikes and you’re in” rule in general practice?

General practice is changing fast. There is an abundance of digital technology supporting many new service delivery models.1 The NHS App is increasingly used to access GP services. Almost 40 000 new “direct patient care” staff, such as paramedics, physician associates and care navigators, have been recruited through the alternative roles reimbursement scheme (ARRS). The Pharmacy First scheme allows walk-in access to treatment for seven common conditions, such as earache, sore throat, and urinary tract infections.

These changes have increased appointment capacity and made access more convenient for some patients. There is mixed evidence about patient satisfaction associated with new roles23 and digital technology.4 There are downsides. Patients are confused about which clinician they have seen and want better communication and choice over who they consult with.5 There have been several clinical incidents and a small number of patient deaths associated with remote consultations and new roles in general practice. These illustrate three problems.

Firstly, there is a risk associated with patients having multiple remote consultations without being seen in person by a clinician who can adequately assess clinical severity. In 2020, David Nash died from complications of a brain abscess after four telephone consultations with clinicians at his GP practice.6 The coroner concluded it is “more likely” he would have lived if he had been seen face to face.7

Secondly, there is a risk when non-medical ARRS staff see patients with inadequate clinical supervision. Emily Chesterton’s death in 2022 from a pulmonary embolism followed two consultations with a physician associate whose clinical assessment and prescription for propranolol were not reviewed by a supervising GP, going against practice policy.8

Thirdly, remote consultations and new roles risk the loss of continuity of seeing a known GP who can spot a change over time in a patient’s health. Jess Brady died of an adenocarcinoma in 2020 after 20 consultations with four different doctors, only three of which were in person. Her cancer was eventually diagnosed after a consultation with a private GP. Secretary of State for Health Wes Streeting has met with her family to explore options to prevent similar tragedies in the future.

This fragmentation of care and dilution of GPs’ professional responsibility for diagnosing and managing patients’ problems is becoming more common with more ARRS staff and multi-professional team working. Various researchers have explored how to improve safety in new models of general practice.

Payne et al (2024)9 propose a range of improvements to increase safety in remote consultations, including revised practice policies and workflows to support safe remote working; optimising history taking and verbal communication, and identifying high risk and vulnerable patients. Various authors have highlighted the need to improve supervision of ARRS staff and to train and fund more supervisors.101112Several approaches have also been described for improving continuity of care in general practice.13

But each requires a fundamental redesign of current working practices, additional training for staff, robust quality assurance arrangements, and may need significant extra resources. In the short term, easier and more pragmatic changes could be made.

The “Remote by default study”14 of digital general practice proposed various rules of thumb to guide the introduction of digital services. One suggestion by the authors of the study was a “three strikes and you’re in” rule,6 ensuring that every patient requesting a third appointment for the same problem after two remote contacts is seen in person by an experienced GP. With current shortages of GP appointments, as a minimum, their own GP could review their notes to assess clinical risk and decide whether face to face assessment and continuity of care with a GP are needed. In a series of case studies on continuity of care, one practice had a policy that any patient consulting their own GP three times for an ongoing problem was booked to see a different GP for a second opinion.15

These approaches would not be foolproof. For example, Emily Chesterton was only seen twice in her GP practice. But they are simple to implement as interim measures to reduce the risks described above. Longer term and more substantial improvements are still needed to pathways, training, supervision, governance, and assurance of quality and safety in new models of GP care.

There is not yet a strong evidence base for this approach. And, yes, some patients who have requested a third appointment for the same problem may not need care from an experienced GP. But there is surely a case to consider a simple and pragmatic short term solution while we sort out the complex changes needed to ensure adequate access to continuity of care from an experienced GPs for ongoing health problems.