Postal deliveries. Hairdressing appointments. Even services which handle sensitive information, like your bank, will use text messages to let you know what's happening. So why not GP surgeries?

The answer is that many do. Almost 40% already use texts to communicate with patients. In an era when we expect instant access to almost any kind of service, text messaging offers a low-cost, low-effort way for GPs to keep patients updated.

Texts are more likely to be read than emails with some surveys showing that people would rather be contacted this way than any other method. There are other benefits as well; a 2012 pilot study1 found that text message reminders improved attendance at mental health outpatient clinics by 25%.

The GMC in its guidance on confidentiality recognises that text messaging can be convenient for patients and support effective communication, but highlights that doctors should take reasonable steps to make sure that whatever communication method they use is secure.

Clearly text messaging is a useful tool, but the potential for breaches of confidentiality or falling foul of data protection legislation is also substantial. That said, the rules are relatively simple.

The term 'text messaging' can be considered to cover a wide variety of systems and apps, from simple SMS messages to more advanced systems such as WhatsApp, Facebook Messenger or others. All of these are covered by the Data Protection Act and overseen by the Information Commissioner.

These rules will be updated in the pan-European General Data Protection Regulation (GDPR) which comes into force from 25 May 2018, and the government has confirmed that this will not be affected by Brexit. While the overall principles remain largely the same, under GDPR, organisations must be able to justify holding and processing data by reference to one or more of the 'lawful bases for processing'. In most medical cases this will be condition 9(2)(h), which relates to the performance of medical duties.

Permissions

When communicating with patients by text, that individual needs to have opted in to the arrangement. Giving the practice a record of their mobile phone number is not deemed consent for this purpose. Instead they will need to have actively agreed to receive texts, and this consent should be clearly marked on their records.

It's also important to let the patient know what kind of information they will receive (such as appointment confirmations or repeat prescription reminders), as you can only send them text messages on those or closely-related subjects. The individual needs to be able to opt-out of the arrangement at any time by informing you.

Arguably the best and most effective use of text messaging in a general practice environment is for large-scale communications to a list of consenting patients. Generic reminders (for flu jabs and so on) are a perfect example of this.

Doctors should take reasonable steps to make sure that whatever communication method they use is secure.

Confidentiality

However, if you decide to text patients individually, you should bear in mind that there a number of potential pitfalls. Foremost amongst these is the issue of confidentiality. It is rarely possible to tell if a text has been read, and never possible to tell by whom.

Family or friends may easily access an unlocked mobile phone, and phones are often passed on to family members or sold and your text could end up being received by a stranger. This issue is especially acute amongst 18-24 year olds, statistically the highest users of text messaging.

As such, there is a risk that a text message, even when sent to the correct number, will not be as secure a route of communication as you might wish. Therefore, when you take the phone number and obtain the patient's consent, make sure to stress the importance of keeping you updated to any changes to that number.

On the subject of children and young adults, while texting 16 and 17-year olds is acceptable, be aware that this age group is also particularly prone to frequent changes in phone numbers. The use of text messages for the under-16 age group can be complicated.

On the one hand an older child with capacity to make decisions about their health (and considered Gillick competent) might wish to have some aspects of their care managed confidentially. The same child might in some instances wish their parents to be involved in communications about their health.

Care should be taken to update the contact details of all competent young persons to make sure their parents/guardians don't receive confidential information if the parental contact numbers are stored in the child's records.

For example, a parent might not know their child had attended the surgery, but because of a misplaced or mis-sent text they could still inadvertently receive test results or a text saying the child's prescription was ready. This would alert them to the attendance; something the young patient may not want them to know about.

Remember also that the phone's messages might be linked to other devices such as tablets. Depending on the settings chosen by the user such messages might be displayed as notifications, even when the device is locked. This means in practice that a text message sent to a mobile telephone number could also pop up and be visible on another device belonging to the patient, even when the device is locked.

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Professionalism

Text messaging has developed its own language, but in a clinical context the messages you send are considered professional communications and should be couched in similar terms to emails or letters, without abbreviations or 'text speak'.

At the same time, remember that text messages by their very nature are brief. This has the potential to lead to misunderstandings, so it's a good idea to run any more complicated messages by a colleague before sending them and to make sure that standard messages are reviewed and agreed by the practice before being put in to use.

As they are professional communications, text messages should be noted on the patient's medical record, along with any responses received and the time and date in each case.

It should be made clear to patients that it is not a channel for medical enquiries or conversations, and a standard response should be given to any such texts received, such as 'We can't discuss medical conditions via text message, so please contact us on…or call 999 if you need urgent attention'.

It may sometimes appear convenient to communicate investigation results or other clinical matters to patients by text, but great care should be taken and specific consent should be sought for each instance where it is intended for results to be communicated in this way. In most such cases it will usually be better to discuss the matter face to face or by telephone. Never rely on text messages as the only source of communication, where urgent matters are concerned.

Finally, there is the very ease and informality of text communication. Billions of texts are sent and received every day, and it's such a part of our lives that it's only too easy to enter into casual text conversations which may end up as 'consultations by text'. For this reason you should consider carefully whether to give out your own mobile number to patients, and always stick to an agreed policy.

It's a good idea to have the practice policy on use of text messages printed and posted up in a prominent place such as a waiting room, and given to patients as a leaflet when they give you their number.

Provided reasonable care is exercised, text messaging offers a powerful tool for saving time and improving outcomes at minimal cost, and the potential advantages far outweigh the drawbacks.

FOOTNOTES

1: Sims H, Sanghara H, Hayes D, Wandiembe S, Finch M, Jakobsen H, et al. Text Message Reminders of Appointments: A Pilot Intervention at Four Community Mental Health Clinics in London. Psychiatry Serv. 2012 Feb 1;63(2):161–

This article was correct at publication on 21/12/2017. It 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.

Dr Helen Burnell

Medico-legal adviser

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