The potential of alternatives to face-to-face consultation in general practice, and the impact on different patient groups: a mixed-methods case study

Evidence explaining why this research is needed now

The underlying assumptions that drive the policy rhetoric relate to convenience and accessibility for patients and an efficient use of practitioners’ time. 27,28 However, there is little evidence to support such assumptions. The Nuffield Trust,29 among others, have identified the potential for the use of remote consultation in primary care, but also the need for more evidence on the impact of remote consulting.

Evidence to date has assessed the potential impact of some alternatives on clinical outcomes. 30,31 Although trial evidence for some types of alternatives is poor, observational data have pointed towards some clinical benefits, such as improved outcomes from e-mail communication for those with diabetes mellitus and hypertension32 and better monitoring of health concerns with online access to records,33 at least in market-driven health systems. When combined with self-monitoring, telephone and e-mail consultation have been effective in the management of hypertension and diabetes mellitus. 34,35

Studies have sought opinions from patients and health-care professionals on whether or not, and how, they would use alternatives,20,36,37 but these data have been based on hypothetical opinions rather than experience. Other studies have attempted to assess the impact of alternatives to the face-to-face consultation on workload and consultation numbers in primary care settings;38–40 however, these studies have been of low quality,30 or have assessed impact in the context of a patient portal that offers additional functionality,33,41 making it difficult to draw conclusions about the impact of the alternative to the face-to-face consultation alone.

Recent years have seen a plethora of small and local pilot projects and commercial initiatives around specific systems,42,43 which proliferate in an environment of patchy and inconclusive evidence.

What the existing literature does not tell us is under what conditions, with which patients and in which ways alternative methods of consultation actually work. This project addresses this need and builds on previous research by focusing on the experiences of patients and practitioners who have used these alternatives to the face-to-face consultation with different groups of patients for different purposes. 19,44

Where GPs have started to use alternatives to the face-to-face consultation, we can learn from their experiences and from their rationale for introducing them, as well as their reasons for persisting with or discontinuing use. The feasibility of these alternatives to the face-to-face consultation is likely to rely on factors that are identifiable only when they are used in practice (e.g. patient characteristics or the purpose of consultation). Barriers to, and facilitators of, use become apparent as patients and practitioners navigate their way through use. The existing literature on experience can be utilised to develop a picture of how alternatives might be expected to work. 45–47

Existing research has demonstrated a limited understanding of the fact that consultation methods are complex interventions. 30 The lack of good quantitative evidence on technologies such as e-mail and video consultation reflects the difficulties of testing them in trials, as their use has not been clearly defined. 48 Often, distinct elements of the consultation have not been taken into consideration. By developing a theoretical framework, we hope to deconstruct what makes alternatives different from face-to-face consultations, allowing us to assess if and how they should be tested, in relation to the appropriate populations, outcome measures and methodological approach.

This research builds on the previous literature in related fields on how new technologies are adopted and implemented in health care. There has been some research in relation to telehealth interventions to support patients in their own homes. For example, the application of the normalisation process theory to the implementation of telehealth has demonstrated that it is the work involved in adopting new approaches that influences whether or not they normalise in practice; that is, they must fit in with health-care professionals and their roles for successful implementation. 49,50 Other work using the technology acceptance model has highlighted the importance of both usefulness and perceived ease of use in influencing behavioural intentions to use new technology. 51

Work by Greenhalgh et al. 52 on the failed introduction of the HealthSpace communication platform also highlighted the importance of ensuring that the technology used meets people’s perceived needs and fits with their other health-care arrangements. 52 We will take account of these related theoretical perspectives, including insights from the normalisation process theory, the technology adoption model and the diffusion of innovations theory, but we do not propose to base our analysis on any of these specific models.

Health-care needs differ between patient groups. Evidence around how different groups are affected by the introduction of new consultation methods is sparse. Studies have included patient populations in general practice, and this has not tended to include consideration of different patient groups. For telephone consulting, there has been some consideration of the effects on different patient groups, such as patients with brain injuries. 53 However, for other alternatives to the face-to-face consultation, little is known about the impact on different groups of patients. 19,46,54 Existing data from a range of countries and settings indicate that young people, those with tertiary education, the employed and students are more likely to use alternatives to the face-to-face consultation, along with those in poor health. 55,56 It is important to understand more about the use of alternatives to the face-to-face consultation by different patient groups in general practice and whether or not they provide better access to care in relation to need, and, subsequently, their influence on health inequalities.

What is the problem being addressed?

It is important to understand how these alternatives work for patients, and to determine the benefits, advantages and disadvantages for different groups of patients and for a practice as a whole. Some groups are likely to benefit more than others. 55,57 Although attempts have been made to determine the impact of some alternatives on clinical outcomes,30,31,58,59 there has been a lack of focus on appropriate application and implementation, and this is key if we are to inform safe use and to be able to successfully evaluate their use in practice.

Telephone consultations

Telephone consultations have been in use for a long time; therefore, the issue for our study is not plausibility but, rather, optimal application. This includes gaining a greater understanding of how practices have addressed potential problems, such as concerns about increased workload or safety.

Several telephone-based initiatives have been introduced in general practice, with a view to reducing GP workload, for example, telephone triage. 60 Some practices offer a system of care in which almost all patients are offered a telephone consultation initially (variously labelled GP Access61 or Doctor First62); however, as the National Institute for Health Research (NIHR) has funded another parallel study that specifically looks at this model of care, we will exclude these approaches from our study.

E-mail consultation

The application and use of e-mail consultation are varied. Some GPs offer e-mail consultations using conventional e-mail programs, whereas others favour asynchronous consultations via a structured online form. 63 There are commercial providers that offer website services to general practices, which can act as a secure host for e-mail consultations (e.g. MySurgeryWebsite). 64 In the case of e-mail communication with patients, NHS Digital has supported NHS policy with the introduction of NHSmail 2. 65 This system allows clinicians to engage in secure e-mail communication with patients, but NHS Digital does not provide guidance on how this might be done.

E-mail consultation includes secure messages sent using webmail. The most commonly described method of applying practice-wide access is via a secure website, whereby patients log in to the practice website and are given the option to send online messages. Responses are received via the patient’s e-mail inbox or an inbox they can access via the website. These sites also tend to offer appointment-booking and repeat prescriptions in the manner of a patient portal, and there is speculation that they could also offer access to medical records. UK policy-makers draw on examples of these sites from the USA, for example, from Kaiser Permanente and the Mayo Clinic, where patient portals are in use. 3,32,66 Thus, UK policy-makers appear to believe that a patient portal system is the most plausible model for the introduction of online consultation,7 despite the fact that this is not backed by robust evidence and has not been tested in a UK setting. Even in the USA, the uptake rate of electronic communication is low and it has not achieved widespread adoption. 67

E-consulting

In this study, e-consulting refers specifically to consultations mediated by software provided by two commercial providers (eConsult, previously known as WebGP,68 and askmyGP69), which claim to manage demand by allowing patients to complete a ‘structured online consultation’. 70 Patients enter information about their symptoms and, in some cases, leave an electronic message for the GP. This provides the GP with a history to enhance the subsequent contact, which is usually made by telephone. eConsult68 software is linked into the practice website and supported by Egerton Medical Information Systems (EMIS; EMIS Web, EMIS Health, Leeds, UK), a main supplier of electronic medical record software in the UK. 71 NHS England has openly supported the roll-out of these software systems in its plans for how general practice will deliver care in the next 5 years, providing:

£45 million [for a] national programme to stimulate uptake of online consultations systems for every practice.

NHS England. 7

Contains public sector information licensed under the Open Government Licence v3.0

Video

There are some examples of the use of internet video to provide consultations in general practice. 42 The use of video consultation is much less well known in UK primary care. There are many reports of practices taking it up (including projects funded by the GP Access Fund, NHS England),14 but little evidence of its feasibility and effectiveness. As described previously, despite six practices piloting video-consultation tools, there was in fact a low level of uptake by practitioners and patients; thus, conclusions could not be drawn about their use. 15 Facilities are emerging to support this type of consultation. For example, EMIS has recently introduced a feature into its systems that provides video consultations, and the feature offers secure communications. 72

Identifying the evidence base

Objective 1: to conduct a conceptual review, synthesising the literature (qualitative and quantitative) on patients’ and practitioners’ experiences of alternatives to face-to-face consultations, with a particular focus on the views of different groups of patients and factors that promote or hinder the wider implementation and uptake of these alternative forms of consultation.

Developing a theory

Objective 2: to use a scoping exercise to identify the range of ways in which general practices in England and Scotland are currently providing alternatives to face-to-face consultations in order to create a typology of these alternatives.

Objective 3: to identify and recruit approximately eight practices with varied experience of implementing alternatives to face-to-face consultations to act as focused ethnographic case studies.

Objective 4: in the case study practices, to explore how practice context, patient characteristics, the type of technology and the purpose of the consultation appear to interact to determine the feasibility and impact of alternatives to face-to-face consultations, from the perspectives of both patients and staff. This includes the impact on the clinician–patient dynamic. The impact for people living in isolation, people with disabilities, disadvantaged groups and other vulnerable or hard-to-reach groups will be a particular focus.

Objective 5: to identify the factors that act as the main barriers to, and facilitators of, wider use of these alternatives.

Modelling the process and outcomes

Objective 6: to use the findings to develop guidance and a website resource for general practice, detailing the most promising applications of alternatives to face-to-face consultations for different patient groups and different purposes, and in different practice and population contexts.

Objective 7: to treat the provision of alternatives to face-to-face consultations as an intervention, in order to develop a framework for a subsequent evaluation. We will clarify the target population, appropriate outcome measures and best methodological approach for this evaluation.

The research is focused to fill the gaps in the existing evidence base in a way that leads to practical and applicable findings, and provides a framework for future evaluation. It is hoped that the research findings will broaden the scope for research in this area.

Types of studies

The review included material from any study design or article type. Given the changing nature of the field, the review focused on recently published articles (2012 onwards), but included sources from before 2012 where relevant.

Setting

The setting of interest for this review was primary care, but material from related settings (e.g. e-mail consultation between patients and specialists) was included where it provided lessons directly relevant to primary care.

Types of alternatives to the face-to-face consultation

We sought material on the following technologies: telephone consultations (but not those used to triage all requests for consultations before offering any face-to-face appointments), e-mail, e-consultations and internet video (e.g. Skype) technologies, short messaging service (SMS), telehealth and any other ‘care at a distance’ application.

Search for material

Our search was devised in conjunction with an information specialist at the University of Oxford. It was designed to identify articles that have explored, or tested, the effects of alternatives to face-to-face consultations in relation to how patients or staff experience their use, or described theories or ideas about the potential effect.

The search was intended to identify a wide range of study designs and articles. A sensitive search was designed, which yielded a high number of retrieved articles. Databases searched included the Cumulative Index to Nursing and Allied Health Literature, Cochrane Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, EMBASE, MEDLINE, PsycINFO, Science Citation Index, Social Science Citation Index and Conference Proceedings Citation Index (see Appendix 1 for search strategies). We searched the databases from date of inception to 2015, and then a filter was applied to limit the retrieved articles to those from 2012 onwards.

We used additional sources: (1) key systematic reviews in the field and included studies, (2) papers identified by HA and SZ in the course of our work, (3) papers suggested by experts in the field (including the project team) and (4) papers identified by snowballing from the references lists of interesting and relevant studies.

The news archives of several related news websites and eHealth Insider, Pulse and GP Magazine were all searched for relevant material.

Selecting material

Within the articles identified using the database search, we examined all articles. A two-phase approach was taken; first, titles were examined, before looking at selected abstracts in more depth. Selected articles were then read in full. We checked the reference lists of full studies as we read them. When a ‘key’ paper was identified, we examined the references. The process was iterative, with further material sought as the matrix was populated.

Collation of material and identification of themes

For the purposes of collating material for the review we devised a matrix, which allowed for identification and extraction of key ideas and provided a constant comparison framework.

Either HA or SZ, and sometimes both, read articles. Where useful information was present in a study or article, it was added to the matrix. The matrix template was developed iteratively as material was extracted. For an example of the matrix template see Appendix 2.

Using a matrix allowed us to extract material according to the participants we were interested in, in line with the aims of the wider study: reception staff, nurses, GPs, practice managers, patients (particularly disadvantaged groups) and carers. Additional detail was added as extraction commenced; this meant including other groups (secondary care clinicians, policy-makers, professional bodies) and also acknowledging roles that apply outside a UK setting (e.g. service manager and primary care physician).

We extracted information from the studies by technology type, and initially split it into two categories: positive effects and negative effects. We added a further two categories once the extraction process commenced. These were ‘positive speculation on effects’ and ‘negative speculation on effects.’ This reflected the studies and articles that provided opinion on the technology, and also the studies and articles that included both empirical data and speculation.

Collating material in this way allowed us to identify the potential mechanisms through which each effect might work. Early in the process we (SZ and HA) met to compare the extraction into the matrix and to discuss key themes arising. We continued extraction of material until saturation was reached for the emerging themes.

Appraisal of articles

We did not apply formal quality appraisal tools in this conceptual review; however, each article was considered in relation to:

• relevance – does the research address the topic and enable us to add to, adapt or amend the initial matrix?

• rigour – does the research support the conclusions drawn from it by the authors?

When articles were not relevant, we excluded them from those used to develop the matrix. When rigour was in question, we did not exclude the article, but, instead, this was noted for the purposes of interpreting the data.

Synthesis of findings

We identified the main themes from the matrix and put these into an initial ‘map’, using the OSOP90 (one sheet of paper) method for grouping the material. From this point, we used a constant comparison approach: reading the articles and expanding the themes. We met regularly to discuss the data, and this often involved going back to key articles and revisiting themes that were identified earlier in the extraction process.

At this stage, the contents of the matrix and the initial map were shared at a team meeting to obtain input as the analysis progressed. The main themes were also discussed at a patient and public involvement (PPI) workshop (described below).

Theoretical framework

We based our development of the eventual conceptual map on input gained from the wider team and further meetings between the review team (HA and SZ). In organising and structuring the conceptual map, we used the Halford91 sociological framework of health-care work and organisation for information and communications technology (ICT) initiatives.

Halford’s framework91 views that the introduction of new ICT applications threatens to disrupt health-care work and organisation by disrupting social orders mediated by inter-relations of power, knowledge and identity. The analytical framework positions ICT initiatives within orderings of health-care work and organisation, with ICT applications posing three potential disruptions to the organisational, professional and spatial dimensions of health-care work and organisation.

This framework was chosen because it helps to understand, at a general level, how ICT initiatives disrupt the prevailing order of health care. The dimensions of the framework were used to structure the conceptual map, with the acknowledgement that the processes presented are inter-related, shaped by health-care work and organisation, but do not occur independently.

Development of the conceptual map

Once the material had been mapped, we developed it into a series of key questions to be asked when ‘planning, implementing and researching’ alternatives to face-to-face consultations, guided by Halford’s framework. 91 The conceptual map was also used, along with the protocol for the study, to devise a case study guide for the ethnographers to use while conducting the fieldwork. The guide was designed to align the information in the protocol with the information emerging from the review, to ensure that the data collected were in line with the aims of the study and built on existing research. The ethnographic team used it as a supporting guide when conducting the fieldwork.

Patient and public involvement workshop

In order to refine the emerging findings of the review, we held a workshop with patient and public participants. The workshop was facilitated by Andy Gibson. It lasted approximately 3 hours and was attended by five members of the public. We shared the themes from the review, and then members of the research team worked in small groups with the workshop participants to discuss the themes, followed by a whole-group discussion.

Initial themes

In the initial map, we identified the positive and negative effects of alternatives to face-to-face consultations, the effect on patients and staff working in primary care and other health-care settings and the potential mechanisms through which each effect might work. We identified nine main themes: organisation/workload, convenience and efficiency, the self-documenting nature of alternatives, economy/false economy, the technology itself, the nature of general practice, fear of change, asynchronicity and safety (Figure 2). This map provided the basis for the analysis.

FIGURE 2.

Map of initial themes.

Patient and public involvement workshop

Throughout the discussions, the themes from the review were compared with the perspectives of those attending the workshop. We further explored any differences or possible new ideas within the review material to see if they could add to the conceptual map.

Conceptual map

The final conceptual map covered 10 themes under three headings: organisational disruptions and dynamics, professional disruptions and dynamics and spatial disruptions and dynamics.

Uptake and awareness

In settings in which the availability of alternative forms of consultation is a matter for individual practices, rather than being required by policy directives (as in Denmark), then the question is raised as to how patients find out what is available to them at their practice. In a survey of patients’ reasons for not consulting their doctor by e-mail,92 the lack of awareness of the possibility of an e-mail consultation was one of the main reasons for non-use. Primary care professionals have described selectively offering alternatives to patients who they feel are able to use them appropriately. 19,93 Awareness will clearly affect uptake, as will the attitudes of members of the primary care team towards offering these alternatives. There was a lack of material relating to the perspectives of reception staff and their contribution to the uptake and awareness of alternatives, despite their patient-facing role.

Organisation of alternatives to the face-to-face consultation in the health-care setting

Several of the misgivings that have been raised about alternative consultations relate to the organisation and administration of the practice rather than to the consultation itself. Common concerns include what will happen if a part-time member of staff does not pick up an urgent e-mail and if alternatives to the face-to-face consultation will introduce inefficiencies for the practice. 67 Staff sometimes express concerns about whether or not patients will exercise their options responsibly, fearing that the relative ease of sending an e-mail (or a stream of e-mails) may mean that some patients will overconsult or misrepresent their symptoms. 94,95 Although the evidence is limited, in settings in which e-mail consultations have been introduced, they have not, as yet, opened the floodgates for patient demand. 96 Even in practices and health systems in which patients have had the right to e-mail their family doctors for some time, these alternatives are not widely used. 55,97 In Denmark, where e-mail consultations are a standard part of primary care, some doctors admit to managing their patients’ expectations by deliberately delaying their responses to non-urgent e-mails. 44

Primary care is set up to deliver the face-to-face consultation. As yet, there is little evidence about how best to time, conduct and record other forms of consultation. 94,98,99 These uncertainties make changes to service delivery difficult. 30,48 Potential inefficiencies include duplicated consultations if patients consult remotely and then attend the practice or need a home visit. 60,100,101 A study of telephone triage in general practice found that, where telephone triage led to a face-to-face consultation, the duration of this subsequent face-to-face consultation was no shorter, despite a clinician speaking with the patient during the telephone encounter. 102

Making arrangements for recognising and reimbursing some of these alternatives to the face-to-face consultation is an ongoing process. 103,104 In the USA, problems have arisen where reimbursement for Medicare patients is at the discretion of individual insurers, with many patients not being reimbursed for alternative types of communication with their health-care provider. 105

Different alternatives to the face-to-face consultation also differ in their impact on practice organisation. The face-to-face consultation is usually booked via reception staff. This is also the case for most telephone consultations. E-mail can allow patients to bypass the gatekeeping role of the reception staff and obtain direct contact with the primary care professional, or whoever is allocated the task of replying to the e-mail. 19,106 This prospect is sometimes viewed as unacceptably disruptive by clinicians. 107 There is a lack of evidence relating to the roles of team members, such as reception staff, in delivering alternatives to the face-to-face consultation.

Safety

Patient safety is crucial in any form of consultation, but alternatives to the face-to-face consultation present an unknown in terms of what these issues might be. Despite patient safety being cited as a reason to be wary of introducing alternatives to the face-to-face consultation,108 there is very little documentation of what these concerns are. Patient privacy and confidentiality are described as being important, but reports of privacy and confidentiality breaches are few, and collection of these data is uncommon. The Cochrane review of trials relating to e-mail for consultation found that the trials did not report any harms, but this is not the same as stating with confidence that no harms occurred. 30 There is much work to be done in identifying potential patient safety issues and mitigating the risk associated with these.

Organisation of space

As a visual method of consultation, there are considerations to be made when using video conferencing. To benefit from video conferencing, practices may need to allocate a well-lit, private area for the staff to use, as well as reliable connections, so that screens do not freeze mid-consultation. 107,109 This also applies to the systems that the patients are using. 110 A reliable contingency arrangement may be needed in case of technological failure. The potential for ‘freezing’ or image breakdown during a video consultation may have clinical consequences – for example, it can be particularly disturbing for people with mental illness. 109

Proximity in the consultation

The common feature of all alternatives to the face-to-face consultation is that they are not face to face. A different medium inevitably changes some aspects of the performance of the consultation; these elements may be lost, or may need to be expressed in a different way or performed at a different time, for core elements of the doctor–patient relationship to be maintained. 111,112 There is particular uncertainty around the ‘rules of engagement’ for e-mail and video consultations. 19,44,113 The proximity with the patient that is afforded in the traditional face-to-face consultation permits diagnostic cues, such as smelling the patient’s skin and breath, noting how the patient walks into the room and using casual contact, such as shaking hands, to assess skin temperature and tone. 114,115 The health-care professional may lose some of their ability to check the patient’s understanding, which is often conveyed via non-verbal communication. 116,117 As yet, there is little research indicating whether misunderstandings are increased or diminished with alternatives to the face-to-face consultation.

Professional indemnity

Related to the lack of guidance or consensus on best practice, patient safety and the risk of litigation are often raised when alternatives to the face-to-face consultation are proposed. 93,118 This could be understood as a proxy reason, given that highlighting safety concerns is undoubtedly a more ‘acceptable’ form of resistance than voicing concerns about threats to professional identity and power. However, there is also some evidence that clinicians’ safety concerns are leading to safety-netting, demonstrated by prescribing behaviour; for example, primary care doctors are more likely to prescribe antibiotics during an e-visit than when they consult face to face. 119 This may reflect uncertainty around the medicolegal consequences of this type of prescribing. In trying to understand how alternatives are working, it is necessary to be alert to how safety-netting procedures are enacted.

Health-care professional attitudes

When health-care professionals are asked about their views on using alternatives to the face-to-face consultation, concerns tend to focus on whether or not their clinical duty to provide safe and effective care might be compromised. 37,45 Much of this concern relates to the potential impact of these additional consultation methods on their workload. Fears expressed include increases in consultation volume24,120 and increased administrative load. 20

Those with experience of successfully using alternatives to the face-to-face consultation in their own practice raise similar issues: still feeling uncertain about the long-term effects on their workload and, consequently, their patients. 19 Research suggests that any new technology needs to be seen to enhance what the professional sees as their core role,121 otherwise it is unlikely to be accepted into practice. 122,123

There have been far fewer studies collecting the views and experience of practice nurses on alternatives to the face-to-face consultation, but there is evidence that nurses feel that their role requires proximity to the patient. 111,124–126 In a study of a telehealth self-care support system for people with chronic health problems, the nurses who were providing the service positioned their work as ‘proper nursing’, whereas nurses who were using the telecare system suggested that the calls with patients were ‘just chat’ and doubted that real nursing could be delivered via the telephone. 127 A Norwegian study of nurses working in emergency medicine found that the approach of nurses changed when they consulted remotely: they were more assertive and gave more advice.

Health-care professional skills

An important consideration is whether the technology is familiar and easy for both parties to use or whether it requires new skills. Some health-care professionals worry that their lack of confidence with technology may be exposed, and that such exposure might undermine their authority. 128,129 In a study of breastfeeding support via video consultation, lactation consultants were concerned about technical issues, such as the quality of images, but patients were very satisfied with the remote consultation. The lactation consultants were not confident about undertaking clinical assessments via video – a concern that the authors concluded could be addressed by specific training in using the medium. 110 Although the balance of power within the consultation may change if the primary care professional’s skills come under patient scrutiny,130 this is not necessarily damaging and could even be a helpful shift in longer-term relationship dynamics.

The nature of the communication medium

There are already many different technologies that patients could use to consult their doctor without meeting face to face, for example telephone, e-mail, SMS and video communication. Although specific platforms are likely to be superseded in a fast-changing field, it is possible to differentiate according to whether the method provides (moving) images, audio or written content, and whether the exchange is in real time or asynchronous. Asynchronicity allows both patients and health-care professionals to send and act on contacts at a time that suits them. For the health-care professional, they can draw upon external resources or check evidence, perhaps providing sources of information for the patient. 67,131 For patients, it allows them time to construct an enquiry, perhaps with help from family or friends, and to send follow-up questions that occur after a consultation. E-mail allows patients to upload images. Methods that allow video connection give health-care professionals the opportunity to view the patient, including visual symptoms (such as a rash) and also, potentially, the patient’s home setting. All of these factors allow for the collection of information on the state of the patient, beyond that communicated verbally.

Patient interface with alternatives to the face-to-face consultation

Where patients have been offered an alternative to the face-to-face consultation, they usually report liking them. 132,133 E-mail and telephone consultations remove the need to attend the GP or nurse’s professional space, which tends to be viewed as a benefit by patients. 67,106,119 Other reported benefits include the convenience of being able to consult while at work,134 to choose when and how to consult and the perceived advantage of avoiding the practice receptionist. 44,124 The ability to communicate with a doctor via e-mail means that the patient can compose a message when something is bothering them, which may be outside office hours. The patient (and their family) may like to exchange information relevant to health and care decisions within their personal contacts. Parents can photograph, record and attach digital files with images of a child’s rash, or recordings of an infrequent cough or breathing difficulty. 44,128 For patients preparing for a visit to hospital, or recovering at home afterwards, these methods can provide a way to keep in touch without necessitating a visit. 111

E-mail exchanges can provide a consultation record, and possibly clearer explanations and subsequent understandings than information obtained during face-to-face contact. 111 This may be particularly advantageous to those who are less articulate or confident in person, those who wish to discuss their consultation with others and those who need help with translation. 94 Some patients may be more willing to disclose intimate or sensitive information via an e-mail than in person or over the telephone – especially if they are at work or in a public place. 44 For others, the reverse will be true, not least because of concerns about confidentiality in e-mails.

Health professionals raise concerns that older patients, disabled patients, people without literacy skills and patients who are less educated3,55 may be disadvantaged through alternatives to the face-to-face consultation. 45 There is some evidence that, for those who have internet access, patients who are disabled, elderly, less confident or living at some distance from the practice are often among those who are particularly keen to use e-mail consultations. 56 Patient skills in using these technologies should be considered. Providing information or training may not be enough on its own. Varsi et al. 131 recommend that patients should be shown how to use a system at a point when it is relevant to them, rather than as part of a general induction to their health-care organisation. If the information does not come at the right time, the patient may not remember the system, or (as is likely in a fast-moving field) the system may have changed by the time they come to use it.

Although there is a lot of speculation about the potential benefits and disadvantages for patients, and particular subgroups of patients, much of it has been written from the health-care professional perspective, and credible empirical evidence from patients is very limited. The perspectives and experiences of patients (and especially those from groups who are assumed to be disadvantaged by the introduction of alternatives to the face-to-face consultation) clearly need further attention when designing, implementing and evaluating systems.

Key questions

As the conceptual map was developed, a series of key questions was created (Box 2). These questions were used to form the basis of an essay: ‘What do we need to consider when planning, implementing and researching the use of alternatives to face-to-face consultations in primary healthcare?’. The essay was submitted to and accepted by the Journal of Digital Health and published in September 2016. 83 The content of the essay overlaps with the material presented in this chapter, although the essay was designed for broader application beyond the study.

Case study guide

The findings of the review fed directly into the case study guide. The case study guide was produced to guide the focused ethnographers in their understanding of the required scope of data collection across the three case study sites. Each ethnographer came from a different background, and two had not conducted research in general practice settings before. The guide was used to ensure that they understood the scope of the focused ethnography and felt confident going into the field.

The guide outlined specific areas of interest, including the staff members they should consider observing (e.g. focusing on reception staff as well as clinical staff), things they might want to look out for (e.g. dynamics within the clinic between staff members) and where they might look (e.g. areas where team members interact beyond the consultation areas) in this particular setting.

The 13-page guide was written systematically, and began by reiterating the objective of the case studies and outlining the participants of interest. Then, for each group of interest, such as reception staff, the tasks required (observation, interview) and the per-protocol approach to conducting the tasks were outlined, and the factors to explore were detailed. These factors were derived from both the protocol and the review findings. The guide finished with a summary of each technology type and the specific factors to explore in relation to these. This was helpful for the ethnographers at the beginning of the study when they were unfamiliar with the research questions. They were told that it was a guide and not a checklist and that it was for their personal reference only. For the case study guide, see Appendix 4.

The postal survey

The single-page survey opened with questions about the age and sex of the respondent, followed by two groups of questions. In one group, participants were asked whether their practice currently provided or planned to provide consultations with patients via e-mail or electronic messaging, internet video or telephone. We excluded telephone triage, as this constitutes a contact rather than a consultation and telephone triage is being assessed in an ongoing project funded under the same call. 137 In the other group of questions, participants were asked how often they personally conducted consultations using each of these approaches. Each question in both groups was scored on a 5-point Likert scale. The questionnaire closed with the opportunity for respondents to add information ‘about any interesting or unusual ways in which you use these different approaches’ in a free-text box (Figure 3).

FIGURE 3.

Questionnaire.

Practices within the English study sites were identified through the relevant Clinical Commissioning Group (CCG) websites. For the practices in Scotland, we retrieved details from the Information Services Division Scotland website. Information about the practice managers, GP partners and salaried GPs were accessed via the practice website if one existed. For those practices without a website [53/421 (13%)], we gained the information through a telephone call to the practice.

We posted questionnaires to each of the practice managers, GP partners and salaried GPs. As the focus of this study was on provision of care at a practice level rather than individual GP attitudes, our aim was to receive at least one response from each practice. If no response had been received following a period of 2 weeks, a postal reminder was sent to all of the GPs and the practice manager within the practice, and 2 weeks after this a telephone reminder was made, if appropriate, to the practice manager. We also offered an incentive, with all those who returned a completed questionnaire within a specified time being entered into a raffle for a tablet computer.

Ethics and research governance permissions

The Health Research Authority and the University of Bristol Faculty of Medicine and Dentistry Research Ethics Committee deemed that no ethics permission was needed.

Analysis

We conducted the primary analysis at the practice level, and then subsequently analysed GPs’ personal use of alternative forms of consultation at an individual level. Numerical data were analysed using simple statistical methods supported by Microsoft Excel^® 2013 (Microsoft Corporation, Redmond, WA, USA) and Stata^® 13 (StataCorp LP, College Station, TX, USA). Where different responses were given by respondents within the same practice, we used the mean result at practice level, rounding to the nearest whole number (since each response was scored from 1 to 5 on a Likert scale). We explored the extent of variation in response by different individuals within the same practice, using the within-practice standard deviation (SD) and the intraclass correlation (ICC) coefficient. Responses regarding GPs’ own use of alternatives to face-to-face consultations were analysed at the individual respondent level. Responses from practice managers were excluded from the individual-level analyses, as they do not consult with patients.

We analysed the results from the free-text box thematically, using NVivo 10 (QSR International, Warrington, UK), and visual mind-mapping was carried out to examine themes and patterns in the data. 90

Exploring practice websites

An attempt was made to access each of the 421 practice websites in our three study areas (186 English and 235 Scottish practices) to see if there was any reference to the use of alternatives to face-to-face consultations. However, websites were not identified for 53 out of 421 practices (13%) at the time of searching (51 of the 53 were in Scotland).

Contacting commercial organisations

A number of companies market software systems to general practices to support them in providing alternatives to face-to-face consultations. We drew up a list of these companies through existing knowledge of the team and extensive searches of the internet. Eight companies were approached to enquire whether or not there were any practices using their technology within our study sites. Although four companies responded, no practices were identified because either the technology was outside our remit, they were reluctant to provide details of the practices that were using their technology, or there were no practices in our study areas.

Utilising local and national links with those working in primary care

In addition to the above methods, we also approached the local CCGs, Health Boards and Primary Care Research Networks in our study areas to ask if there was any awareness of practices adopting any form of alternatives to face-to-face consultations. We were also able to identify any practices or local consortiums that may have been funded by the GP Access Fund. 14 Unfortunately, this approach did not yield any further information, as either we had already identified the sites or there was little knowledge of the local use of alternatives to face-to-face consultations. Our enquiries also demonstrated that, although many sites receiving funding from the GP Access Fund14 had said that they would implement alternatives to face-to-face consultations, such as video-consultation, we were not able to identify any that had actually done so at that point in time.

Postal survey

Of the practices approached, 163 out of 186 practices (88%) in England and 156 out of 235 practices (66%) in Scotland responded, giving an overall practice response rate of 76% (n = 319/421). In addition, 40% of English and 25% of Scottish surveys were returned with an overall individual response rate of 33% (n = 889/2719). The number of responses per practice ranged from 1 to 11.

Profile of respondents

Participating practices were significantly larger (in terms of numbers of registered patients and doctors per practice) than those that did not participate. There were no significant differences between responding and non-responding practices in terms of their deprivation score (Table 2). Of the 696 respondents who reported their sex, 59% (413/696) were female. Respondents categorised their ages as 25–34 years (n = 90/889; 10%), 35–44 years (n = 239/889; 27%), 45–54 years (n = 362/889; 41%) or ≥ 55 years (n = 189/889; 21%). Of all the responses, 12% (105/889) came from practice managers and 88% (784/889) from doctors.

The current and planned use of alternatives to face-to-face consultations at the practice level

Although the majority of practices reported routinely offering telephone consultations, few (6%) reported facilitating e-mail consultations (Table 3). One-fifth of practices intended to offer e-mail consultations in the future, but half of the practices had no such plan. None of the respondent practices reported offering internet video consultations, and very few reported any plans to do so in the future. There was also evidence that 21% of practices had previously offered e-mail, and that 10% had previously offered internet video, but that they had subsequently withdrawn these services.

There were some inconsistencies between respondents within the same practice about their practice’s use of telephone (within-practice SD 0.91, ICC 0.53) and e-mail consultations (SD 1.1, ICC 0.39). There was less variation between respondents about their practice’s use of video consultation (SD 0.52, ICC 0.20), related to the limited use of this consultation method in general.

The current provision of alternatives to face-to-face consultations at an individual general practitioner level

The majority of GPs reported personally providing telephone consultations on most working days or every working day (79%). Only 8% of GPs reported providing e-mail consultations on most working days or every working day, whereas 45% did so rarely or sometimes and just under half (47%) never provided e-mail consultations. Furthermore, 99% stated that they never conduct consultations via internet video (Table 4). Provision of telephone, e-mail or video consultations did not vary by GP age or sex, or by study site (data not shown).

Thematic analysis of free text

All respondents were invited to complete a free-text box to ‘highlight any interesting or unusual ways in which you use these different approaches as an alternative to face-to-face consulting’ and 249 out of 889 responses (28%) included some form of free text.

Rather than answering the question posed, the majority of the respondents described their views on the idea of introducing e-mail or video consultations. Most of these comments expressed resistance to the idea of e-mail or video consultations. Only a few opinions were related to actual experience, and many respondents expressed strong views, despite reporting no actual experience of using such methods (e.g. ‘only politicians and the naive would think this a good idea’).

A number of GPs expressed concerns that adopting e-mail or video consultation would add to their already demanding workload:

Increasing access options, increases GP stress . . .

E-mail is a nightmare – access all the time and hundreds of e-mails.

Currently overwhelmed and under resourced.

or that it would have a negative impact on the practice:

If we take on e-mail consultations we will have possibly hundreds of emails. Who will deal with them? Medicolegal consequences of delay we have no capacity, this will possibly increase workload.

We already get > 100 e-mails EACH daily. This would open the floodgates and we would drown. It is unmanageable.

We are all too busy to synchronise this.

The practicalities of managing alternatives to face-to-face consultations were also voiced as a concern:

We have talked about these being future possibilities but I have concerns about managing the amounts via e-mail - difficult to cap them.

At the moment there is no way of providing protected time for e-mail consulting and would therefore be reticent to encourage this.

E-mail’s a problem as difficult to store but can copy the essentials into system. It doesn’t save much time. Text is worse as have to make separate note so not used routinely.

The respondents also expressed a fear that offering alternatives to face-to-face consultations would be a challenge in terms of privacy and confidentiality, and would increase clinical risk with medicolegal consequences:

It’s a personal preference but I find the increased access too intrusive and increases risk of information getting lost/filed with other documents.

We have discussed use of e-mail communication but find there is a risk of e-mails not being acted upon when certain GPs are on leave leading to unnecessary risk and delay.

I feel the level of risk with these are higher than a face-to-face or phone.

Issue with confidentiality using e-mail.

Query issues with medicolegal problems + confidentiality.

Practical issues, such as the reliance on appropriate internet provision and broadband reliability, and local concerns about information governance were mentioned as further barriers to implementation:

Internet connection currently barely up to current software requirements for e-referrals etc. Don’t have software & hardware capacity for more modern techniques.

I have tried to discuss use of internet video consults. Health Board have concerns re security - additionally agreeing role out of suitable user friendly secure system may be an issue.

We are not allowed to use the internet due to confidentiality.

alongside a concern that there could be an additional cost to the practice:

Need additional funding/additional admin time (reduced clinical time) to accommodate.

Funds are the only barrier currently.

Skype/facetime would involve investment in IT. This is not funded by our CCG.

A few GPs had experience of some vulnerable and elderly people who preferred alternative consultation methods, whereas others thought that these same groups would be disadvantaged:

Concern that most vulnerable (deaf/blind/elderly/demented/mentally ill) least able to access and so unintentionally disadvantaged.

Very elderly population – technology difficult.

Most of my patients with real health needs are > 85 yo [years old] and not skyping. Most of the patients with electronic ‘wants’ are < 45.

A few GPs mentioned experience of benefits of using an alternative to a face-to-face consultation, such as patients being able to send pictures of a transient rash or an audio file of a child’s cough:

I think patients using media, e.g. bringing in photos of their transient rashes, or recordings of their baby’s cough are great.

In combination with phone consult (and with consent) I have got patients to text me photos of problem e.g. rash, eye inflammation to help confirm diagnosis or whether need to be seen etc.

or their use as part of ongoing medical care and a way of providing patient support or for sharing information:

In my experience telephone consultations useful for F/U [follow up] of problems.

I kept in weekly contact with a T1 DM pt [type 1 diabetes mellitus patient] by text.

E-mail and telephone are usually simple issues such as drug queries or results. Patients report blood pressure I e-mail advice leaflets/links.

The use of alternatives to face-to-face consultations was also seen as a way of managing the practice workload:

We encourage patients to use email to send info to us (stops clogging up the phone lines).

Telephone very effective use of time and resources esp. follow ups.

Some respondents also reported benefits for their patients who preferred to use e-mail because of communication difficulties or disabilities that made it difficult to get to the surgery:

I use e-mail for one patient who has MND [motor neurone disease] and so cannot speak on phone.

E-mail really helpful for deaf patients (who sometimes send me an e-mail before attending a consultation to save time) and for tracheostomy patients.

Some also mentioned using e-mail with particular ‘selected’ patients, and being in e-mail contact with their own GPs:

For what it is worth, my GP has e-mailed me but only as a ‘special patient’!

Exploring practice websites

Within the practice website search, 128 out of 184 English and 125 out of 184 Scottish practices stated that they offered telephone consultations (not including those used for triage). These ranged from same-day call-back to booking a telephone consultation in advance. Five English practices and one Scottish practice offered an electronic messaging service (e-consultations), and four English practices and one Scottish practice invited patients to e-mail their doctor; however, for one there did not appear to be an e-mail address provided, and one English practice had a ‘webform’ box on their site for non-urgent messages. None mentioned offering video consultations. Although some of this information was clearly displayed, for some of the alternatives to the face-to-face consultation offered, particularly e-mail, it was difficult to find the information on practice websites. It was useful to cross-reference the findings from the website search with those from the survey, as sometimes websites were out of date. It was also useful to acknowledge the website information that applied to the case study practices selected for the ethnographic phase of the study, as this gave us more background on the practices we were going to approach for recruitment to the case studies.

Focused ethnography approach

This study used team-focused ethnographic methods. In a focused ethnography, rather than embedding a single researcher in a social setting for a lengthy period, more targeted data collection is used to explore the study topics. Using existing information from the literature and from what is known in clinical practice helps to determine the research question and, subsequently, to generate findings that are relevant and useful. 139

This project is a team-based ethnography as it involved three ethnographers working across a total of eight general practice sites in three regions (Scotland, Oxford and Bristol). Team-based ethnographies have become increasingly popular across disciplines. 140–142 This trend has been linked to funding bodies that encourage multidisciplinary team-based research, because of the wider range of expertise that will be brought to a project. 140,142 The use of a team-focused ethnography for this study has been explored further by Bikker et al. 143

Although ethnographic methods have been used in primary care for several notable studies,144–146 they have usually required an intensive period of immersion (often by a sole researcher) in the study setting. The focused ethnographic approach lends itself well to health services research, because it is an efficient way to obtain an insightful understanding of concepts and processes within the fast-moving context of health-care policy development. This method was particularly suited to this study’s research questions as it allowed data to be collected on a predefined topic guided by the conceptual review work, while emphasising the importance of the context and the cultural landscape of the practices within a limited time frame.

Composition

The case study team consisted of three researchers with experience of ethnographic research who were employed to conduct the focused ethnographic fieldwork. Although having three researchers collecting data was time efficient, to minimise the costs, two of the researchers were employed solely for the duration of the data collection (12 months). The third researcher was employed for the duration of the project (27 months) and also took on the role of project manager. The ethnographic researchers were based in two universities in England and one in Scotland. They had different backgrounds, which included medical and social anthropology, nursing and mixed-methods research methodologies. The three ethnographers were managed by two co-applicants: Helen Atherton on a day-to-day basis with input from Sue Ziebland (see Table 1, Chapter 1). This subteam of five researchers made up the ‘focused ethnographic team’. The wider study team was also involved in providing a ‘check’ on the data the ethnographic team were collecting.

Communication

Steps were taken to ensure that the focused ethnographic team worked cohesively on the data collection and analysis. Over the period of the fieldwork and analysis, this involved:

• the focused ethnographic team setting out a strategy for teamworking during their initial meeting

• the three ethnographers having a weekly telephone meeting

• the three ethnographers and the day-to-day focused ethnographic team lead (HA) having a fortnightly telephone meeting

• the three ethnographers contacting the day-to-day lead (HA) via e-mail or telephone, when necessary

• the day-to-day lead meeting regularly with the senior focused ethnographic team lead (SZ)

• the entire focused ethnographic team attending three data collection and analysis workshops over the course of the project: two in Oxford and one in Edinburgh

• the ethnographers attending the project meetings (both face-to-face and telephone meetings) during the 12 months of fieldwork, allowing for updates to be made to the wider study team, and for the ethnographers to hear about the progress of all elements of the project.

Selection of sites

We recruited eight practices as planned. Two were in Scotland, three were in Oxfordshire and three were in Bristol. The scoping survey (see Chapter 3) was used to identify potential practices. Based on our survey data, we constructed a matrix of practices detailing various practice characteristics. Characteristics included experience of implementing different types of alternatives to face-to-face consultations; the size of population the practices serve; and location, in terms of whether it is urban or rural and deprived or affluent (based on deprivation scores). We then selected practices to approach, ensuring that we covered a range of demographic characteristics and applications of alternatives to the face-to-face consultation, for example ‘currently using’, ‘tried and rejected’ or ‘substantially modified their plans to use’ alternatives.

We sent invitation letters to practices, followed by telephone calls to the practice manager and/or GP to ensure that the invitation had been received. When practices were interested, a researcher visited to provide more information and discuss the implications of participation. Practices that declined to participate stated excessive workload and/or staff shortages as the reason.

Consent and observational work

The ethnographers observed practice staff in all areas of the practice, such as clinical areas, reception desks and administrative offices. Observations included consultations, both face to face and alternatives to face-to-face consultations.

In the first instance, the practice manager agreed to the practice participating in the research and informed all staff that the ethnographers would be situated in the practice for a number of weeks.

On commencing the research within the practice, informed consent for observation was sought by the ethnographer from all members of the practice. This involved providing all staff members with an information sheet about the study and providing a consent form. The information sheet outlined that the ethnographers may observe them at work, engage in informal conversation and take notes. They were given up to 1 week to read the sheet and complete the consent form before a further enquiry was made. Some staff members were not based in the practice and declined to consent, on the basis that we would not be observing them. A small number of staff members declined to consent. We ensured not to engage them in informal conversation or directly observe their work. We did not take notes on any work they were engaged in. In addition, those consenting were informed that, at any point during the research period, they could decline observation or conversation. Staff members engaging in interviews were given an additional information sheet and completed an additional consent form for participation in the interview.

Observations of consultations were at the discretion of the GP. Patients were invited to consent to their face-to-face consultation being observed, given an information sheet and asked to consent to the observation. For observation of telephone and e-mail consultations, the ethnographers were not party to patient-identifiable data and so consent was not required; however, the clinician was able to decline the observation if they felt that it was not appropriate. If the ethnographer observed the GP within their consulting room but outside a consultation, they took notes but did not make notes relating to a patient or their condition, being focused only on how the GP worked (e.g. when they responded to e-mail consultations or when they scheduled their telephone consultations). Data were collected using field notes in all cases, and these did not include patient-identifiable data.

Summary profile

In each practice, the ethnographers completed a summary profile for that practice. This was designed to capture the detail obtained by the ethnographers in the field in their own words. It included, among other details, the types of alternative consultations that are (or were) provided, how these are/were provided (e.g. timing, volume, staffing) and any parameters for the types of patients who are/were allowed or encouraged to use alternatives to face-to-face consultations, including variations between practitioners. Over the course of the data collection, the ethnographers added any new observations about the practice to the summary profile template for each of the eight sites. This allowed individual field notes to be transformed into a common format. As a result, comparing the observations between practices became more straightforward, even though the personal styles of completing field notes differed between the ethnographers. At the start of the data collection, the discussion about the research topics among the focused ethnographic team was more general, reflecting the exploratory nature of the study and the process of familiarisation with the field. However, as the data collection progressed, the format of the summary profile template evolved and became more focused on alternatives to the face-to-face consultation.

The ethnographers recorded their own field notes during observations. In more formal settings, such as practice meetings, minimal notes were made by ethnographers in real time, followed by more detailed field notes retrospectively.

Document collection

In each of the case study practices, we sought to review notes and minutes from practice meetings over the preceding 6-month period. Some practices were reluctant to give our researchers full access to these notes and minutes, and so the practice managers in each practice reviewed the minutes, identifying and extracting any relevant information.

In each practice, researchers requested that they be invited to observe practice meetings during which alternatives to the face-to-face consultation would be discussed. In the end, this was the case for only one meeting in one practice, where the researcher attended the meeting and kept notes.

Semistructured interviews

Each interview participant provided informed consent. Interviews were digitally recorded, using an encrypted recorder. The files were transcribed verbatim by a professional transcription service.

Staff interviews were usually conducted in the general practice (one GP was interviewed at home). Additional interviews relating to video consultation at non-case study sites were conducted over the telephone. Information was collected on sex, age, ethnicity, role in the practice, length of time in the role, length of time since qualifying and the type of alternative to the face-to-face consultation used.

Patient and carer interviews were conducted at a location of their choosing, usually their home (or the general practice). Information was collected on sex, age, ethnicity, whether or not they were a carer, whether or not they had a long-term condition or disability, level of education and occupation.

The initial design of the topic guides was based on the findings of the conceptual review and templates used by focused ethnographic team members in previous studies. The topic guides were then revised iteratively among the ethnographic team once the ethnographers were working in the field, and a final topic guide was agreed on for both staff and patient interviews. The staff topic guide differed slightly according to the staff member being interviewed; for example, GPs were asked specifically about how the alternative to the face-to-face consultation affected their relationship with patients (see Appendix 5 for the topic guide).

Case study site staff

Once they had been conducting observations in the practice for a few weeks, the ethnographers identified relevant staff members to participate in the interviews. The ethnographers had made contact with potential interviewees during non-participant observation, and provided them with the information sheet relating to the interview. If they were willing to participate, an interview was arranged at a time that was convenient for the staff member.

In each practice, administrative staff (including receptionists), GPs and nurses were recruited to be interviewed. When relevant, other members of the practice team were also interviewed, for example, a rural health worker in one practice, a patient manager and an IT manager in another. The team of ethnographers remained in close contact throughout the process, to ensure that the range of staff members being interviewed was suitably varied in regard to factors such as role in the practice, knowledge or involvement in alternatives to the face-to-face consultation.

At the protocol stage, we intended to interview allied health professionals working in general practice, such as phlebotomists and community-based pharmacists. However, it became apparent during observations that, where allied health professionals were working in the practices, they had little to no involvement in the introduction or use of alternatives to face-to-face consultations. Recognising the importance of the wider study team members within general practice, each ethnographer engaged in informal conversations with these staff members to ensure that their perspectives were covered. These conversations were recorded in the researcher’s field notes and subsequently referred to in the structured summary profile.

Users of video consultation

As described in Chapter 3, we recruited an additional four participants from outside the case study sites. These were general practice staff members who were using, were about to use or employed a system that used video consultations.

• We approached practices that had been funded by the GP Access Fund14 to employ video consultations.

• We approached practices that had publicised their use of video consultation in news articles or reports.

• We posted a message on Twitter:

  Has your practice offered patients video/skype consults? We are looking for GPs to do a 30m phone interview for AltCon study.

  Helen Atherton has 865 Twitter followers and tweets about digital health in primary care.

• We used personal contacts (HA and CS) obtained via related research studies.

Two participants were recruited via Twitter, and a further two were recruited via personal contacts (HA). We were unable to contact all of the GP Access Fund14 practices and, in the case of those we did contact, we could not identify individuals who were using video consultation. We received no reply from the practices that had publicised their use of video consultation via news articles or reports.

Patients/carers

The aim was to interview patients with different characteristics in relation to age, sex, ethnicity, disability, frequency of attendance and whether or not they had long-term health conditions. All patients invited to participate in interviews had experience of using an alternative to the face-to-face consultation within the practice.

Initially, patients were identified opportunistically, based on those who had engaged in contact with the practice via an alternative to the face-to-face consultation. In subsequent interviews, patients were purposively sampled to ensure that participants with the range of characteristics listed above were included. Practice staff and GPs helped to identify patients and carers and provided potential participants with a study information pack, either via post or in person when attending the practice. This pack included information about the study, an invitation to take part and a reply slip, which they could return via prepaid post. The researcher then called to arrange a convenient time for the interview.

Hard-to-reach and disadvantaged groups

In using a purposive sampling technique, we specifically included people who were identified in the protocol as being in hard-to-reach groups with regard to accessing general practice. Examples included parents/carers of people with complex needs, young men, the vulnerably housed and minority ethnic groups.

The other groups of interest were those that might be disadvantaged by limited provision of alternatives to the face-to-face consultation. These groups were described in the protocol, and further relevant groups were identified in the conceptual review (see Chapter 2). These included patients with mental health conditions, patients living in rural areas, patients with restricted mobility, patients with hearing loss, patients at a great distance from the practice (e.g. working away) and patients with low health literacy and/or low computer literacy.

The aim was to look at the range of problems and issues for these groups, rather than making statements about specific population subgroups. To make it easier for people in these groups to participate, there was flexibility about timings and locations for interviews, with telephone interviews offered when appropriate. Participants in hard-to-reach and disadvantaged groups were identified by the practices so that they could be invited to interview.

Coding

The coding frame for analysis of the ethnographic data was devised by the focused ethnographic team at a face-to-face meeting early in the data collection period. Each ethnographic team member had read a series of field notes and transcripts, and contributed to devising a coding structure for the staff data and another different coding structure for the patient data, which comprised interview data only. The three ethnographers read and coded interview transcripts and field notes [using the comment facility in Microsoft Word 2013 (Microsoft Corporation, Redmond, WA, USA)]. Once the coding frame was in place, the field notes were coded and each ethnographer condensed their findings into a summary profile. The day-to-day lead (HA) read the coding of the field notes into the summary profile and read every transcript, checking the coding to ensure reliability and comparability, and adding or making adjustments where relevant. The transcripts and summary profiles were then entered into NVivo software, which allowed thematic reports to be generated.

Analysis

A series of NVivo reports were generated to gather related sections of the data together. At this point, two of the ethnographers had completed their contracts. The day-to-day lead of the focused ethnographic team (HA), senior team lead (SZ) and remaining ethnographer (HB) read all of the reports. They applied the OSOP method90 to identify the line of argument in each thematic report and identify outliers or negative cases. The data from the staff and patient interviews and the field notes were integrated, and a condensed summary was produced for each thematic code.

At this point, the wider study team became involved and were paired with the remaining members of the ethnographic team to discuss the interpretation of the data (HA and BM, HB and CS, SZ and JC). The core messages were presented at a wider team meeting and the analysis refined through discussion among all the team members.

In addition, we held a stakeholder workshop to present and discuss the initial findings and their application. Attendees included academics, policy-makers and health-care professionals. The responses from the workshop delegates were considered during the final stages of the data synthesis. See Chapter 7 for further information on the stakeholder workshop.

Staff interview participants

We interviewed 45 members of staff from the case study sites, and a further four from other practices. In the case study sites, we interviewed 19 GPs, eight practice managers, two deputy practice managers, one practice co-ordinator, two senior practice nurses, three practice nurses and one nurse practitioner, one rural health worker, four senior receptionists, one receptionist, one patient service manager, one practice administrator and an IT manager. The four participants from practices outside the case study sites were three GPs and one practice manager. Various different types of alternatives to the face-to-face consultation were used by staff in the case study sites. All GPs and nurses were using telephone consultations.

The participants from outside the case study sites were interviewed about video consultation; one had used video consultation with patients, two had limited experience of using video consultation with patients and one practice manager was in the process of setting up a video-consultation service.

Of the 48 staff interviewed, 33 were female. The age of participants ranged from 31 to 68 years. The majority of participants were white British. For clinical staff, the length of time since qualifying varied from 7 years to 40 years. Staff had been in their current role for varying amounts of time, from 10 months to 31 years. Of the GPs, 16 were partners and six were salaried.

Full details about staff interview participant characteristics can be found in Appendix 7.

Patient and carer interview participants

We interviewed 39 patient and carer participants. All participants were using or had used an alternative to the face-to-face consultation with a health-care professional at their practice. We collected information on their ethnicity, age, sex, current health conditions and whether or not they were carers, alongside information about their level of education and current employment status. Full details about patient interview participant characteristics can be found in Appendix 8.

Hard-to-reach and disadvantaged groups

The sample included a wide range of participants who may find it difficult to engage with general practice settings for varying reasons. These included a parent looking after a disabled child, an asylum seeker who was vulnerably housed, two men aged < 30 years (who typically do not engage in health care) and three participants in minority ethnic groups with English as a second language.

The sample also included patients who may find themselves disadvantaged by the current limited provision of alternatives to the face-to-face consultation, namely six patients with mental health conditions, four patients living in a very rural area, nine patients with restricted mobility and two patients with hearing loss.

Patient and public involvement and young people

The age range of our patient/carer participant sample was wide, but it did not include any participants younger than 24 years (range 24–91 years). Young persons below the age of 18 years were not eligible for inclusion in the study. Being mindful of the potential importance of alternatives to the face-to-face consultation in young people, we sought to obtain the views of young adults to supplement the study. We did this by organising a PPI event for young people. We were able to do this via ‘Bristol Young Health Watch’, a group of young people aged between 16 and 19 years who work alongside the Bristol CCG. The study PPI lead (AG) met with the group during one of their regular existing meetings. Group members were asked to comment on a number of issues related to alternatives to face-to-face consultations in primary care. These comments were recorded on flip charts during the meeting.

Although the people attending the workshop felt comfortable with potentially using new technology to access GP services, they reported similar concerns to other patient groups about issues of confidentiality, being able to exert choice over when to use alternatives and seeing these as a supplement rather than an alternative to face-to-face consultations. The content of the discussion was used to provide context for the findings obtained via interviews and observation.

Rationale for introducing an alternative to the face-to-face consultation

We observed a range of rationales for introducing an alternative to the face-to-face consultation, and these were not mutually exclusive. Different rationales were expressed by different members of staff within the same practice. For instance, in practice F, one GP said that telephone consultations could be a useful way to manage their work more efficiently:

Obviously it’s, it’s easier for us, it’s much more time efficient to phone a patient and often more convenient for them as well.

GP1, practice F

However, the patient manager suggested that the rationale was to give GPs more time to consult with patients who had complex needs. The practice nurse suggested that it was to provide a better and more convenient service for their patients.

At another practice (practice A), the practice manager explained the rationale of adopting an e-consult service as ‘making the GPs’ lives easier’ and ‘to keep people away’; this was a perspective with which one of the GPs concurred, saying that it was ‘to try to manage demand’. In contrast, their colleague, a GP, was ‘looking at how to make ourselves more accessible’, which ‘coincided with the time that the Prime Minister’s Challenge Fund money was going around’.

Such variation suggests several possibilities, including:

• The decision to implement an alternative to the face-to-face consultation was not fully shared within the practice.

• The introduction of an alternative to the face-to-face consultation may not have been based on a single rationale.

• There were differing experiences of the alternative to the face-to-face consultation between members of staff.

• Staff members may have retrofitted the rationale for the introduction.

Rationales observed and described by staff included:

• the desire to be a modern practice and respond to the expectations of busy, time-poor patients –

There’s quite a drive, patients very often expect to be able to e-mail us, they want to e-mail us and you know, we like to try and go with the times and you know, reflect what our patients want, so that’s part of a driver for it.

GP2, practice F

• an alternative being the only way of providing health care for patients in remote locations, or with other barriers to attending the practice –

The only reason for having it on the [name of area] is because physically we’re separated by the water and we don’t go out there every day.

Practice manager, practice D

• the acknowledgement that the previous system was broken and unethical in providing a first come, first served system that left patients without appointments that they needed –

We were working exceptionally hard, but we were aware that there was a good proportion of our patients who weren’t getting into the system at all and that is very concerning to me. I think if you have a limited resource the only ethical way to distribute that resource is to find out what’s out there and then prioritise, you know . . . And there’s no question that the system we previously ran caused real harm.

GP1, practice E

• the recognition that reception staff and telephone lines were overwhelmed –

We are aware that we have a very old-fashioned telephone system which doesn’t really have enough lines, but we haven’t been able to do anything about that. So it is quite difficult, embarrassingly difficult for patients to ring in at many times of the day.

GP2, practice A

• to manage demand and improve efficiency –

It [the introduction of telephone consultations] was done to try and reduce pressure of face-to-face appointments.

GP2, practice C

Alternatives to the face-to-face consultation came into being in different ways. Some practices demonstrated resourcefulness, drawing upon existing structures (e-mail and telephone), whereas practice D developed internet video-consultations from an existing facility for communication between health-care professionals.

In some cases, funding for free pilots and specific project support, such as the GP Access Fund,14 provided a stimulus for trying e-consultation software:

Our pilot of [e-consultation system] is about to come to an end. We were given this on free trial basis to see what we, and our patients would make of it . . . Patient satisfaction has been good and we’re pretty sold on the concept.

GP1, practice E

Marketing strategies employed by these e-consultation companies claimed that the software would increase access while reducing workload:

So I think one of the things that they said at the initial presentation was that it would be, you would perhaps deal with two or three interventions in the space of seeing a patient.

GP2, practice A

The locality of the practice and a consideration of the population it served were often key in the decision about which alternative to the face-to-face consultation to implement, although assumptions (e.g. about the likely uptake) were sometimes ill founded, with uptake being subsequently low (see Chapter 6 for an analysis of the routine consultation data in the case study practices). Although representatives of one of the practices told us that they had discussed the introduction of the alternative to the face-to-face consultation with their patient advisory group, there was little indication that practices had reviewed a range of options with either patients or the whole practice team. Instead, it was deemed adequate for practices or GPs to have considered what they personally understood to be the patient perspective.

Uptake was influenced by patient awareness; for example, where alternatives to the face-to-face consultation were adopted across the practice there was widespread advertising (Box 3), although this had initially been a challenge.

The offer of an alternative to the face-to-face consultation was observed to be dependent upon practice staff members’ perceptions of it, in terms of its purpose, when it should be used and their own beliefs and attitudes towards it. Inconsistencies in promotion were linked to attitudes about the alternative to the face-to-face consultation. This led patients to ‘stumble’ across the alternative to the face-to-face consultation:

I went online and it [eConsult] cropped up online. I wasn’t actually looking for it at the time, I just came over it by accident online. I think it’s a very good system, actually. I think it is.

59-year-old female patient with multiple comorbidities, practice E

Not all staff members embraced the use of alternatives to the face-to-face consultation. Individual use by staff was predominantly attributable to personal characteristics [e.g. confidence, experience, familiarity with/tolerance of the system, own skill set (both clinical and technological), own sense of professional identity and their ability/willingness to adapt]:

I have had a lifelong problem with using the phone – I am very visual, and am unusually good at reading faces and body language, and find the phone takes away a huge amount of information, so get very stressed. They tell me I’m actually not bad on the phone, but it always feels difficult to do.

GP2, practice E

This did not apply only to clinical staff; reception staff held opinions about the merits of alternatives to the face-to-face consultation, and they were often responsible for its promotion:

It [telephone consulting] is not the best way I don’t think, not really. Face to face is always better.

Receptionist, practice B

There was a complexity observed whereby no one key reason emerged to explain any reluctance to promote alternatives.

Organisation of workload

Workload was a key issue for practices, and alternatives to the face-to-face consultation offered a way to organise this. Depending on how practices organised the working day, alternatives to the face-to-face consultation could offer flexibility to both staff and patients. GPs and nurses could prioritise their work by choosing when, and in what order, to reply to messages or make telephone calls, rather than taking them as they are scheduled:

If I’ve got a quick injection it’ll take me a couple of minutes, I would maybe tag on a quick one [telephone consultation] of my tasks in between, outside the dedicated slots. I can be doing two or three in between patients, some days I might not get any as well as the two I get, and then of course we’ve got the e-mail stuff.

Nurse, practice F

This allowed them to work more flexibly, fitting around traditional consulting times:

I think it [telephone consulting] has improved my satisfaction and possibly my stress levels as well . . . I’m able to manage my time a bit better.

GP2, practice H

However, they also raised the possibility that the working day could be stretched and include considerable ‘hidden work.’ For example, there was an observation that alternatives to the face-to-face consultation tended to be undertaken by GPs or nurses before the beginning, or after the end, of face-to-face consulting sessions:

All of the telephone consultations aren’t appointmented [sic] in a given slot, they’re just an addition to the workload already.

Practice nurse, practice B

A key example was the assumption that telephone consultations could be shorter than face-to-face consultations. Those practices that scheduled them allocated less time to telephone consultations than face-to-face consultations. Their length, however, appeared to be similar to that of a face-to-face consultation:

But we’d thought that we might be able to do two things, two, do two telephone consultations in the time it took to do a face to face . . . and that hasn’t proved to be the case.

Practice manager, practice F

Although the working day could be organised to include booked e-consultations and telephone appointments, there seemed to be some acceptance of a trade-off between flexibility and additional work. This was illustrated by an informal conversation with a nurse in practice B (Box 4).

Flexibility was a relative term in relation to workload. E-consultation provided patients with a flexible approach, available 24 hours a day. However, four of our practices using these systems were engaged in a complicated system requiring the administrative staff to monitor new e-consultations. They had to first inform the GP, and then the GP had a large amount of information to read before deciding on a course of action:

The process as it’s set up at the moment, it is laborious . . . the patient submits something on the web form, that comes to the administration by an e-mail, the administration forwards it to our personal e-mail accounts and also puts a message on the virtual surgery list to say it’s there so we don’t overlook it. I don’t think personally I would overlook it, but maybe other people would. Then sometimes I’ll pick up the phone, but otherwise I will reply to the administration copying in my secretary with a bit of bumf I put at the top to the administrator saying, ‘Please forward this back to the patient cutting out this bit of bumf’.

GP2, practice C

With telephone consultation, the flexibility that alternatives to the face-to-face consultation offered the GPs and nurses meant that patients did not know when to expect a call. In some practices, the patient was given a time period within which to expect a telephone call, but this could be lengthy and not necessarily held to:

Oh yeah, well no they turn round and say if it’s in the morning, [GP] will ring you between 11.10 and 11, so in my mind I usually say right that means half past 11. It’s never usually when they say because obviously he has to wait until he finishes his morning surgery, so I totally understand that, but I know he’s going to ring me in the morning. Or again, it will be – if it’s in the afternoon, it will be between 4 and 5 or something. I try and tie them down, but I’m wasting my breath.

50-year-old male patient with multiple comorbidities, practice C

If the patient missed the call, for whatever reason, this might lead to a delay in receiving care or a different course of action (Box 5). What was a convenient way to consult became inconvenient for the patient, despite it offering flexibility for the clinicians.

Conversion to a different consultation type

Workload was affected if an alternative to the face-to-face consultation converted to a face-to-face consultation. Apart from consultations with young children, there was a lack of consensus among clinicians about the kinds of patients or problems that were more likely to be converted to a face-to-face appointment (Box 6).

During consultations, clinicians had to elicit the nature of the patient’s problem, which might be more difficult to assess remotely. Observed discussions between practitioners suggested that their approaches varied, with one GP feeling that being face to face did not add anything when patients were consulting on particular conditions:

Diagnosis of a UTI [urinary tract infection], for instance, is primarily on the history . . . So, a thing like that, by the time you’ve asked them the right questions and made a diagnosis and treated them you might as well do that on the phone as actually seeing them in person, because it adds nothing to the consultation.

GP1, practice D

The lack of physical cues on the telephone or via e-mail/e-consultation meant that some clinicians were cautious and converted an alternative to the face-to-face consultation to a face-to-face consultation. A clinician was observed converting a telephone consultation to a face-to-face consultation, despite deeming it unnecessary, as illustrated in the following field note extract (Box 7).

We also saw conversions between different types of alternative to the face-to-face consultation (e.g. from e-consult to telephone consultation) when the patient had not provided enough information via the online form, or when the content was contentious (e.g. requesting a referral). This led to repetition of content during subsequent consultations.

Adaptation

The alternatives to the face-to-face consultation underwent adaptation once they had been introduced. Adaptation did not occur in the same way for all practices, involving decisions to continue, revise or discontinue offering alternatives. Sometimes practices were surprised by patient uptake – whether this was higher or lower than anticipated:

We created more telephone slots because there was a demand for it.

Practice administrator, practice D

Continuous improvement and refinement of the service was observed, reflecting population needs (e.g. during an informal conversation, a practice administrator in practice D explained that they offered telephone consultation slots during after-school hours for school-aged children). When practices introduced an alternative to the face-to-face consultation, this was often with an expectation that patients and staff would use them in the same way as they had been designed to work; however, both staff and patients applied adaptations. Some patients found ways to access what they required despite the inflexibility of formats:

All I want is a blood test, which takes me like 3 seconds to say, but filling on the online it was remarkably detailed. So I had to make up something. I made up heavy periods, it’s not made up, it’s kind of true, but because they didn’t have, ‘I want a blood test.’ Then that’s why it took half an hour and then it was like, ‘Tell me this, what size clots? How often? What like…’ It was like, ‘Blimey that took a lot of time.’ But it took my time and not their time, which is efficient in terms of the NHS.

48-year-old female with mental health problems, practice A

This patient adapted the e-consult system to try and ensure that they received the treatment they were seeking.

Patient–clinician relationship

Clinicians reflected on the types of patients with whom they consulted using alternatives to the face-to-face consultation. Some clinicians thought that the use of alternatives to face-to-face consultations enhanced their relationships with patients and, therefore, they would promote and encourage their use, whereas others felt that it inhibited the relationship and the dynamic of the consultation:

‘think it [a telephone consultation] is good at sort of maintaining your doctor/patient relationship, because I think that they feel that you’re listening to them and following up and that rapport is maintained, so I think that’s a positive thing.

GP3, practice A

There was some disagreement among patient respondents on whether having an existing relationship was important before using an alternative to the face-to-face consultation, such as a telephone consultation – some patients felt that it was essential, whereas others were more ambivalent. For the former, they felt that it resulted in the consultations being quicker, as a result of the GP knowing the history of the patient:

I mean, I know my GP very well and she knows me . . . I’m less confident with another GP because they don’t really know me.

59-year-old female patient with comorbidities, practice E

Types of patients and conditions

Clinicians held assumptions about which patients were most likely to be suitable for the use of alternatives to face-to-face consultations.

In some cases, these were based on age group, ethnic group or socioeconomic status:

It’s just by knowing them, really. I mean, yeah, just by knowing them and what they’re like I suppose. You can usually tell from their address to be honest whether they’re going to be appropriate for an e-mail, of whether they’d be sensible enough to use e-mail.

GP1, practice G

One GP commented that telephone consultations were best used with patients who had been born in the UK, and thus had shared knowledge and assumptions about how the system works:

I do notice that generally the patients that are born and raised in the UK, you can process their problems quicker, and that’s just simply because, like I say, communication, shared cultural links that you have, and that’s amazing how much that makes a difference and the more you do it you just think, gosh, it’s turns of phrase or just general understanding about conditions and what happens.

GP1, practice B

Clinicians also talked about the category of the ‘sensible patient’ or the ‘known patient’ who could be relied upon to give a fluent account without being seen, an example being ‘special patients’ such as friends and other professionals (Box 8):

I think some of that gives you a feel of how sensible do I think the patient is? How confident am I that they’ll give me good information?

GP1, practice B

Asynchronous and textual methods were recognised as useful for people who were very anxious or found face-to-face contact difficult, who had hearing or communication difficulties and those who ‘struggle to express themselves’:

I have a patient who is so anxious she can’t speak, but she can write, so she can send a text and I’ve had lots of concerns about her safety. So that was one reason, and the receptionists couldn’t understand her, nobody could understand her.

GP2, practice A

This was reflected by some patients who reported the benefits of being able to express themselves better through the use of alternatives to face-to-face consultations, such as e-mail:

Well, I feel that you can express yourself better, I think, for me, message, writing it down, you know, typing it. I just feel sometimes if you are, like, if I’m really not feeling good I can’t really express it.

44-year-old female patient who is a carer with mental health problems, practice E

Alternatives to the face-to-face consultation were considered potentially unsuitable if a new health problem was being presented, if the patient was elderly and confused or isolated, or if the patient was using a complex array of medicines. GPs also preferred to see a patient face to face if a translator was needed, if people had strong accents or when the health-care needs were complex. Some GPs said that they would always squeeze in an extra appointment for a child to be seen face to face:

. . . because the stakes are too high with children.

GP, practice D

E-mail was seen as useful for GPs to share and gather information when co-ordinating complex health-care packages with patients accessing multiple treatment centres:

She had seen the consultant in [hospital 1] who said it was entirely appropriate that she would have this surgery done and the exceptional funding. It got quite complicated because of dealing with [hospital 1] and dealing with [hospital 2], and so [hospital 1] were e-mailing me and [hospital 2], I was getting paper letters through, but I also wanted to keep her in the loop as well because she was not a person who would abuse the service basically, so I would say ‘When you’ve heard from [hospital 1] can you let me know so then I can chase up [hospital 2].

GP2, practice B

Some GPs told us that they gave their personal e-mail or mobile phone number to patients who were terminally ill, or to their family carers for use in emergencies.

Telephone consultations and e-consultations were considered most appropriate for factual, practical, single-issue, straightforward and follow-up appointments, according to both staff and patients. Some GPs suggested that they were particularly valuable for ‘the easy stuff’, for example recurrent issues for which the patient was already aware of what they needed (e.g. this included chest infections, antibiotics for recurrent urinary infections and anti-anxiety medication for a long-haul flight):

You know, why would you be doing something complicated on the phone? That’s the whole, that is the take-home message. You shouldn’t be. Do the easy stuff on the phone.

GP1, practice E

Nurses in particular found alternatives to the face-to-face consultation, such as the telephone, useful for managing patients with diabetes mellitus:

So I sorted her on the insulin a few, probably 2 months ago now, and I’m trying to get her, I’m putting her dose up, she’s very reluctant, so I ring her about every 2 weeks at the moment just trying to get her to take more insulin . . . But I wouldn’t normally follow anybody else up like that . . . So, yes, so I’m trying to really keep her on track, I suppose to keep her motivated and trying to keep her going.

Nurse, practice C

Nurses often used the telephone, but also e-mail, for specific tasks such as ‘discharge checks’ and ‘medication reviews’. Nurses reported that not only was this for patients’ convenience, but also to allow flexible working and to monitor patients who were non-attenders.

Alternatives to the face-to-face consultation were also useful for people seeking advice about the side effects of medicines, and telephone calls were used by GPs for checking that symptoms had improved and did not require further investigation (‘safety-netting’):

I guess just following up medications that you might have started just to make sure you know they’re not getting side effects or, I’d say sick certificates is another one, just sort of checking on how somebody is before issuing another certificate.

GP1, practice F

The use of alternatives to the face-to-face consultation was reliant on the judgement of the clinicians with regard to whom it might work for and for which problems. As demonstrated here, the judgement varied, and as described previously, we also observed these judgements being made about whether or not to convert to a face-to-face consultation. In both cases, this influences the patterns of use.

Patients’ perspectives of alternatives to the face-to-face consultation

Although patients were not involved in choosing what types of alternative to the face-to-face consultation their practice offered, they could exercise agency by waiting for a face-to-face appointment instead. Patients who had recently used an alternative to the face-to-face consultation told us that benefits included that they did not need to travel, or sit in a waiting room full of ‘bugs and germs’:

A doctor’s surgery is full of bugs and germs and I didn’t want to be sitting next to people who might pass something onto you . . . Yeah, it’s one of the worst places to be, really, isn’t it, if you’re not well?

40-year-old woman with cancer, practice D

The participant quoted above also said that she considered visiting the practice a waste of her time.

Patients expressed the view that alternatives to face-to-face consultations were more efficient for themselves and the practice. An e-mail or e-consult allowed the patient to keep a record of the consultation; they could take time to prepare what they wrote and make sure that they had covered everything. This was particularly important for those who found the practice intimidating or had trouble remembering what they wanted to discuss with the GP.

Another benefit that patients ascribed to using e-mail or e-consultations was that they could send a direct message and not have to trouble the receptionist. This was more efficient, quicker than trying to get through on the telephone and preferred by those who found the receptionists intimidating. Some liked the idea that the GP could make the decision about whether or not the problem was sufficiently urgent for an appointment, rather than the onus falling on either the patient or the receptionist:

Then the decision whether I need to be seen is his [the GP’s] . . . if you phoned the receptionist, you haven’t got a hope in hell.

76-year-old male patient with comorbidities, practice F

Patients saw alternatives to face-to-face consultations as suitable for ‘basic’ consultations:

If it was e-mail sort of basic stuff, but like if there was more sort of like in-depth stuff, I would probably use the phone, or go down there or you know, I wouldn’t e-mail anything like how I was feeling or anything like that, I’d rather talk to somebody or have a phone appointment.

41-year-old female patient with mental health problems and diabetes mellitus, practice C

Another woman with mental health problems explained that, as she was comfortable with the technology, she liked being able to decide how she wanted to consult:

I think part of the thing with me is I generally feel – is the term empowered? I feel pretty empowered to pick and choose methods of communication that suit me.

34-year-old female patient with mental health problems, practice C

When asked about the quality of care they received in a telephone consultation, a patient from practice D said that it was comparable to face-to-face consultations:

‘The exact same’ as the face-to-face consultation. I’d say it’s the exact same, I don’t see any problems with the call at all . . . I think you still get good care.

54-year-old male patient with diabetes mellitus, practice E

Patients were aware that a face-to-face consultation, with time and physical contact, as well as the opportunity for non-verbal communication, was needed to discuss more complex health problems:

Yes, I mean even when – even though I’m talking to [name of GP] on the end of the phone, there – it’s still more impersonal than face to face, obviously. Because what you’re lacking is that sort of physical interaction, you know, when the subliminal reading body languages and all that sort of thing. But it serves a purpose.

50-year-old male patient with multiple comorbidities, practice C

For patients using e-consultations, there were positive experiences, including that ‘it was straightforward to use’, ‘it made life easier’ and they appreciated the quick turnaround.

However, some patients worried about whether or not their GP’s system worked properly, wondering how long they would have to wait for a response, or felt frustrated by a long list of seemingly irrelevant questions on the standardised form. One patient voiced a concern that no-one seemed to be taking ownership or responsibility for her GP’s e-consult system:

I just found out there is nobody owning the system or responsible for looking after it. If it is a serious project, I would expect someone to be taking control of it, making sure everyone has a reply or something.

34-year-old female patient with young children, practice A

When the patient felt that they needed to see a doctor but there were no appointments available, the opportunity to talk on the telephone or send a message was sometimes perceived as ‘better than nothing’:

There’s a set amount of things that they can ascertain without looking at it. It’s better than nothing, but not 100 per cent.

50-year-old female patient, practice D

As observed among clinicians, patients were applying their own judgement about the suitability of an alternative to the face-to-face consultation for different conditions and situations.

Lack of shared understanding within the practice

There was not always a shared understanding of what was happening, or who was doing what or why in relation to alternatives to the face-to-face consultation. A GP from practice C stated, during an informal conversation, that ‘I do the same as every-one else in the practice,’ but was not able to confirm what this was. This was especially true for the practice managers, who would give a different account of the roles of the reception and clinical staff compared with those described by the staff in question during our observations:

They don’t know that I know this, but I know that they will have patients . . . who e-mail them and that is patients probably that they have had a longstanding relationship with . . . The thing with – e-mail is, it is very difficult to close the conversation off, as you know. So it goes backwards, forwards, backwards, forwards.

Practice manager, practice A

Another practice revealed that their use or acceptance of alternatives to face-to-face consultations differed from their colleagues, as a ‘practice-wide’ versus a ‘lone wolf’ approach:

I know that [name of lead GP] has given his e-mail out on a couple of occasions and, generally speaking, it’s not abused . . . I think if I took a poll round, it would be a small percentage of GPs that have given patients their work e-mail address.

Practice manager, practice E

A key example of the lack of shared understanding was the use of e-mail. Many of the GPs in the case studies used e-mail, unbeknown to their colleagues. Furthermore, although some of the practices offered a webform e-mail system, many of their staff were unaware of this. In one practice (B), there was confusion regarding the status of both e-mail and e-consult software. The GPs thought that the e-mail system would and should continue, the practice manager felt that they would continue only with one or the other, depending on whether the e-consult software was a success, and the reception staff thought that the e-mail system was being phased out:

If we continue with e-consult through the [e-consultations] package which we haven’t made a decision on yet, if we did, we may look at whether we somehow switch off our own, or feed into that, so there’s one system.

Practice manager, practice B

Both patients and staff demonstrated difficulty in defining a consultation, leading to uncertainty about what distinguished telephone ‘triage’ from a telephone ‘consultation’. A patient from practice A described the e-consult as ‘it’s a triage system, an electronic triage.’ Communications via telephone and e-mail were often not seen as consultations, but as background information, a perspective that was reinforced if the patient was then asked to come in for a face-to-face consultation. This confusion also led to problems with recording encounters involving alternatives to the face-to-face consultation. For example, we observed administrative enquiries by telephone being recorded as telephone consultations. Other reports suggested that some communications with patients were seen as unofficial, and, therefore, had not been recorded (e.g. some e-mails and personal telephone calls). There was evidently a lack of discussion among practice staff and with patients about exactly what was happening and why.

Where there were policies, we observed interesting contradictions between practice policies and what GPs actually do. For example, a GP who was routinely using e-mail with selected patients described during interview how, as a practice, they were trying to discourage patients from sending e-mails to the practice:

What we’re envisaging is . . . saying, ‘No reply @ X Medical Practice,’ to make it a bit more obvious that you’re not meant to reply as well as putting the other bits in the letter saying this is a non-reply, if you do need to contact the practice then do it through traditional means, and these are what they are.

GP3, practice F

In practice B, there was an example of a patient who had been using e-mail with two previous GPs. Her most recent GP had left, and her new GP would not engage in e-mail communication with her (by not responding at all). This was a big change for the patient, who had used e-mail consultation for a long time. It demonstrated that alternatives could be taken away, as well as offered, where their use was not a practice-wide decision.

Role of reception staff

Practices differed in where the workload was shifted and who appeared to have control over allocating the tasks. Reception staff were often involved in the administration of alternatives to the face-to-face consultation. One form of e-consult involved a manual step, whereby the reception staff allocated the patient to an appointment/contact using a protocol. The onus was on the reception staff to make the right decision:

Not all reception staff are good at that. So, you know, [e-consult software], flu symptoms, you know what’s in it. [e-consult software] full stop could be anything, you know, so you don’t know until you’ve click, click, clicked into it and opened up the letter to find out that it was urgent or not urgent. So there’s a wee bit of training still there.

GP1, practice E

Both the observations of the reception staff and the interview data suggest that alternatives to face-to-face consultations were not routinely offered to patients who asked for an appointment, unless there were no face-to-face appointments available. Telephone consultation, in particular, was used as a tool for managing demand:

They’re often offered, personally I offer them if there isn’t a telephone, a routine face-to-face appointment, so it’s always offered as a kind of secondary option.

Receptionist, practice G

The GPs and management did not mention potential difficulties for their reception staff. They deemed dealing with alternatives to face-to-face consultations an acceptable part of their role in managing patient demand. However, this did create extra work for reception staff, whether explicit or implicit:

And if there’s a red slash, we’re going, ‘Oh, somebody’s missed that telephone call. It’s purple.’ But it relies on somebody to manually pick that up. So if I was not here and [my deputy] was dealing with something in the call room, she might not look for that for half an hour. And by that time usually the patient’s rung in saying, ‘The doctor hasn’t rung me.’ And then we have to react by getting to the doctor and saying, ‘Did you not ring that patient?’ It might be he has tried them and they’ve not been there. But we have to deal with that then. So there, there can be some extra work.

Receptionist, practice F

The role of the receptionist in administering alternatives to the face-to-face consultation was key, but not always adequately considered when organising these consultation types in the practice.

Practice investment and training

On a practical level, investment and training at the practice level were key. E-consult systems, or provision of more telephone lines, required substantial investment:

So you’ve patients ringing in, doctors can’t get lines out because we’ve got limited amount of time, so with the new system it’s cloud based, we can limit the calls in so that people aren’t hanging for ever, they’ll either get the engaged tone or they’ll be sort of like 4th or 5th in the line, but the lines out will be I think unlimited, but certainly enough for the doctors to call out while patients are still ringing in.

Deputy practice manager, practice F

The availability of pilots and the GP Access Fund14 money had helped some practices that had been considering investing in e-consult systems:

We were probably going to buy it anyway, it’s always great when you don’t have to in the end. I think it’s if we were paying for it, we would have to look at the business case for it more closely. If we didn’t have significant uptake of it, if it didn’t give us value for money we would have to stop doing it. So I suppose that’s the bottom line isn’t it? It’s that it would be a significant number of thousands of pounds to buy it, so we’d have to be saving that amount of doctor/nurse time.

GP2, practice A

One manager hesitantly mentioned that the cost could be offset by reducing staffing levels, although cost–benefit considerations were not fundamental to all decisions:

We don’t do anything on a financial basis, otherwise we wouldn’t operate at all.

Practice manager, practice C

A GP reasoned that the cost of the £1000 per month system would require the practice to lose one of the reception staff. There were unintended consequences, such as the cost of additional patient call-backs related to electronic forms of alternatives (e.g. e-mail or e-consultations):

Well I suppose initially, is there a cost? Well you’d say technically you’ve got to phone patients back, so there’s a phone call cost.

Practice manager, practice C

Financial investment included the outlay involved in training staff, which practices were reluctant to invest in. New systems require changes in workflow, roles and responsibilities, and staff having to learn how to use new processes. The majority of practices chose to deliver in-house or ad hoc training, with the main cost being related to covering staff time away from their normal duties:

Some of the doctors have done, in their own sort of like study time that they’re allocated, have done telephone consultation courses, but that’s been, we haven’t organised anything as a practice for them.

Deputy practice manager, practice G

Many staff reported having no training at all, with training focused on the GPs who would be using the consultation method, despite other team members being involved in its administration:

I never had any training in using the telephone as a consultation method, so I just picked it up, did what I thought was appropriate, yes.

Nurse, practice A

One staff member (practice F) described training as ‘being the poor partner, the poor relation’.

Investment and training featured far less in our observations and accounts than the aforementioned workload, which was clearly a priority.

Logistics

There were many practical issues associated with introducing alternatives to the face-to-face consultation, which were not always adequately considered beforehand. In the one site where video consultation was used, the technology fell short of what was needed because of a lack of facilities, slow computers and insufficient bandwidth. Video-consultations could be time-consuming to set up, especially if used infrequently, and the video images were not always good enough. There was also the challenge of keeping a child still in front of the video camera. Because of this, there was an expectation that video consultations might not work and consultations defaulted to the telephone:

And when we do use video it’s actually quite uncommon because most of the time, as I said, you can deal with it on the phone and the problems with the quality of video are such that you don’t get anything extra from doing it.

GP1, practice D

Similarly, the use of e-mail and e-consultations relied on adequate technology and staff surveillance. There were concerns around e-mails arriving at the correct destination, systems being unstaffed and the lack of clarity about when the patient should expect a response. Some practices chose to use automated responses to inform patients when they could expect a reply from the doctor. We saw examples of missed e-consultations being either not noticed by the practice or not acted on. In one case, the patient had to follow this up by contacting the practice online for a second time. As described, these consultations often reverted to face-to-face consultations.

There was a concern around patients using e-mail in ways that might compromise their safety. This required ensuring that patients were informed that their messages may be read by other practice staff, and what would happen if the e-mail was missed or not read. One patient described the use of an out-of-office message by her GP to let her know he was not available:

If you e-mail a doctor you, it’s useful to know that they’ve got that e-mail . . . because I got that bounced straight back it was like okay, plan B . . . because the bounce back, you know because the out of hours bounced back at me it meant I could rethink what I was going to do.

39-year-old female patient, practice G

One of the greatest challenges with telephone consultations, for both patients and practitioners, was the difficulty in getting through on the telephone, whether that was a result of not having enough lines, having poor telephone reception or patients not being available to answer (which often required the clinician to leave a message raising security concerns). There was a limit to how many call-backs were practical, which was determined by the clinician’s judgement. Even if more telephone lines were provided, the number of calls that could be answered was limited by the number of receptionists. Some of these logistical challenges became apparent only once the alternative to the face-to-face consultation was in place, rather than being considered or identified beforehand. This led to the kind of adaptation we described earlier in this chapter.

Recording the consultation and storing data

Record-keeping is important for patient safety, the measurement of workload and medicolegal purposes. None of the systems for alternatives to face-to-face consultations was well integrated with the GP-computerised records systems; therefore, practices tried to adapt what they would do for face-to-face consultations.

Not only did different practices use different methods for recording the content of alternatives to face-to-face consultations, but staff within practices also varied in terms of their attitudes towards this (see Chapter 6), leading to a lack of internal consistency. For example, some practitioners deleted their e-mails, whereas others saved them to a document store. One practice printed and then scanned their e-mails to include them into the patients’ records, whereas another practice recorded all their scheduled telephone consultations in a big red book in reception before putting them into the electronic health record, regarding the book as a back-up:

So the book is basically as a second back-up, so if the system broke down or we didn’t have any electricity or we didn’t have, so the computer just crashed we are still going to be able to phone this patient and we know exactly who has requested a call. But we also print out all the lists every night so the lists of who is coming in for an appointment is there, so we always have a safety net. So, yeah so the book is the magic book [laughter].

Practice manager, practice H

The lack of integration between the systems used for consultation, such as e-mail, with the patient record system resulted in ‘fiddly/clunky work’, especially for the administrative staff who were tasked with routing the e-mail to the GP, where it came into a central account, and sending out the responses. This all created work that could be reduced with better technology, such as integration with EMIS (the practice’s GP computer records system):

Ultimately, it will be tailored so that it goes straight into our EMIS system. So the patient enters the system, they send that e-mail, that e-mail then goes straight into EMIS and it is coded and it is dealt with there . . . At the moment, it is a bit clunky insomuch as the consultation then has to be put into EMIS, but that will change.

Practice manager, practice A

Technology was perceived as acting as a hindrance, and, as demonstrated by the example above from Practice H, was not always to be trusted.

Information governance and clinical governance

Attempts had been made to ensure confidentiality and consent in conducting the consultation, but this was led by individual clinicians applying their own standards (e.g. leaving ambiguous answerphone messages, or avoiding the assumption that the person answering the telephone is the right person):

The first thing you do is you ascertain that you’re talking to the right patient. That’s why, when I leave messages on the answer machine, it’s very basic. ‘Hello, I want to talk to Mr John Smith. This is [own name] from the doctor’s surgery, could you please give me a call back?’ Or I might actually add, ‘don’t worry, it’s nothing serious’.

Nurse, practice D

Decisions were sometimes made in conjunction with the patient. Consent was sometimes taken as implied when using online methods:

By them e-mailing me I’m assuming they’ve got, they’ve given me consent to reply back to them with their information. But yeah I’m, yeah you’re right, it is a risk there but it’s a risk I’m willing to take because I think the patients have, would prefer, the patients are happy to turn a risk on, you know take a risk that sending e-mails to non-secure addresses.

GP1, practice G

Practices were knowledgeable about the appropriate processes required to ensure privacy and confidentiality, but this did not necessarily translate into application when dealing with patients. Instead we heard about ‘instinct’ and ‘listening skills.’ Reception staff were tasked with confirming numbers and providing information on protocols (numbers of times the GP will try to call, times to call) as described by a receptionist from practice G:

I mean obviously you don’t give any information away . . . it might be to their relatives, but you do have to keep confidential things . . . you might be phoning a home number to speak to the wife, and then the husband answers the phone . . . ’Oh hallo, it’s the doctor’s surgery isn’t it?’ And you can’t even say, ’No’. So you have to be tactful and not give any, you know, disclose anything.

Receptionist, practice G

Tying in with the previous sections Recording the consultation and storing data and Adaptation, changes and solutions were arising in an ad hoc fashion, rather than through using a formal framework.

This extended to the view that clinicians had to trust their patients, and patients needed to take some responsibility with regard to confidentiality:

I don’t see there’s much difference in speaking to a patient on the phone as compared to speaking to them in the room . . . I suppose I can’t be entirely sure if somebody comes in and tells me their name that they are that person . . . You can just have to trust them. So I, I don’t really have views on confidentiality in terms of phone calls.

GP2, practice H

This was appreciated by some of the patients, who generally felt a degree of trust in their practice approach to confidentiality:

I’m assuming correct sort of checks and balances have been put in place anyway and the people that work behind the reception have to obviously sign for confidentiality, so yeah. Be a bit wary if the cleaner come in with access to my account.

50-year-old male patient with multiple comorbidities, practice C

Conversely, e-mail seemed to be a special case. As it was often used by individual GPs, rather than as a practice policy, it was the least standardised form in use. GPs used their own initiative with regard to storing e-mail communication, deletion of e-mails, recording e-mail consultations in patients’ records and what to do with any attachments, such as pictures. There was a sense that, for small numbers of patients, the clinician knew well that this could be managed and that it required higher levels of trust and discretion:

So I think I’m equitable in giving out my e-mail, but actually that’s why I manage to edit it down to about 20 active e-mail relationships at any one time.

GP1, practice H

General practitioners described using e-mail sparingly and being aware that it is not openly available.

Protocols existed for the use of alternatives to the face-to-face consultation in some practices. For example, software packages, such as those for e-consultation, were associated with a strict protocol for recording in some practices, but less so in others. However, staff members’ knowledge and use of such protocols varied greatly in line with the variation we observed in how alternatives to the face-to-face consultation were in use.

Practice policies

In each case study practice, the local researcher asked GPs how they recorded consultation type in the patient record. Different consultation types included telephone, e-mail, e-consultations, Skype and any other alternatives, as applicable. The researchers asked how consultations should be recorded, how reliably the GPs thought they recorded different types of consultations themselves and if they believed that other doctors in the practice used the same processes. If the practice had any formal policy for recording different types of consultation, the researchers collected examples of these. The researchers observed how different types of consultation were recorded in patients’ records at the time of consultation, and reflected on how this compared with stated practice policy. The researchers were asked to be alert to any systematic biases in recording; for example, pre-booked telephone consultations might be reliably recorded as telephone calls, but incoming calls from patients might not be.

Assessing the reliability of data recording

Where possible, the researchers audited the reliability of data recording by identifying individual consultations of different types, using sources other than the computerised consultation records, and comparing how these were recorded in patients’ records. In some cases, it was possible to cross-reference by identifying different types of appointment in the appointment system and then to open the patient’s consultation record to see whether and how the consultation was recorded. For e-mail consultations, it was possible for the GP to use the e-mail system to identify consultations. GPs were also asked to remember any recent examples of consultations of a particular type that could be compared with the practice record. Researchers were asked to identify a minimum of 20 consultations of each type in each practice, and to record their findings on a structured summary (see Appendix 10).

Extracting pseudo-anonymised data

All six of the case study practices in England used the EMIS computer system, whereas the two practices in Scotland both used Vision149 software (In Practice Software Ltd, London, UK), which serves the same purpose. Similar data appeared to be available for extraction in both systems, but, because of the difficulties of combining data from the different systems, we focused on establishing the feasibility of extracting and analysing pseudo-anonymised data from the EMIS system. 150 This is the most widely used GP computer system in the UK. One of the English practices used EMIS for their clinical records, and a separate but linked system for appointments (FrontDesk148). In this practice, it was necessary to collect data from EMIS and FrontDesk separately and merge them.

Because key variables needed for the analysis were contained in different parts of the computer system (patient register, appointments system and consultation records), it was necessary to develop three electronic searches of the medical records and then to merge the outputs, using a linked pseudo-anonymised identifier.

Searches were based on all patients registered on the date the search was done. Searches were carried out between 11 November 2015 and 7 March 2016 in different practices. We estimated that this would lead to a slight underestimation of annual consultation rate (because some patients leaving or joining the practice would not contribute a full year’s data), but to adjust for this by collecting dates of registration would have added a further complication to data extraction and analysis, and was not considered to be essential for this feasibility study.

Patient details

The first search provided details of each registered patient in the practice and their demographic characteristics, including age, sex, ethnicity and deprivation based on the Index of Multiple Deprivation (IMD) derived from the patient’s postcode. Deprivation is associated with a high IMD score and a low IMD rank – in our data set, quintile 1 was the most deprived.

The search included variables for a range of chronic conditions to create an index of multimorbidity at the individual patient level. Patients with specific chronic conditions can be identified based on clusters of Read codes for each condition defined by the Quality and Outcomes Framework business rules. 151 We developed a search within EMIS, which extracted information about whether or not each patient’s record had any of these disease codes, in a form that could be exported to Excel for analysis. Details of the disease clusters are provided in Appendix 11. We calculated a multimorbidity score for each patient by summating the number of chronic conditions, and created a binary multimorbidity variable for patients with a score of two or more. As with all such multimorbidity indices,152 the prevalence of multimorbidity will depend on the diseases included and how they are coded, so the multimorbidity indicator developed for this study cannot necessarily be directly compared with other indicators. The multimorbidity search routine and Excel score sheet will be made freely available as a resource to practices. 153

Details of appointments

We extracted data on all appointments between 12 November 2014 and 11 November 2015. This included details of patient identifier, date of appointment, type of appointment, whether or not the patient attended, appointment time and consultation duration.

Details of consultations

We extracted data for all clinical consultations within the same 12-month period. This provided details of the patient identifier, date of consultation, type of consultation and professional type. We excluded all entries that had a ‘consultation type’ of an administrative nature (e.g. hospital letters, test results, requests for a repeat prescription).

Practice policies

Practices were selected for our case studies because they used different forms of alternative to a face-to-face consultation; therefore, we did not observe or audit consultations of all types in all practices.

Within the computer system, there are some standard consultation types, such as ‘telephone consultation’ or ‘administration’, but practices can create their own consultation types. Some practices did this, for example, to define appointment types for urgent appointments, same-day appointments or routine pre-bookable appointments. Even when practices used standard types provided by EMIS, practices used different types to mean the same thing, or the same type to mean different things. In some practices, although the type of consultation was usually recorded in some way, how this was done varied from doctor to doctor, and there was no clear policy or norm. The reliability of coding also appeared to vary by consultation type, so face-to-face surgery consultations (the default) were nearly always coded reliably. As a new technology implemented in a fairly structured way, e-consult entries appeared to be coded reliably where there was a protocol for their use. By contrast, the use of telephone consultation appeared to have grown in a more informal and organic way, and no practices had protocols to determine how these should be recorded.

E-mail consultations were recorded in varied and irregular ways, reflecting that these consultations involved the use of e-mail software not integrated with the main EMIS patient record system. Therefore, recording these consultations required an extra step to copy and paste the e-mail into the notes. Some practices had a policy of doing this, and estimated that it happened most of the time. One GP stored his practice-related e-mails in a private folder, but did not upload these to the patient records (although he did note that an e-mail had occurred). He explained that copying them to the patient records would create extra work, but accepted that it meant that his work involved in considering and responding to e-mails was therefore hidden. Unrecorded e-mail consultations also meant that the patient record was incomplete.

Assessing the reliability of data entry of consultation types

We conducted audits in the practices to assess whether or not consultations were recorded systematically and accurately, based on up to 20 consultations of each type in each practice. The use of some alternatives was infrequent, making it difficult to find 20 consultations to audit. In some practices, the recording of consultations was too varied and idiosyncratic to audit against a standard. In the two practices that used Vision (rather than EMIS) to keep records, staff could not audit the number of consultations of different types, or extract data for more detailed analysis; therefore, the comments below are based on their understanding of the situation, rather than data from records. In Table 6, the numbers represent the number of consultations of each type included in the audit (the denominator) and the number recorded using the appropriate consultation type (the numerator).

The results shown in Table 6 suggest that telephone consultations were recorded reasonably reliably across practices, but e-mail consultations were not. Although, overall, 63% of e-mail consultations were coded, this was largely due to the reliability of coding in just one practice. Coding of consultations resulting from the use of e-consultations appeared to be reasonably reliable, in accordance with protocols which were used in all three case study practices. These protocols had all been devised by the individual practices.

Feasibility of assessing the use of alternatives to the face-to-face consultation

We set out to assess the feasibility of analysing consultation data from routine records, rather than seeking definitive data on the frequency of consultation types. Because of this focus on feasibility, we report below as ‘results’ some issues we identified in conducting the analyses, as well as the results of the analyses themselves.

Issues with data cleaning

Initial data cleaning identified a number of issues that make this type of analysis difficult:

• Some patients are excluded from extracts of patient data in some practices, for example patients who have died. Whether these patients are included or excluded appears to depend on the data access permissions of the individual who is logged in when the search is run.

• Some items held as separate variables within EMIS were merged into one column when the data were exported to Excel, but had to be split again for analysis.

• There were difficulties in handling dates, which were stored in different ways in EMIS (the source), Excel (how the data are exported) and Stata (the statistics package into which the data were imported for analysis).

• Some professional or consultation types created by practices contained typographical errors or different terms (e.g. dietician vs. dietitian; health-care assistant vs. HCA), so the data had to be visually inspected for each practice to resolve this.

Because of the above problems, a considerable amount of cleaning and reformatting of the data from each individual practice was necessary before the data sets could be merged for analysis.

Patient demographics

Appendix 14 shows the characteristics of the patient population in each practice. These data highlight some aspects of the variation between the practices, which were selected to include different locations, sociodemographic profiles of the patients and size. Several have a high proportion of younger patients; in three practices about three-quarters of the patient population are aged < 45 years, and there are few elderly patients (Figure 4). Two are in deprived areas, with a high proportion of patients from ethnic minority groups, whereas practice H serves many students. In three practices, around half of the patients live in areas within the highest quintile for deprivation, whereas (at the other extreme) 79% of patients in one practice live in areas within the lowest deprivation quintile. The recording of ethnicity was variable, covering around two-thirds of all patients.

FIGURE 4.

Distribution of patients’ age by practice.

Multimorbidity

Using the set of 15 conditions defined earlier in this chapter, 34% of all patients (n = 26,362) and 39% (n = 24,257) of adult patients aged ≥ 18 years had one or more of these long-term conditions. If multimorbidity is defined as two or more of these conditions, 11% of all patients (n = 8314) and 13% of adult patients (n = 8264) had multimorbidity. These figures are compared with the population of England in Appendix 15. The prevalence of chronic conditions and multimorbidity in each case study practice is shown in Appendix 16.

The prevalence of chronic conditions identified in our case study practices was similar to that reported nationally, except for respiratory conditions. The code set used to define asthma included patients who had either a diagnostic code or a relevant prescription, and this may have led to an overestimation of prevalence. Appendix 17 shows how multimorbidity was associated with age. As expected, there was a clear positive relationship between the prevalence of multimorbidity and increasing age. These data, along with the details of prevalence of individual conditions reported above, accord with expected patterns18 and support the reliability of the approach we used to capture multimorbidity.

Annual consultation rates

The full data set included data on 274,517 entries relating to 77,513 patients contributing to the data set. There were entries related to 209,677 valid consultations in the relevant 6-month period with 46,817 patients. Of these, 79.8% (n = 167,363) were face-to-face consultations in surgery, 61.6% (n = 129,197) were consultations with a GP and 43.0% (n = 90,113) were face-to-face consultations in surgery with a GP.

The overall consultation rate (with GPs or nurses in general practice) varied from 3.85 to 7.47 consultations per patient per year in participating practices, with an overall mean of 5.34 consultations. This is similar to the national average consultation rate of 5.16 consultations, based on data on 398 English general practices in 2013–14, using similar definitions and methods. 18 Nevertheless, four of the practices in this study had low consultation rates. These were the practices serving younger populations, with a consultation rate of only 3.85 consultations per patient per annum in the practice serving a predominantly student population.

The annual consultation rates in this study are only estimates, because the inflation from a 6-month period to calculate an annual rate does not take account of the busier winter months from mid-November to mid-May. Furthermore, as previously mentioned, the denominators consider all patients registered at the practice on a specific date, some of whom may have already left or not yet joined the practice during the 6-month period analysed.

The mean rates of consultation of each type and by each type of professional are shown in Appendix 18.

However, it is more informative to consider the rate of consultations of each type in each practice individually, because not all consultation types were offered in all practices. These data are shown in Table 7.

As well as highlighting the variation in overall consultation rate between the participating practices, these data also show considerable variation between practices in both the rate and proportion of alternative types of consultations (noting that not all practices offer all of the alternatives). For example, the proportion of all consultations conducted by telephone varies from 8% to 31%. Among practices offering e-mail consultations, the highest proportion of consultations conducted in this way is 0.58% in one practice, with other practices conducting only 0.02% of consultations in this way. E-consultations also appear to be very rarely used, accounting for 0.22% and 0.23% of consultations in those practices that offer them. It is important to note that, across all practices, face-to-face consultations in surgery still account for the vast majority (79.8%) of all consultations, with home visits accounting for another 1.4% of consultations. As anticipated, the use of alternatives to face-to-face consultations in our case study practices was higher than the national average (86% of consultations in a study of 398 English practices were conducted face to face in surgery). 18 However, among the case study practices chosen because of their interest in the use of alternatives, such approaches account for only a small proportion (18.7%) of all consultations, and 98.6% of these were telephone consultations.

We then explored the extent to which different consultation types were used by patients of different ages, sex, deprivation and multimorbidity. These results are shown in Appendix 19. All of these analyses should be considered as being exploratory, given the small numbers of consultations within some cells, the issues about the reliability of coding previously highlighted and the fact that not all types of alternative were offered in all practices. However, they do demonstrate some general trends and also demonstrate the feasibility of this type of analysis subject to these limitations.

Patterns in consultation rate by age are illustrated in Figure 5, which shows rates of consultations in natural units and also on a logarithmic scale (base 10). This better demonstrates the pattern of rates of each type of consultation in different age groups, given the much lower rates for alternatives to face-to-face consultations.

FIGURE 5.

Rates of different types of consultation by age group. (a) Natural units and (b) logarithmic scale.

Rates of telephone and surgery consultations follow a similar pattern, with higher rates in babies and older people. Unsurprisingly, there is a strong association between older age and home visit rates. There is a trend towards greater use of e-consultations (but not e-mails) among young adults, although this should be interpreted with caution, as numbers of consultations of these types are small.

Appendix 19 shows that females had higher rates of most types of consultation than males. The numbers of e-mails sent were similar in both sexes, but the total number of e-mails was very small. Appendix 19 also suggests that patients from non-white ethnic groups had a higher rate of telephone consultations and a lower rate of home visits and electronic consultations than white patients.

In this univariate analysis, rates of surgery consultations and e-mails appeared to be highest in the least deprived quintile, but this analysis does not take account of confounding factors, such as age (see Appendix 19).

Unsurprisingly, there is a strongly positive relationship between multimorbidity and consultation rate (see Appendix 19), and patients with more chronic diseases have more consultations of all types (see Appendix 20).

It is important to note that the above findings relate to crude rates, and there are obvious associations between variables (e.g. multimorbidity is more common in older people, and practices in less deprived areas tend to have more elderly patients). In order to explore the independent association between these variables and the use of alternatives to face-to-face consultations, we conducted a multivariate analysis using negative binomial regression models to provide adjusted estimates.

Multivariate analysis

The rate of face-to-face consultations in surgery was higher in older patients, women, those from non-white ethnic groups and those with multimorbidity (Table 8). Patients living in the least deprived quintile had slightly higher face-to-face consultation rates than those in the most deprived quintile. The rate of telephone consultations showed similar relationships with patient characteristics, except that there were no strong relationships with ethnicity or deprivation (Table 9).

For electronic consultations (e-consultations or e-mail consultations, combined), some of these relationships were quite different. Electronic consultations were less common in children and more common in patients who were white and those who lived in more affluent areas (Table 10).

Feasibility of assessing duration of consultations

We explored the feasibility of determining the duration of different types of consultations using routine data recorded in the EMIS system. It proved impossible to reliably attribute durations to different types of consultation for a variety of reasons, including an inability to link consultations to duration (which is held in the appointments file) when there was more than one consultation on one day, problems with unfeasibly long consultations and missing data. These problems were particularly relevant to telephone consultations, which were often followed by a surgery consultation on the same day.

Patients reconsulting within 14 days

Table 11 shows the proportion of consultations of each type that were followed by another consultation within the subsequent 14 days, including the index day and the types of reconsultation. In interpreting these data, it is important to note that the same consultation may be included as a reconsultation, but could also form an index consultation for another subsequent reconsultation.

Table 11 shows that 50% of patients having a telephone consultation had a subsequent surgery consultation within 14 days, and 29% had another telephone consultation. Some patients will have had both, so 62% of patients had another consultation (compared with 48% of patients who had a surgery consultation then having another consultation within 14 days). For patients having an e-consult, 39% also had a surgery consultation and 31% also had a telephone consultation (62% had at least one additional consultation) within 14 days.

A similar analysis restricted to GP consultations only is shown in Appendix 21.

Table 12 shows that 29% of patients having a GP surgery consultation also had another consultation within 14 days (including 23% having another face-to-face consultation at surgery or at home), whereas 54% of patients having a telephone consultation also had another form of consultation (including 41% also have a face-to-face consultation).

Unintended consequences

Although patients (and some practice staff) saw improvements in access to care as a benefit, this did not take away from their worries about demand. Even if the use of alternatives to the face-to-face consultation does mean that consultations can be conducted more quickly and efficiently, there was a concern that increased access will increase demand, outstripping any efficiency gains. Concerns about supply-induced demand caused by offering access to alternatives to the face-to-face consultation were demonstrated by GPs; however, we did not find evidence about whether or not the provision of alternatives does indeed lead to supply-induced demand. Our case study practices experienced the opposite problem, in that use was so infrequent as to question the investment in these new approaches. It is unclear if low uptake results from GPs applying the use of alternatives selectively, patients not being aware of their availability or not wishing to use them, or problems with implementation.

A further unintended consequence expressed was the possibility that the provision of alternatives to the face-to-face consultation might lead to increased consultation rates among groups of patients who are confident with technology. These people may have fewer health needs, and self-care because access to primary care is currently difficult. Lowering the threshold to access would not only increase practice workload, but could also increase health inequalities. This point is considered further under the discussion about the impact on different patient groups.

Contextual factors affecting implementation

A range of contextual factors affected which alternatives were implemented and how they were implemented, often in relation to practice population and geography. Our case studies illustrated extreme examples of this. The introduction of video consulting at the rural practice in Scotland was motivated by the difficulty of reaching a doctor by boat, whereas the use of e-mail consultations at another was partly related to the large student population. However, practice culture was also very important, with some of the case study practices introducing alternatives to the face-to-face consultation because they had a long history of being innovative, and they wanted to be forward-looking. As previously noted, in England, the support provided by the GP Access Fund14 was another contextual factor affecting implementation. Some practices had introduced e-consulting systems chosen by their local consortium, without necessarily having thought through how these systems would be used in their practice.

Moderating factors affecting implementation, barriers and facilitators

The GP Access Fund14 also acted as an important facilitator of implementation, providing an impetus to change, financial support and, in some cases, training and support with protocols for provision of a new service. Innovations introduced in this way were more likely to be accompanied by campaigns to raise patient awareness, including messages in the waiting room and in practice websites, although this did not necessarily relate to increased uptake levels.

It was clear that in several practices, introduction was driven by one or two ‘innovators’ in the practice. This could act as a facilitator of implementation, but could also lead to inconsistency. In some practices, it was evident that practice staff were working in different ways, not necessarily knowing how others were working, and with no formal practice policy on how to apply or use an alternative to the face-to-face consultation.

There were several barriers to implementation. These included a lack of training for practice staff, particularly receptionists. In some practices, receptionists felt that there was a lack of awareness from both patients and doctors of the complexity of their role. Furthermore, the use of alternatives to the face-to-face consultation had grown organically in most practices without a plan, and new ways of working had not necessarily been implemented in an efficient or organised way.

Structural factors also had a major influence on implementation. The use of video consulting in one practice was constrained by the inconvenience of using the equipment. Many practices experienced problems because of the limitations of their GP computer records systems, which made it difficult to include records of e-mails or e-consultations. Changes in the use of the telephone for consulting sometimes required more telephone lines than were available.

There were also more subtle factors that acted to impede or modify use, and these were related to the impact on professional identity. New ways of working could be perceived as a threat to aspects of work that were seen as fundamental to professional values. For example, a core tenet of general practice is the importance of the doctor–patient relationship, and forms of consulting that are not based on face-to-face contact may have an impact on that relationship. Alternatives to the face-to-face consultation have often been promoted on the basis of quick and convenient access to care, but clinicians in the case studies speculated that this may be seen as being to the detriment of continuity of care (associated with relationships), as well as potentially to the quality and safety of care.

Some forms of alternatives to the face-to-face consultation were associated with changes in professional roles, for example the greater use of nurses to conduct telephone consultations. This was seen positively by some staff, and has the potential to increase staffing capacity, but in other cases was perceived negatively, with some staff (both nurses and doctors) feeling that the nurse’s time might not be used appropriately. One example of how alternatives to the face-to-face consultation were associated with changes to professional roles is a system (not observed in our case studies, but widely reported during our research) in which practices contract with another organisation so that patients have the opportunity to have a telephone or video consultation with a doctor unconnected with the practice, and who does not have access to the patients’ records. 18,154,155 Such developments challenge some of the key principles on which general practice is based, such as the provision of comprehensive, co-ordinated care provided through a single point of contact. However, this approach can improve access and expand the GP workforce by employing doctors working from home who cannot or do not wish to work in routine general practice. Given the scale of these changes, it is not surprising that the implementation of alternatives to the face-to-face consultation is met with resistance from some professional staff, which may have more to do with the implications for their professional values than it is related to the technology itself, and this was highlighted in the conceptual review (see Chapter 2).

Effects on different patient groups

One of the questions of interest for this research was the impact on different groups, including which groups might be most suitable for different forms and the possibility of increasing health inequalities if other groups are unsuitable. The key finding from our study is that, although individual patients’ perspectives varied, these could not be predicted based on factors such as age, sex or health status. In addition, there was a recognition that an individual patient’s reasons and ability to use a particular form of consultation may change over time and with experience.

Those who contributed to the stakeholder workshop felt that many of the assumptions about which patients benefit most were challenged by the evidence and, therefore, it would be more appropriate to consider how and when to use alternatives to the face-to-face consultation, rather than with which groups. Some forms have primarily been viewed as a way to respond to requests for quick access to care, but stakeholders felt that the same technologies might be more useful for follow-up and monitoring, rather than for initial assessment.

Although differences between patient groups were fewer than might have been anticipated, some concerns were expressed about the potential to increase health inequalities. This is supported to some extent by the findings reported in Chapter 6, that the characteristics of patients using e-consultation (more common in white, affluent, young adults) were in marked contrast to those of patients using telephone or face-to-face consultation. This could be interpreted as providing choice and improving access for people who find conventional forms of access to be inconvenient. However, it could represent inequity, by diverting resources and consultation time to the groups of patients with the fewest health needs. Given the very low number of patients using e-mail or e-consultations, it is important not to overinterpret these findings.

Potential research questions

In respect of alternatives to face-to-face consultations, our research has been partly about generating hypotheses, in order to create a logical framework for future definitive studies. Our work has indicated a need for further research on a range of questions:

• Is it possible to improve the uptake of alternatives to face-to-face consultations and, if so, does this lead to benefits for patients and general practices?

• What is the impact on access to care as perceived by patients (speed of access, convenience, timely access to care that meets their perceived needs)?

• What is the impact on NHS workload and, in particular, on different sectors of the NHS (primary and secondary care) and different professional groups (doctors, nurses, receptionists and administrative staff)?

• What is the impact on the quality and safety of patient management?

• For which patients and for which conditions are different forms of alternatives most efficient and effective?

• How do different forms of consultation change the content of the consultation?

• How satisfied are clinicians and patients with different forms of alternative to the face-to-face consultation?

Our research has shown that telephone consultations are well established, whereas other forms of alternatives to the face-to-face consultation are very little used. Therefore, future research would need to apply different methods and explore different questions for these different technologies, and these are described below.

Telephone consulting

Telephone consulting is the only widespread alternative to the face-to-face consultation in common use. Although a large body of literature exists on telephone consulting [both qualitative and quantitative, including randomised controlled trials (RCTs)],60,156,157 most of this addresses the use of telephone triage of requests for same-day appointments and for out-of-hours work. There is some qualitative research on the use of telephone consultations for follow-up conditions and in long-term condition management, but little in the way of quantitative research, with a few exceptions for specific diseases. 108,158–160 There is a need, therefore, to consider the impact on the quality and safety of patient management and NHS and patient resource use of the introduction of structured telephone follow-up of acute and long-term conditions.

The best way to determine quantitative outcomes (see Table 13) would be to conduct a RCT. This could be randomised at the patient level, but would rely on GPs to recruit and randomise the patients, which is unlikely to be successful. Instead, a cluster randomised trial along the lines of the ESTEEM trial60 is likely to be more successful. An alternative might be a controlled before-and-after study. A qualitative process evaluation could be readily embedded in such a study, possibly within a realist evaluation framework. An economic evaluation with a wide scope would also be essential, because the impacts of this change in practice might be felt in several sectors of the NHS (e.g. role substitution in primary care, changes in the numbers of investigations or use of outpatient or emergency departments).

In recent years, the use of telephone consultations as the main first point of contact for all consultations has been promoted and widely taken up by practices. We did not include such practices within our case studies, because these schemes are well established and now need to be evaluated using different research methods to assess outcomes.

E-consulting

We have identified very low uptake of e-consultations in this research. These systems incur a subscription charge, and, to be cost-effective, would have to be both widely used and reduce practice workload considerably. Research into these systems should begin with further investigation to determine why, as we observed, there is low uptake and how much time it takes a patient to complete the online forms and for clinicians to read them. If it appears that these systems can be made more attractive to patients, there is potential to see how their usage may affect the workload of the practice. Depending on the likely uptake of the intervention, this could be as an individually randomised trial (e.g. patients willing to use the system are randomised to those given immediate and delayed access after 1 year) or, if taken up by large numbers, as a cluster RCT. The study would explore the impact of the intervention on the outcomes described in Table 13. Such a trial should have an inbuilt qualitative process and economic evaluation.

E-mail consulting and webmail

In contrast to structured e-consultation methods, the use of e-mail for patients to enter into a two-way dialogue with the clinician is less well developed in the UK. It is a technology with which many are familiar and it is potentially inexpensive to introduce. However, as is clear from our case study practices, robust systems for handling e-mail have not been established in practices, and this would be difficult to achieve using standard e-mail (e.g. establishing with confidence the identity of patients using the system). Webmail has the potential to be more secure, requiring a logon from the patient. Such systems can be provided through practice websites. They would involve simple triage questions with respect to the nature of the problem to determine the suitability of the medium (e.g. speed of response, considered need for examination). Our work highlights serious concerns from clinicians about being overloaded, by lowering the bar to consultation and inappropriate use of e-mail as a means of fast-tracking to a face-to-face appointment. Unfortunately, there appears to be little in the way of quantitative research on the impact of the use of e-mail on workload, and on the analysis of the content of e-mails in comparison with face-to-face and telephone consulting for similar problems.

Clinicians would have to be reassured that the interventions will be introduced in a controlled manner. As with e-consulting, research should include Phase II research to develop and test the feasibility of robust webmail systems. Once such systems have been devised, then it is possible to consider introduction of webmail for a restricted number of interested patients who could be randomised to having immediate and delayed access. Embedded studies would explore how the content of e-mails compares with face-to-face and telephone consultations and patients’ and clinicians’ perceptions of the use of the medium. A reasonable intervention period (at least 1 year) would be required, as it takes time for people to become used to using new systems.

Video consulting

Although there is a relatively large body of literature exploring the potential for video consulting, many studies are small and descriptive. 59,124 This is particularly true of primary care consultations, mainly demonstrating the potential for the medium, rather than exploring its impact on the content of the consultation or on GP workload or patient satisfaction. There have been no RCTs in general practice, and those studies in the UK have been confined to patient attitudes to video-consultation.

The major hurdle in undertaking research into video-consultation in the UK will be to encourage GPs and practice nurses to use it initially. Before undertaking any trials in the UK, it will be important to address the barriers to these consultations that we have identified. These include the attitudinal and logistical barriers identified by clinicians and the technical difficulties that may be encountered working within the heavily firewalled, low bandwidth systems of the NHS. Thereafter, it will be necessary to explore those types of patients for whom video-consultation is most appropriate, how video-consultations differ in length, content and quality from face-to-face and telephone consultations and patients’ and clinicians’ experience of these different media. At present, the use of video-consultation is so minimal that we are unable to answer these questions. Given the mismatch between the rhetoric and financial support being given to video-consultation compared with the almost non-existent use of it, the priority should be a cautious stepwise introduction, beginning with overcoming technical difficulties and establishing feasibility and potential impact, before widespread implementation of this approach. Once the use of video-consultation is more established, it may be possible to consider RCTs of the use of the medium versus face-to-face and telephone consultations.

Which patients

With the exception of telephone consulting, all new forms of consulting require an internet connection. Almost 8 in 10 households now have fixed broadband access at home and 61% of people regularly access the internet by phone or tablet. 161 According to Ofcom in 2015, 68% of people aged > 55 years owned a smartphone, rising to 90% in younger age groups. At least until 2015, around 25% of non-smartphone users were converting to smartphone use each year. 162 However, not all people who own a smartphone have large data allowances and this could be a problem for people with modest incomes who have no Wi-Fi connection. In contrast, home broadband usage appears to have peaked. 161 People in the poorest households rely more on mobile phones than fixed broadband for internet access. 162 It is clear that, for those consultation formats requiring internet connectivity, there may be a significant number of people excluded from their use, largely older and poorer people.

Analysis of our own data supported this finding and indicated that, although the demography of patients using telephone consulting was largely similar to the demography of patients attending the surgery, e-consultations tended to be carried out with younger and more affluent patients. There were insufficient instances of use of video consulting to determine the demography of users with confidence.

Interviews and observations with clinicians and patients also indicated that telephone consultations were more challenging for people who have communication difficulties (primarily those who did not use English as a first language or who had hearing problems), learning difficulties or cognitive impairment. However, for some of these groups, written communication such as webmail/e-mail and e-consulting systems might be helpful. Future developments would have to be carefully planned to ensure that the introduction of these technologies was not at the expense of those who may not have access to or be able to use them.

The choice of patient group relates closely to the question of how alternatives to the face-to-face consultation are implemented and for which purposes. If patients can choose from a range of consultation options that are equally available, then the patient group using each type of consultation will be determined by patients themselves. If use of alternatives to the face-to-face consultation is mandated by the practice as the default way to gain access to care, it will be important to facilitate other routes to care for these groups with particular needs, as described above.

Which technology

In summary, our research suggests that there are three types of technology that are priorities for robust evaluation, because they are being widely implemented in the absence of evidence. In each case, the research needed is less to do with the technology and more to do with the impact of the system redesign. The three priorities currently for evaluation of alternatives are as follows:

1. The use of the telephone for follow-up consultations; as previously noted, most attention has been given to the use of the telephone for initial consultations or triage, but there is great scope for use of the telephone for follow-up and monitoring of previously diagnosed problems, review of chronic conditions, support for self-management and simple queries. As we observed in the case studies, many practices use the telephone in a variety of ways that are often ad hoc. There have been several studies of telephone support for a range of specific chronic conditions,158 but few studies of a whole-system redesign that maximises the use of telephone consulting for follow-up in an organised way. 159,160

2. E-consulting systems are being heavily promoted, and their implementation has accelerated greatly as a result of the GP Access Fund. 14 These systems often come with support and standardised protocols, and have often been acquired as a result of the decision of all the doctors in the practice. The use of these systems is quite formalised, which may facilitate research. Despite the attention given to these systems, there is very little evidence about their impact, and this is therefore a priority for research. However, in our case studies, we observed very poor uptake of these interventions, despite their being heavily promoted by practices. It would be important to explore the reasons for this, before embarking on a large-scale evaluation.

3. The use of ‘telephone-first’ models of access to care. This is currently being studied by another research team using mixed methods, including a before-and-after study of patient experience and hospital utilisation, qualitative interviews with patients and analysis of routine data about consultation rates, waiting times and continuity of care in a sample of practices. These studies will provide much-needed evidence, but will inevitably share the limitations of all such quasi-experimental studies, particularly the potential for confounding and selection bias. It is likely that practices that take up telephone-first models differ from other practices in important ways (particularly relating to local context and practice culture) that are hard to measure. Nevertheless, this is likely to be the best evidence available, as a true experimental study, such as a RCT, would probably be impossible to conduct.

Clearly, many of the issues above will pose a challenge to future research in the area. Particularly for those interventions that are little used currently (e.g. webmail/e-mail and video consulting), many clinicians will need to be persuaded of the possible long-term benefits, and will probably require some form of support/incentive to identify and agree the need for the change in their current practice.

Is there a need for a standard implementation of alternatives to the face-to-face consultation in undertaking research?

Our research shows that similar technologies are implemented differently in different practices. Some of these had been planned carefully and others had evolved, possibly not always with a great deal of thought. Implementations were sometimes somewhat piecemeal, with not all clinicians involved in their use and with no written or accepted protocols for handling them. It seems very likely that, regardless of the final implementation, one that has been planned and agreed with members of the practice team is more likely to be successful than one that has not. For the purposes of researching the impact of alternatives to face-to-face consultations, it makes sense to ensure that practices agreeing to take part in research should be supported to develop protocols for handling novel consultations in a way that suits their practice demography and existing management style to increase the chances of a successful implementation. However, it is likely, for example, that a solution that suits a remote and rural island practice will not necessarily suit an inner-city practice with a large non-English-speaking population. It is also possible that the implementation will evolve with time as practices gain experience. Alternatives to the face-to-face consultation are a good example of a complex intervention, and a range of research designs may be more or less applicable. A rigid, unalterable intervention, such as is normal for a traditional RCT, is unlikely to be appropriate. Regardless of approach, it will be important to specify the key features of the alternative to the face-to-face consultation (which, depending on study design, may be an intervention) that are fundamental to its intended purpose, and, therefore, must be implemented as planned, and those features that are flexible and appropriate for local modification.

Although there are many other potential uses of alternatives apart from the three listed above, these are less established, and attention should be given to further development and feasibility testing before definitive evaluation. In the case of some technologies, such as video consulting, for which there is little experience of use in primary care and different technological options are available, it will be important, prior to attempting to assess impact, to determine which are most accepted and used by clinicians and patients.

Measures of the process of care

This research has highlighted the range of factors that may act as mediators or moderators to the successful implementation of alternatives to the face-to-face consultation. Some of these factors are related to the presumed mechanisms and assumptions about how they might improve general practice (e.g. that managing an e-consultation will be quicker than a face-to-face consultation, leading to lower practice workload and shorter waits for a face-to-face appointment). In future research, it will therefore be important to assess these factors as measures of the process of care. This will help to illuminate how and why the intervention was effective, or if it was not effective, whether this was because of a failure to deliver the intervention as intended or a failure of the intervention to have the desired effect. Some factors, such as the number of consultations of different types, could be considered as measures of the process of care or as the outcome of the implementation. We have therefore considered both process and outcome measures together in Table 13.

Measures of outcome

The parameters best used to capture the outcomes of most importance will depend on the chosen methodology and the type of alternative to the face-to-face consultation under investigation. However, the key outcomes that matter to patients, practice staff and the NHS are listed in Table 13. Some of these outcomes are a direct result of the use of alternatives to the face-to-face consultation, whereas others may well be related and are important to patients (e.g. health-related quality of life), practices (e.g. staff morale) and the NHS (e.g. possible knock-on effects on emergency department attendance rates).

The parameters listed in Table 13 reflect the priorities of patients and practitioners identified in this research and we have proposed suitable measures and made comments about their feasibility based on the experience of the research team.

Feasibility of practice recruitment

In order to evaluate alternatives to the face-to-face consultation in a rigorous research design, it will be necessary to recruit a sufficient number of practices in a range of settings. However, our survey of practices reported in Chapter 3 demonstrated a low level of willingness to implement. Therefore, a prospective study may be impossible to conduct, unless alternatives to the face-to-face consultation are developed that appear to offer advantages to general practices and are implemented for the purpose of evaluation. The only evaluative research that would appear to be possible at present would be studies of approaches that are being widely implemented, such as new forms of telephone consulting or the introduction of e-consultation.

Feasibility of patient recruitment

We did not seek to recruit patients on a large scale in this study, but previous experience suggests that it is possible to recruit at least 39% of people attending general practice to complete a questionnaire166 and 78% to allow access to their records for analysis of consultation rates. 60 However, the feasibility of patient recruitment to research on some forms of alternatives to the face-to-face consultation will be constrained by the small number of patients using them.

Sample size

In the study reported in Chapter 6, up to 30% of consultations were conducted by telephone. With a telephone consulting rate of between 0.4 and 1.4 consultations per patient per year at different practices, it would be feasible to recruit a large number of patients within a short period. In contrast, e-consultations accounted for < 1% of all consultations in the three case study practices that provided them. Therefore, it would not currently be feasible to evaluate the impact of e-consultations unless uptake increases.

Feasibility of data collection for process measures and outcomes

Table 13 above shows that most measures can be collected from patient-reported outcome measures or routine GP computerised records. Suitable questions are available from validated patient questionnaires for most of the relevant variables. Our research has demonstrated that routinely acquired data from GP computer systems can be interrogated to determine the number and types of consultations, including the number of subsequent consultations within 14 days. It was also possible to describe characteristics of the demography and medical history of patients using these consultations, as well as the professional characteristics of the clinicians consulted. Although not carried out in this study, it would also be feasible to collect data from GP computerised records of prescriptions and investigations.

However, the quality of recording of data in general practice is variable, particularly in respect of accurately recording consultation type. We found that telephone consulting was systematically under-recorded and that e-mail consultations were particularly poorly recorded. It was difficult to detect if a telephone consultation was for triage or a complete consultation (although the former may be inferred through searching for follow-up consultations within a defined period after the index consultation). Some forms of e-consulting systems (e-consult) were designed to remind GPs to record them, and as a result, were better recorded.

Although consultation type may not have been well coded, there were instances when this could be deduced from free text within the consultation record. Research utilising machine-learning techniques is promising in terms of identifying consultation type from free-text entry. 167 Although we did not use these in our research, we are aware that algorithms have also been devised that can infer the likely consultation type from arrival time, start time and consultation length. 168

The use of routinely recorded data in primary care therefore poses problems of accuracy and completeness. It seems unlikely that clinicians will improve the accuracy of their recording in the absence of changes to the design of current GP consulting software. Potentially, incentives may improve this. If this is not possible, it has implications for the size of studies that may be needed to demonstrate changes in outcomes.

Conceptual review

The review provided a comprehensive assessment of the recent literature in relation to alternatives to the face-to-face consultation. We included opinion pieces, as well as studies including qualitative or quantitative data. The review provided a conceptual framework for the data collection and analysis, highlighting under-researched groups and topics for the case studies and suggestions for future evaluation. The conceptual analysis focused on the ideas present in the articles that we reviewed and did not attempt to synthesise numerical or thematic analyses from empirical papers. There were limitations to the approach taken in conducting the review. In restricting the database search to the previous 3 years, some relevant studies may have been missed. We aimed to include all relevant ideas, but some fledgling ideas, for example, from discussion sections of apparently tangential studies, may have been missed among the large amounts of material within the review. To help mitigate this, we asked three leading research and policy experts in the field to comment on the draft review and highlight any ideas we had missed. The applied focus of the conceptual review is a strength in a fast-moving field that lacks a substantial empirical evidence base.

Scoping study

The practice survey is the first in the UK designed to assess the use, and planned use, of alternatives to the face-to-face consultation in primary care from the perspective of GPs and practice managers. The large number of practices represented in this survey is a strength of this study. In this postal survey of general practice in three areas of England and Scotland, at least one response was obtained from a high proportion of practices (76%), which could be a reflection on the strength of feeling for this subject, but could also be related to the brief structure of the questionnaire and the incentive offered (a tablet computer in a prize draw). These practices were representative of all practices approached in terms of size, region and deprivation. The use of free-text comments, as well as the closed questions of the survey, added to the understanding of GPs’ concerns.

The survey included practices from areas with a range of characteristics: urban to rural, inner city to remote, and affluent to deprived locations. Such practices have differing local contexts, policies and incentives to implement alternatives to face-to-face consultations. The study covered only three broad geographical areas; practices in other areas of the UK could be using alternatives to face-to-face consultations differently.

We found in the case study work that there was different awareness of alternative methods among different members of the team; therefore, depending on which member(s) of staff replied to the survey, a different picture might emerge. The very idea of offering consultations using an alternative medium was controversial in some practices, especially where this was not an official practice policy. Therefore, it is also possible that there was some response bias169 whereby responders might have been reluctant to admit to using e-mail or internet video. With free-text comments, those who responded may have particularly strong views about the topic. Although the practice-level response rate was high, the response rate from individuals was lower. As such, the findings from this survey offer a previously unknown insight into the current use of alternatives to face-to-face consultations, but may not be generalisable.

The results of the survey were accompanied by further scoping methods, a strength of the study. Access to the practice websites was used both to check information given via the survey (and to add information from practices that had not responded). We had not anticipated the number of practices without active websites at the time of the scoping exercise. Supplementing this further by utilising contacts with local or national knowledge of the use of alternatives to the face-to-face consultation within primary care and approaching companies supporting practices in providing alternatives was another strength to the scoping exercise.

Focused ethnographic case studies

There are several advantages to using a team-based focused ethnography in multiple sites. It is a quick approach, and data can be collected at different sites concurrently. This speed is advantageous in research areas where the policy context is constantly changing. Similar fieldwork completed by one ethnographer would take much longer. Using multiple sites over a wide geographical area allowed for the capture of diversity in the use of communication technologies across several different locations.

Team working has benefits; in this study, it offered the opportunity for reflection and sense-checking, made the work less lonely and isolated and allowed for the sharing of ways of working, with the ethnographers building research skills. The regular meetings among the focused ethnographic team members allowed for constant comparison of the data and appraisal of the emerging areas of interest to explore further.

There were also some challenges presented by this approach. The nature of the posts required the appointment of ethnographers who had similar skills and were likely to get on with each other, something that was challenging when looking for specialist skills across three employing universities (University of Bristol, University of Edinburgh and University of Oxford). Data management was a huge task for the day-to-day lead (HA); for example, there was a lot of time taken to check coding across all transcripts and to ensure that data were safely and appropriately saved and stored. Research assistants employed in the senior ethnographer’s wider team (SZ) were drafted in to assist with entering coded transcripts onto NVivo (this requirement had not been anticipated) to free up time for the ethnographers to contribute to the analysis.

Another challenge was to ensure appropriate comparisons between case study sites that had been selected because they were using different approaches in different contexts, and were also located in very different geographical areas and managed separately by our ethnographers. Feedback from our ethnographers led to an initial period of adjusting the study documents (i.e. interview questions and coding framework), to balance the focus on the anticipated themes from the research questions and the emergent issues that were captured within the context of the different practices.

Ideally, each of our ethnographers would have visited the case study sites other than their own, to obtain a better grasp of the field and to compare perspectives between team members. Furthermore, longer contracts for our ethnographers would have allowed for more in-depth sharing of field notes and more face-to-face meetings, as well as for all three of the field ethnographers to be involved throughout the data analysis and writing up. The wider study team were engaged at the data analysis stage, and having input from experienced researchers with different disciplinary backgrounds, including general practice, was invaluable to the interpretation and final stages of the project. These fruitful discussions led to an understanding of:

• how varied the case study practice cultures were in the experience of the GP members of the wider study team

• potential audiences for the study findings and how to translate the information to practice teams

• different practices about what gets recorded and timed as a ‘consultation’.

The case study sites were selected on the basis of their varied use of alternatives to the face-to-face consultation. We included a range of urban and rural practices, covering a broad geographical area, and having a wide range of deprivation scores. Some of the practices served communities with low levels of patients from ethnic minority backgrounds. Some practices had a high proportion of younger patients, which may have been connected to their willingness to offer alternatives to the face-to-face consultation. We interviewed patients from a wide range of ages, health conditions and socioeconomic groups.

Routine consultation data

The study set out to assess the feasibility of analysing consultation data from routine records, rather than necessarily providing definitive results about the frequency of consultations of each type. Because of this focus on feasibility, issues in conducting the analysis have been described. As described in Chapter 6, a series of problems associated with the data collected were identified, only some of which were foreseen. The data required a considerable amount of cleaning and reformatting from each individual practice before the data sets could be merged for analysis. For all types of alternative to the face-to-face consultation, the recorded number of consultations is likely to be an underestimate of the true number of consultations because of the recording limitations discussed in the chapter. Finally, not all practices offered the relevant forms of alternatives to the face-to-face consultation during the whole year covered by the data collection period. For this reason, data were analysed from the second 6-month period (mid-May to mid-November). This may also lead to an underestimation of consultation rates, because it omits the winter months, which are the periods of greatest demand. Despite these limitations, there would have to be an enormous element of under-recording to change the key conclusion, which is that the use of alternatives to face-to-face consultations, other than telephone consultations, is extremely limited.

Advisory group

Throughout the study, there were two PPI representatives in the advisory group. They were not connected with the PPI in the main part of the study, and provided an independent view on the PPI work and critical feedback on the PPI work that was undertaken. Importantly, they helped to ensure that the patient and carer perspective was a central concern in carrying out this work.

Workshop on the conceptual review

The issues raised in the PPI workshop were compared with the findings of the review. Doing this helped to confirm the relevance of issues raised in the literature. The feedback was also used to direct analysis and search for additional literature.

Focused ethnographic case studies

Patient and public involvement input helped to modify the patient-facing documents used in the study. The title of the study on the information sheets and consent forms was modified in response to PPI advice, and all abbreviations were removed from the documents. The information on observing the consultation between the doctor and the patient/carer and that provided to patients and carers invited for interviews was expanded to include more information.

Involving young people in our work helped us to broaden the range of patient and public perspectives in our project. This work confirmed that young people felt comfortable with the use of new technology to facilitate alternatives to face-to-face consultations. However, crucially, it also confirmed that they share the concerns expressed by other patient groups about the use of alternatives to face-to-face consultations. Without this element, the viewpoint of younger people would have been missing from our study.

Stakeholder workshop

Public contributors actively contributed to the discussions, pointing out where there may be areas of consensus and potential disagreement in the adoption and use of alternatives to face-to-face consultations between patients and health-care professionals. The impact of PPI on the synthesis of the study findings is described in Chapter 7.

Search strategy

Search strategy

Search strategy

Search strategy

Search strategy

Search strategy

1. What is it like to work in this practice?

• What is your role?

• Collaborative working, i.e. involvement in decision-making?

• Pros and cons.

2. Your role in alternatives to the face-to-face consultation

• Clarify scope of involvement and role.

• Role in administering alternatives to the face-to-face consultation (how role may have changed over time).

3. Introduction of alternatives to the face-to-face consultation

• What is your understanding of why was it introduced?

• How long did it take you to get used to?

• How has it had an impact on how you do your job, e.g. appointment systems?

• Did you have to have training? What form did this take? If not why not?

• How are security and confidentiality addressed? Are you happy with the systems in use?

4. Delivery of alternatives to the face-to-face consultation

• Type of alternatives to the face-to-face consultation they can offer to patients?

• Types of patients allowed/encouraged to use alternatives?

• Which patients take it up?

• Benefits to the patient?

5. Impact of alternatives to the face-to-face consultation on role

• Has it had any impact on your job role, satisfaction, stress?

• Have you encountered any difficulties? How have these been addressed?

• Has it changed your perspective of the practice as a place to work?

6. View of alternatives to the face-to-face consultation used in the practice

• What has the impact been in the practice?

• Where use has ceased, what has changed?

• Benefits to the practice?

7. Personal views of alternatives to the face-to-face consultation

• What are your thoughts on the future of alternatives to the face-to-face consultation in general practice?

• Where do you think it will go? Does it excite/worry you?

1. What is it like to work in this practice? (just before I start this interview)

• What is your role?

• Collaborative working, i.e. involvement in decision-making?

• Pros and cons.

2. Your role in alternatives to the face-to-face consultation

• Clarify scope of involvement and role (GP involvement? Individual vs team use?)

• Role in administering alternatives to the face-to-face consultation (how role may have changed over time).

3. Introduction of alternatives to the face-to-face consultation

• How did use come about? Were you involved?

• If not, how did you end up using alternatives to the face-to-face consultation?

• Did you have to have training? What form did this take? If not why not?

• How are security and confidentiality addressed? Are you happy with the systems in use?

4. Delivery of alternatives to the face-to-face consultation

• Type of alternatives to the face-to-face consultation you engage in? Why this type?

• How long did it take you to get used to?

• Who uses it, why and what happens as a result? E.g. type of patients encouraged to use it, others discouraged?

• What are the benefits to your patients?

• Impact on dynamic/relationship with patient.

• Experienced any critical incidents/significant events?

5. Impact of alternatives to the face-to-face consultation on role

• Has it had any impact on your job role, satisfaction, stress?

• Have you encountered any difficulties? How have these been addressed?

• What are your feelings about level of responsibility in your role when using alternatives to the face-to-face consultation?

• Has it changed your perspective of the practice as a place to work?

6. View of alternatives to the face-to-face consultation use in the practice

• Have views about technology in the practice changed since introducing alternatives to the face-to-face consultation?

• Where use has ceased, what has changed?

• Benefits to the practice?

7. Personal views of alternatives to the face-to-face consultation

• What are your thoughts on the future of alternatives to the face-to-face consultation in general practice?

• Where do you think it will go? Does it excite/worry you?

1. What is it like to work in this practice? (Just before I start this interview)

• What is your role?

• Collaborative working, i.e. involvement in decision-making?

• Pros and cons.

2. Your role in alternatives to the face-to-face consultation

• Clarify scope of involvement and role (GP involvement? Individual vs team use?)

• Role in administering alternatives to the face-to-face consultation (how role may have changed over time).

3. Introduction of alternatives to the face-to-face consultation

• How did use come about? Were you involved?

• If not how did you end up using alternatives to the face-to-face consultation?

• Did you have to have training? What form did this take? If not why not?

• How are security and confidentiality addressed? Are you happy with the systems in use?

• Any steps taken to ensure medicolegal protection?

4. Delivery of alternatives to the face-to-face consultation

• Type of alternatives to the face-to-face consultation you engage in? Why this type?

• How long did it take you to get used to?

• Who uses it, why and what happens as a result? E.g. type of patients encouraged to use it, others discouraged?

• What are the benefits to your patients?

• Impact on dynamic/relationship with patient.

• Experienced any critical incidents/significant events?

• How do you record these consultations?

5. Impact of alternatives to the face-to-face consultation on role

• Has it had any impact on your job role, satisfaction, stress?

• Have you encountered any difficulties? How have these been addressed?

• What are your feelings about level of responsibility in your role when using alternatives to the face-to-face consultation?

• Has it changed your perspective of the practice as a place to work?

6. View of alternatives to the face-to-face consultation use in the practice

• Have views about technology in the practice changed since introducing alternatives to the face-to-face consultation?

• Where use has ceased, what has changed?

• Benefits to the practice?

7. Personal views of alternatives to the face-to-face consultation

• What are your thoughts on the future of alternatives to the face-to-face consultation in general practice?

• Where do you think it will go? Does it excite/worry you?

1. What is it like to work in this practice (just before I start this interview)

• What is your role?

• Collaborative working, i.e. involvement in decision-making?

• Pros and cons.

2. Your role in alternatives to the face-to-face consultation

• Clarify scope of involvement and role (Individual vs team use?)

• Role in administering alternatives to the face-to-face consultation (how role may have changed over time).

3. Introduction of alternatives to the face-to-face consultation

• How did use come about? Were you involved?

• If not how did you end up using alternatives to the face-to-face consultation?

• Did you have to have training? What form did this take? If not why not?

• How are security and confidentiality addressed? Are you happy with the systems in use?

4. Delivery of alternatives to the face-to-face consultation

• Type of alternatives to the face-to-face consultation you engage in? Why this type?

• How long did it take you to get used to?

• Who uses it, why and what happens as a result? E.g. type of patients encouraged to use it, others discouraged?

• What are the benefits to your patients?

• Impact on dynamic/relationship with patient.

• Experienced any critical incidents/significant events?

• How do you record these consultations?

5. Impact of alternatives to the face-to-face consultation on role

• Has it had any impact on your job role, satisfaction, stress?

• Have you encountered any difficulties? How have these been addressed?

• What are your feelings about level of responsibility in your role when using alternatives to the face-to-face consultation?

• Has it changed your perspective of the practice as a place to work?

6. View of alternatives to the face-to-face consultation use in the practice

• Have views about technology in the practice changed since introducing alternatives to the face-to-face consultation?

• Where use has ceased, what has changed?

• Benefits to the practice?

7. Personal views of alternatives to the face-to-face consultation

• What are your thoughts on the future of alternatives to the face-to-face consultation in general practice?

• Where do you think it will go? Does it excite/worry you?

1. What is it like to work in this practice (just before I start this interview)

• What is your role?

• Collaborative working, i.e. involvement in decision-making?

• Pros and cons.

2. Your role in alternatives to the face-to-face consultation

• Clarify scope of involvement and role.

• Role in development and introduction of alternatives to the face-to-face consultation in the practice.

3. Introduction of alternatives to the face-to-face consultation

• Reasons for introduction, perceived benefits? Who was involved in establishing alternatives to the face-to-face consultation?

• Alternatives to the face-to-face consultation occurring throughout or just by certain staff?

• Investment by the practice in alternatives to the face-to-face consultation.

• Are there protocols in place for use? How did these come about?

• How were systems for information handling developed?

• How are security and confidentiality addressed?

• How long did it take to embed into the practice?

4. Delivery of alternatives to the face-to-face consultation

• Types of alternatives to the face-to-face consultation on offer in practice?

• Which members of practice staff involved and why?

• Which patients use it and why?

• Parameters around who can use alternatives to the face-to-face consultation and what for?

5. Alternatives to the face-to-face consultation and information handling

• Experienced any data breaches?

• How have medicolegal concerns been addressed?

• Have any issues arisen with the computer systems, appointment systems or telephone systems?

• Have there been any critical incidents/significant events?

• Training of staff in using alternatives to the face-to-face consultation

• How have patients been informed about alternatives to the face-to-face consultation?

• Impact on workload, workforce planning, utilisation of resources.

• Difficulties encountered and how these have been addressed?

6. Impact of alternatives to the face-to-face consultation on role

• Has it had any impact on your job role, satisfaction, stress?

• Has it had any impact on the roles of the staff you manage?

7. View of alternatives to the face-to-face consultation use in the practice

• Have views about technology in the practice changed since introducing alternatives to the face-to-face consultation?

• What have been the benefits of the different types of alternatives to the face-to-face consultation to the practice?

• What barriers have been encountered in using alternatives to the face-to-face consultation?

• Where use has ceased, what has changed?

8. Personal views of alternatives to the face-to-face consultation

• What are your thoughts on the future of alternatives to the face-to-face consultation in general practice?

• Where do you think it will go? Does it excite/worry you?