Cargas según las normas cubana, tipos y combinaciones.

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:

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

l potential audiences for the study findings and how to translate the information to practice teams l 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 inChapter 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.