We set out to understand how, under what conditions, for which patients and in what ways alternatives to face-to-face consultations may offer benefits to patients and practitioners in general practice, and to use this understanding to develop guidance for general practices and a framework for subsequent
definitive evaluation.
The first stage of our research was a conceptual review, which culminated in‘key questions to consider when planning, implementing and researching alternatives to face-to-face consultations’.83This review helped to provide a focus for some of the subsequent stages of research, but was also designed for broader use beyond our study and to act as a guide for practitioners, policy-makers and researchers.
We found that alternatives to the face-to-face consultation are not in widespread use in general practice in the UK, with the exception of telephone consulting. In the scoping survey, conducted in three areas of the UK, we found barely any use of video consulting and very little use of e-mail or electronic consultation. Bookable telephone calls were used by most, but not all, of the GPs surveyed. When asked about intentions to introduce alternatives to the face-to-face consultation, the majority of practices had no plans to use video or electronic messaging, and 10% of respondents did not plan to introduce bookable telephone consultations. Free-text comments mostly expressed resistance to the idea of e-mail or video-consultations, although only a few opinions were related to experience of an alternative to the face-to-face consultation. Thus, despite the policy pressure to introduce consultations by e-mail and internet video, as described in Chapter 1, there is little actual use and a general reluctance among GPs to implement alternatives, other than the telephone, to face-to-face consultations.
The scoping study guided recruitment of the case study sites. Even in the eight case study sites, selected because alternatives to the face-to-face consultation were in use or had been in use, actual levels of use were low. Our analysis of routine consultation data in these eight practices showed that telephone consultations accounted for only 18% of all consultations. Among practices offering e-mail consultations, the highest proportion of consultations conducted in this way was 0.58% in one practice, with other practices
conducting only 0.02% of consultations in this way. E-consultations were also very rarely used, accounting for 0.22% and 0.23% of consultations in those practices that offer them. In the one case study practice that used video, levels of use were so low that it was not possible to include them in this analysis. Across all eight of the case study practices (chosen because of their interest in using alternatives) the vast majority of consultations (80%) are still conducted face to face in surgery. These low levels of usage of alternatives to the face-to-face consultation challenge assumptions by policy-makers that alternatives will necessarily lead to replacement of, or reduction in, face-to-face consultations, and raise questions about whether or not it is appropriate to actively fund alternatives to the face-to-face consultation.
The lack of practices offering video consultation, and low levels of use in our case study site, led us to conduct four additional interviews outside the case study sites. These interviews were with people setting up or using video-consultation services in primary care. Two of these had very limited experience of using video consultation with patients as a result of low uptake. We had originally hoped to recruit additional participants from those practices that had been awarded funding under theGP Access Fund14and had stated that they would use video consultation. Of the practices that were contactable, it was not possible to identify any practice that had gone ahead and routinely offered video consultation in this way. For several of the awarded projects, it was not possible to contact anyone involved, and there were no published results of the projects available. Therefore, it was not possible to collect much information on the application of video consultation in general practice.
In our case study practices, the uptake of e-mail consultation was closely related to whether, how and to whom individual GPs offered this type of consultation. GPs tended to do this selectively, basing the decision on familiarity with the patient, or other characteristics of the patient or their health condition. For other alternatives to the face-to-face consultation, the role of reception staff was crucial in offering these consultation types. The conceptual review found almost no evidence about how the wider practice staff members influence uptake; by observing these staff members in our focused ethnography, we found that receptionists and administrators had a crucial role in whether or not new consultation methods were offered to patients.
Despite low use and uptake levels, our case study practices were all using alternatives to the face-to-face consultation in varying formats. We were thus able to explore their rationales for introducing these alternatives. The rationales included:
l the desire to be a modern practice and to respond to the expectations of busy, time-poor patients l alternatives being the only way of providing health care for patients in remote locations, or with other
barriers to attending the practice
l 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
l the recognition that reception staff and telephone lines were overwhelmed l the desire to manage demand and improve efficiency.
The rationales were not mutually exclusive; different team members described different understandings of the rationale in their own practice.
During this study, we set out to understand which patients may benefit, or not, from alternatives to the face-to-face consultation. The conceptual review showed that health-care professionals worry about certain groups being disadvantaged by alternatives to the face-to-face consultation, but these concerns were largely speculative. The patients interviewed in our case study sites included many from disadvantaged groups. For the patients, the benefits of alternatives to the face-to-face consultation reflected the characteristics of the medium (e.g. remote, asynchronous or text based). Regardless of socioeconomic circumstances, patients said that they liked the efficiency and convenience offered by alternatives to the face-to-face consultation. Both health-care professionals and patients agreed that there were certain conditions or issues that would require a face-to-face consultation. Health-care professionals made assumptions about the types of patients who were suitable for engagement in alternatives to the face-to-face consultation, referring to the‘sensible patient.’For both patients and staff, there were times when alternatives to the face-to-face consultation represented a second-best option. This was particularly the case with telephone consultation, which was also the approach used most frequently, and was well integrated within the practices.
Our examination of routine consultation data meant that we could explore the characteristics of patients engaging in alternatives to the face-to-face consultation. Within the case study practices, the pattern of consultation rates was broadly in line with what we would expect, with higher rates in children and the elderly, women, patients from ethnic minority groups and patients with multimorbidity. Surgery consultation rates were slightly higher in the least deprived areas, and telephone consultations were slightly higher in the most deprived areas, but otherwise there was no strong relationship with deprivation for these consultation types. For electronic consultations, some of these patterns were reversed, with the highest rates in young adults and white patients. There was also a clear trend towards higher rates of e-mail consultations in the less deprived areas. Low usage levels for e-mail consultations and the limited quality of the data available mean that it is not currently possible to say why this might be, although our observation about GPs’(and perhaps receptionists’) selectivity about‘suitable’patients may be a factor. There may be other reasons why the provision of e-mail consultations increases inequalities of access. If a range of routes to care are offered, they may suit the needs of different sectors of the population.
InChapter 7, we showed how we synthesised our findings from all of the different components of our research to develop a programme theory to articulate the mechanisms through which alternatives to the face-to-face consultation might offer advantages, and the potential benefits to patients and practices. This chapter also highlights the importance of local practice and population context in respect of how alternatives might be implemented, and how these alternatives might have different consequences in different types of setting.Chapter 7then makes use of the programme theory to develop a framework for subsequent evaluation of the use of alternatives to the face-to-face consultation.
In analysing and synthesising our data, we took account of related theoretical perspectives, including insights from the normalisation process theory, the technology adoption model and the diffusion of innovations theory.51,52,80We did not base our analysis on any of these specific models, but were able to draw on their key tenets in interpreting our findings and devising our recommendations. In considering the contextual and moderating factors relating to implementation, we aligned with the normalisation process theory in focusing on the different kinds of work that people do in enacting a new practice. We also drew on the diffusion of innovation theory when understanding how one or two key actors within the practice could influence implementation, although, unlike the pattern described in the theory, we did not necessarily see the spread of the innovation throughout the practice. The perceived usefulness and ease of use of a new technology, as described in the technology acceptance model, were aligned with observations about a perceived threat to professional identity and a perceived challenge to the core elements of general practice being key to the‘usefulness’, or lack thereof.