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Headline
This study showed a low uptake of alternatives, lack of clarity about their purpose and potential for benefit but little evidence at present
Abstract
Background:
There is international interest in the potential role of different forms of communication technology to provide an alternative to face-to-face consultations in health care. There has been considerable rhetoric about the need for general practices to offer consultations by telephone, e-mail or internet video. However, little is understood about how, under what conditions, for which patients and in what ways these approaches may offer benefits to patients and practitioners in general practice.
Objectives:
Our objectives were to review existing evidence about alternatives to face-to-face consultation; conduct a scoping exercise to identify the ways in which general practices currently provide these alternatives; recruit eight general practices as case studies for focused ethnographic research, exploring how practice context, patient characteristics, type of technology and the purpose of the consultation interact to determine the impact of these alternatives; and synthesise the findings in order to develop a website resource about the implementation of alternatives to face-to-face consultations and a framework for subsequent evaluation.
Design:
Mixed-methods case study.
Setting:
General practices in England and Scotland with varied experience of implementing alternatives to face-to-face consultations.
Participants:
Patients and practice staff.
Interventions:
Alternatives to face-to-face consultations include telephone consultations, e-mail, e-consultations and internet video.
Main outcome measures:
How context influenced the implementation and impact of alternatives to the face-to-face consultation; the rationale for practices to introduce alternatives; the use of different forms of consultation by different patient groups; and the intended benefits/outcomes.
Review methods:
The conceptual review used an approach informed by realist review, a method for synthesising research evidence regarding complex interventions.
Results:
Alternatives to the face-to-face consultation are not in mainstream use in general practice, with low uptake in our case study practices. We identified the underlying rationales for the use of these alternatives and have shown that different stakeholders have different perspectives on what they hope to achieve through the use of alternatives to the face-to-face consultation. Through the observation of real-life use of different forms of alternative, we have a clearer understanding of how, under what circumstances and for which patients alternatives might have a range of intended benefits and potential unintended adverse consequences. We have also developed a framework for future evaluation.
Limitations:
The low uptake of alternatives to the face-to-face consultation means that our research participants might be deemed to be early adopters. The case study approach provides an in-depth examination of a small number of sites, each using alternatives in different ways. The findings are therefore hypothesis-generating, rather than hypothesis-testing.
Conclusions:
The current low uptake of alternatives, lack of clarity about purpose and limited evidence of benefit may be at odds with current policy, which encourages the use of alternatives. We have highlighted key issues for practices and policy-makers to consider and have made recommendations about priorities for further research to be conducted, before or alongside the future roll-out of alternatives to the face-to-face consultation, such as telephone consulting, e-consultation, e-mail and video consulting.
Future work:
We have synthesised our findings to develop a framework and recommendations about future evaluation of the use of alternatives to face-to-face consultations.
Funding details:
The National Institute for Health Research Health Services and Delivery Research programme.
Contents
- Plain English summary
- Scientific summary
- Chapter 1. Introduction
- Chapter 2. Conceptual review
- Chapter 3. Scoping study
- Chapter 4. Focused ethnographic case studies, methodology and description of sites
- Rationale for the methodological approach
- Focused ethnographic team
- Patient and public involvement
- Case study recruitment
- Data collection and management
- Interview participant recruitment
- Quantitative data
- Data analysis
- Ethics and research governance permissions
- Description of the case study sites
- Description of interview participants
- Chapter 5. Case study results
- Introduction
- Understand how and in what ways alternatives to face-to-face consultations may offer benefits to patients and practitioners in general practice
- Understand for which patients alternatives to the face-to-face consultation may offer benefits
- Understand under what conditions alternatives to the face-to-face consultation may offer benefits to patients and practitioners in general practice
- Understanding how the findings relate to the conceptual review
- Chapter 6. Collection and analysis of routine consultation data
- Chapter 7. Synthesis and framework for future evaluation
- Chapter 8. Discussion
- Acknowledgements
- References
- Appendix 1. Search strategies used in the conceptual review
- Appendix 2. Matrix template for the conceptual review
- Appendix 3. Conceptual review: list of relevant articles identified in the search
- Appendix 4. Case study guide
- Appendix 5. Topic guides for semistructured interviews
- Appendix 6. Description of the case study practices
- Appendix 7. Staff interview participant characteristics
- Appendix 8. Patient interview participant characteristics
- Appendix 9. Issues related to the recording of consultations in routine general practice computer systems
- Appendix 10. Data collection sheet to assess the reliability of recording of alternative consultation types
- Appendix 11. Clusters of diseases used to create a multimorbidity score
- Appendix 12. Recoding the consultation type in each case study practice
- Appendix 13. Recoding professional type in each case study practice
- Appendix 14. Demographic details of patients by practice
- Appendix 15. Prevalence of conditions in study practices and nationally
- Appendix 16. Prevalence of conditions by practice: patients aged ≥ 18 years
- Appendix 17. Proportion of patients with multimorbidities in different age groups (aged ≥ 18 years)
- Appendix 18. Consultation rates (all practices) by type of consultation and type of professional
- Appendix 19. Rates of different types of consultation by age group, sex, deprivation, ethnicity and multimorbidity
- Appendix 20. Rates of different types of consultation by number of morbidities: natural units and logarithmic scale
- Appendix 21. Consultations and reconsultations with general practitioner only
- Appendix 22. An outline of the structure of the web resource
- List of abbreviations
About the Series
Article history
The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 13/59/08. The contractual start date was in November 2014. The final report began editorial review in February 2017 and was accepted for publication in June 2017. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.
Declared competing interests of authors
Helen Atherton has received fellowship funding from the National Institute for Health Research (NIHR) School for Primary Care Research (SPCR) during the conduct of the study. Chris Salisbury is a member of the NIHR Health Services and Delivery Research board.
Last reviewed: February 2017; Accepted: June 2017.
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