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.

BOX 3

Informal conversation with deputy practice manager

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).

BOX 4

Informal conversation with nurse

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.

BOX 5

Observation of a receptionist

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).

BOX 6

Observation of an informal practice meeting

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).

BOX 7

Observation of a GP

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):

BOX 8

Informal conversation with GP2

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.