The potential of alternatives to face to face consultation in general practice, and the impact on different patient groups
There is international interest in the potential role of alternatives to the face-to-face consultation in primary healthcare, with several countries routinely offering these. In the UK there has been considerable rhetoric from policymakers about the potential for consultations conducted by telephone, email or internet video to alleviate staff workload and improve patient access. Despite this pressure, most general practices have been slow to adopt alternatives to the face-to-face consultation, citing concerns about their potential impact, particularly on workload. There is little evidence to support either the concerns of practices or the assumptions of policymakers. The aim of this research is to understand how, under what conditions, for which patients, and in what ways, alternatives to face-to-face consultations such as use of the telephone, email or Internet video may offer benefits and challenges to patients and practitioners in general practice.
We conducted focused ethnographic case studies in eight general practices in England and Scotland, each with different experiences of implementing alternatives to face-to-face consultations. Data were gathered through non-participant observation, informal conversations and semi-structured interviews with practice administration staff, general practitioners and patients. Practice documents and protocols on alternatives to the face-to-face consultations were reviewed. Data were compared and analysed through charting and the ‘one sheet of paper’ mind-map method to identify the line of argument in each report, as well as outliers or negative cases.
We identified the underlying rationales for use of alternatives to the face-to-face consultation, showing that different stakeholders have different perspectives of what they hope to achieve. The role of reception staff and administrators was key in ensuring that new consultation methods were taken up by patients, as was organisation within the practice. Both healthcare professionals and patients agreed that there were certain conditions or issues that would require a face-to-face consultation. For both patients and staff there were times when alternatives to the face-to-face consultation represented a ‘second best’ and this was particularly the case with telephone consultation, which, amongst the alternatives we examined, was used most frequently and was universally well-integrated within the practices.
The current low uptake of alternatives, lack of clarity about purpose and limited evidence of benefit may influence their uptake on a wider scale. We have been able to highlight key issues for practices and policy makers to consider, and along with the results from our wider study, develop a web resource aimed at general practitioners, practice staff and commissioners who are considering implementing an alternative to the face-to-face consultation. We have developed a framework for future evaluation to be conducted before or alongside future roll-out of alternatives to face-to-face consultation such as telephone consulting, e-consultation, email and video consulting.