The potential of alternatives to face-to-face consultation in general practice, and the impact on different patient groups: a mixed-methods case study

Background: There is international interest in the potential role of different forms of communicationtechnology to provide an alternative to face-to-face consultations in health care. There has beenconsiderable rhetoric about the need for general practices to offer consultations by telephone, e-mail orinternet video. However, little is understood about how, under what conditions, for which patients and inwhat 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 practicecontext, patient characteristics, type of technology and the purpose of the consultation interact to determinethe impact of these alternatives; and synthesise the findings in order to develop a website resource about theimplementation 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 toface-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 theface-to-face consultation; the rationale for practices to introduce alternatives; the use of different forms ofconsultation by different patient groups; and the intended benefits/outcomes.Review methods: The conceptual review used an approach informed by realist review, a method forsynthesising research evidence regarding complex interventions.Results: Alternatives to the face-to-face consultation are not in mainstream use in general practice, withlow uptake in our case study practices. We identified the underlying rationales for the use of thesealternatives and have shown that different stakeholders have different perspectives on what they hope toachieve through the use of alternatives to the face-to-face consultation. Through the observation of real-lifeuse of different forms of alternative, we have a clearer understanding of how, under what circumstancesand for which patients alternatives might have a range of intended benefits and potential unintendedadverse 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 researchparticipants might be deemed to be early adopters. The case study approach provides an in-depthexamination of a small number of sites, each using alternatives in different ways. The findings aretherefore hypothesis-generating, rather than hypothesis-testing.Conclusions: The current low uptake of alternatives, lack of clarity about purpose and limited evidence ofbenefit may be at odds with current policy, which encourages the use of alternatives. We have highlightedkey issues for practices and policy-makers to consider and have made recommendations about priorities forfurther research to be conducted, before or alongside the future roll-out of alternatives to the face-to-faceconsultation, such as telephone consulting, e-consultation, e-mail and video consulting.Future work: We have synthesised our findings to develop a framework and recommendations aboutfuture evaluation of the use of alternatives to face-to-face consultations.Funding details: The National Institute for Health Research Health Services and DeliveryResearch programme.ABSTRACTNIH

Receptionists' role in new approaches to consultations in primary care: A focused ethnographic study

© British Journal of General Practice. Background The receptionist is pivotal to the smooth running of general practice in the UK, communicating with patients and booking appointments. Aim The authors aimed to explore the role of the receptionist in the implementation of new approaches to consultations in primary care. Design and setting The authors conducted a team-based focused ethnography. Three researchers observed eight general practices across England and Scotland between June 2015 and May 2016. Method Interviews were conducted with 39 patients and 45 staff in the practices, all of which had adopted one or more methods (telephone, email, e-consultation, or internet video) for providing an alternative to face-to-face consultation. Results Receptionists have a key role in facilitating patient awareness regarding new approaches to consultations in primary care, while at the same time ensuring that patients receive a consultation appropriate to their needs. In this study, receptionists' involvement in implementation and planning for the introduction of alternative approaches to faceto-face consultations was minimal, despite the expectation that they would be involved in delivery. Conclusion A shared understanding within practices of the potential difficulties and extra work that might ensue for reception staff was lacking. This might contribute to the low uptake by patients of potentially important innovations in service delivery. Involvement of the wider practice team in planning and piloting changes, supporting team members through service reconfiguration, and providing an opportunity to discuss and contribute to modifications of any new system would ensure that reception staff are suitably prepared to support the introduction of a new approach to consultations

Alternatives to the face-to-face consultation in general practice: Focused ethnographic case study

© British Journal of General Practice. Background NHS policy encourages general practices to introduce alternatives to the face-to-face consultation, such as telephone, email, e-consultation systems, or internet video. Most have been slow to adopt these, citing concerns about workload. This project builds on previous research by focusing on the experiences of patients and practitioners who have used one or more of these alternatives. Aim To understand how, under what conditions, for which patients, and in what ways, alternatives to face-to-face consultations present benefits and challenges to patients and practitioners in general practice. Design and setting Focused ethnographic case studies took place in eight UK general practices between June 2015 and March 2016. Method Non-participant observation, informal conversations with staff, and semi-structured interviews with staff and patients were conducted. Practice documents and protocols were reviewed. Data were analysed through charting and the 'one sheet of paper' mind-map method to identify the line of argument in each thematic report. Results Case study practices had different rationales for offering alternatives to the face-to-face consultation. Beliefs varied about which patients and health issues were suitable. Co-workers were often unaware of each other's practice; for example, practice policies for use of e-consultations systems with patients were not known about or followed. Patients reported benefits including convenience and access. Staff and some patients regarded the face-toface consultation as the ideal. Conclusion Experience of implementing alternatives to the face-to-face consultation suggests that changes in patient access and staff workload may be both modest and gradual. Practices planning to implement them should consider carefully their reasons for doing so and involve the whole practice team

Ethnographic investigation of the impact of type 2 diabetes among Indian and Pakistani migrants

This thesis explores the impact of type 2 diabetes among Indian and Pakistani migrants. Indians and Pakistanis living in the UK have a high incidence of type 2 diabetes and associated complications. Research is needed in order to understand factors that make it difficult to adhere to lifestyle advice about diet, exercise and medication. Drawing on data collected during a sixteen-month ethnographic investigation, this thesis explores Indians’ and Pakistanis’ perceptions of diabetes. The research revealed that Indians and Pakistanis related the onset of diabetes to processes of migration and settling in the UK as well as to stress and depression. In particular, holding on to negative thoughts and worries, were perceived by respondents as directly affecting the body by causing stress, depression and eventually illness. Struggles over diabetes control were also perceived as to cause distress. Specifically, respondents struggled to adhere to a healthy diet regime, since food, especially taste, played a crucial role in forming, reinforcing and demarcating social relations and in ensuring cultural continuity. In addition, respondents struggled to ‘adhere’ to their prescriptions of diabetes medications due to the uncomfortable side effects that they experienced, particularly in the stomach. Respondents, however, counteracted side effects by turning to alternative medications which were perceived to facilitate flow within the circulatory and digestive system. Thus, in spite of the difficulties that Indians and Pakistanis experienced in following biomedical recommendations for diabetes control, they still actively engaged in searching and using different treatments available to them in order to control the disease