Contextual factors affecting implementation
A range of contextual factors affected which alternatives were implemented and how they were
implemented, often in relation to practice population and geography. Our case studies illustrated extreme examples of this. The introduction of video consulting at the rural practice in Scotland was motivated by the difficulty of reaching a doctor by boat, whereas the use of e-mail consultations at another was partly related to the large student population. However, practice culture was also very important, with some of the case study practices introducing alternatives to the face-to-face consultation because they had a long history of being innovative, and they wanted to be forward-looking. As previously noted, in England, the support provided by theGP Access Fund14was another contextual factor affecting implementation. Some practices had introduced e-consulting systems chosen by their local consortium, without necessarily having thought through how these systems would be used in their practice.
Moderating factors affecting implementation, barriers and facilitators
TheGP Access Fund14also acted as an important facilitator of implementation, providing an impetus to change, financial support and, in some cases, training and support with protocols for provision of a new service. Innovations introduced in this way were more likely to be accompanied by campaigns to raise patient awareness, including messages in the waiting room and in practice websites, although this did not necessarily relate to increased uptake levels.
It was clear that in several practices, introduction was driven by one or two‘innovators’in the practice. This could act as a facilitator of implementation, but could also lead to inconsistency. In some practices, it was evident that practice staff were working in different ways, not necessarily knowing how others were working, and with no formal practice policy on how to apply or use an alternative to the face-to-face consultation.
There were several barriers to implementation. These included a lack of training for practice staff,
particularly receptionists. In some practices, receptionists felt that there was a lack of awareness from both patients and doctors of the complexity of their role. Furthermore, the use of alternatives to the face-to-face consultation had grown organically in most practices without a plan, and new ways of working had not necessarily been implemented in an efficient or organised way.
Structural factors also had a major influence on implementation. The use of video consulting in one practice was constrained by the inconvenience of using the equipment. Many practices experienced problems because of the limitations of their GP computer records systems, which made it difficult to include records of e-mails or e-consultations. Changes in the use of the telephone for consulting sometimes required more telephone lines than were available.
There were also more subtle factors that acted to impede or modify use, and these were related to the impact on professional identity. New ways of working could be perceived as a threat to aspects of work that were seen as fundamental to professional values. For example, a core tenet of general practice is the importance of the doctor–patient relationship, and forms of consulting that are not based on face-to-face contact may have an impact on that relationship. Alternatives to the face-to-face consultation have often been promoted on the basis of quick and convenient access to care, but clinicians in the case studies speculated that this may be seen as being to the detriment of continuity of care (associated with relationships), as well as potentially to the quality and safety of care.
Some forms of alternatives to the face-to-face consultation were associated with changes in professional roles, for example the greater use of nurses to conduct telephone consultations. This was seen positively by some staff, and has the potential to increase staffing capacity, but in other cases was perceived negatively, with some staff (both nurses and doctors) feeling that the nurse’s time might not be used appropriately. One example of how alternatives to the face-to-face consultation were associated with changes to professional roles is a system (not observed in our case studies, but widely reported during our research) in which practices contract with another organisation so that patients have the opportunity to have a telephone or video consultation with a doctor unconnected with the practice, and who does not have access to the patients’records.18,154,155Such developments challenge some of the key principles on which general practice is based, such as the provision of comprehensive, co-ordinated care provided through a single point of contact. However, this approach can improve access and expand the GP workforce by employing doctors working from home who cannot or do not wish to work in routine general practice. Given the scale of these changes, it is not surprising that the implementation of alternatives to the face-to-face consultation is met with resistance from some professional staff, which may have more to do with the implications for their professional values than it is related to the technology itself, and this was highlighted in the conceptual review (seeChapter 2).
Effects on different patient groups
One of the questions of interest for this research was the impact on different groups, including which groups might be most suitable for different forms and the possibility of increasing health inequalities if other groups are unsuitable. The key finding from our study is that, although individual patients’perspectives varied, these could not be predicted based on factors such as age, sex or health status. In addition, there was a recognition that an individual patient’s reasons and ability to use a particular form of consultation may change over time and with experience.
Those who contributed to the stakeholder workshop felt that many of the assumptions about which patients benefit most were challenged by the evidence and, therefore, it would be more appropriate to consider how and when to use alternatives to the face-to-face consultation, rather than with which groups. Some forms have primarily been viewed as a way to respond to requests for quick access to care, but stakeholders felt that the same technologies might be more useful for follow-up and monitoring, rather than for initial assessment.
Although differences between patient groups were fewer than might have been anticipated, some concerns were expressed about the potential to increase health inequalities. This is supported to some extent by the findings reported inChapter 6, that the characteristics of patients using e-consultation (more common in white, affluent, young adults) were in marked contrast to those of patients using telephone or face-to-face consultation. This could be interpreted as providing choice and improving access for people who find conventional forms of access to be inconvenient. However, it could represent inequity, by diverting resources and consultation time to the groups of patients with the fewest health needs. Given the very low number of patients using e-mail or e-consultations, it is important not to overinterpret these findings.