Clinical risk in remote consultations in general practice: findings from in-COVID-19 pandemic qualitative research

Rosen, Rebecca; Wieringa, Sietse; Greenhalgh, Trisha; Leone, Cláudia; Rybczynska-Bunt, Sarah; Hughes, Gemma; Moore, Lucy; Shaw, Sara; Wherton, Joseph; Byng, Richard

doi:10.3399/bjgpo.2021.0204

Cited by 44 publications

(48 citation statements)

References 14 publications

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“…These simplistic, polarised narratives around modes of consulting were not helped by a commodification of clinical care (patients were depicted as customers who had a right to see the GP in person). The reality of clinical diagnosis and management is, of course, far more nuanced, with multiple interacting influences contributing to safe and effective clinical care and the balancing of good care and patient satisfaction (4,21,22).…”

Section: Discussionmentioning

confidence: 99%

UK newspapers ‘on the warpath’: media analysis of general practice remote consulting in 2021

2022

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Background: Following a large-scale, pandemic-driven shift to remote consulting in UK general practice in 2020, 2021 saw a partial return to in-person consultations. This occurred in the context of extreme workload pressures due to backlogs, staff shortages and task shifting. Aim: To study media depictions of remote consultations in UK general practice at a time of system stress. Design and Setting: Thematic analysis of national newspaper articles about remote GP consultations from two time periods: 13–26 May 2021, following an NHS England letter, and 14–27 Oct 2021, following a government-backed directive, both stipulating a return to in-person consulting. Method: Articles were identified through, and retrieved from, LexisNexis. A coding system of themes and narrative devices was developed iteratively to inform data analysis. Results: 25 articles reported on the letter and 75 on the directive. Newspaper coverage of remote consulting was strikingly negative. The right-leaning press in particular praised the return to in-person consultations, depicting remote care as creating access barriers and compromising safety. Two newspapers led national campaigns pressuring the government to require GPs to offer in-person consultations. GPs were quoted as reluctant to return to an “in-person by default” service (as it would further pressurise a system already close to breaking point). Conclusion: Remote consultations have become associated in the media with poor practice. Some newspapers were actively leading the “war” on general practice rather than merely reporting on it. Proactive dialogue between practitioners and the media might help minimise polarisation and improve perceptions around general practice.

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Section: Discussionmentioning

confidence: 99%

UK newspapers ‘on the warpath’: media analysis of general practice remote consulting in 2021

2022

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“…Whilst our own in-pandemic research found examples of high-quality remote care [8][9][10] , we affirmed these concerns and identified six new kinds of risk: a) practice organisation and set-up (digital inequities which restricted access, technologies that were unreliable and unfit for purpose, and reduced service efficiency); b) communication and the therapeutic relationship (a shift to more transactional consultations); c) quality of clinical care (including missed diagnoses, safeguarding challenges, over-investigation and over-treatment); d) increased burden on the patient (e.g. to self-examine and navigate between services); e) fewer opportunities for screening and managing the social determinants of health; and f) adverse impact on workforce (clinician and staff stress and compromised learning) 21,22 .…”

Section: Remote General Practice During the Pandemicmentioning

confidence: 99%

“…Remote care may compromise the therapeutic relationship and continuity of care 19,20 , lead to more transactional forms of clinical interaction 22 , fewer ' doorknob consultations' 15 , and delayed diagnosis of serious illness 75,76 ; it may be unsuitable for those with complex needs [20][21][22] . Remote reviews may be convenient and safe for patients with stable long-term conditions 77 .…”

Section: Quality and Safety Of Carementioning

confidence: 99%

Protocol: Remote care as the ‘new normal’? Multi-site case study in UK general practice

et al. 2022

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Background: Following a pandemic-driven shift to remote service provision, UK general practices offer telephone, video or online consultation options alongside face-to-face. This study explores practices’ varied experiences over time as they seek to establish remote forms of accessing and delivering care. Methods: This protocol is for a mixed-methods multi-site case study with co-design and national stakeholder engagement. 11 general practices were selected for diversity in geographical location, size, demographics, ethos, and digital maturity. Each practice has a researcher-in-residence whose role is to become familiar with its context and activity, follow it longitudinally for two years using interviews, public-domain documents and ethnography, and support improvement efforts. Research team members meet regularly to compare and contrast across cases. Practice staff are invited to join online learning events. Patient representatives work locally within their practice patient involvement groups as well as joining an online patient learning set or linking via a non-digital buddy system. NHS Research Ethics Approval has been granted. Governance includes a diverse independent advisory group with lay chair. We also have policy in-reach (national stakeholders sit on our advisory group) and outreach (research team members sit on national policy working groups). Results (anticipated): We expect to produce rich narratives of contingent change over time, addressing cross-cutting themes including access, triage and capacity; digital and wider inequities; quality and safety of care (e.g. continuity, long-term condition management, timely diagnosis, complex needs); workforce and staff wellbeing (including non-clinical staff, students and trainees); technologies and digital infrastructure; patient perspectives; and sustainability (e.g. carbon footprint). Conclusion: By using case study methods focusing on depth and detail, we hope to explain why digital solutions that work well in one practice do not work at all in another. We plan to inform policy and service development through inter-sectoral network-building, stakeholder workshops and topic-focused policy briefings.

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“…A government policy of 'remote-by-default' care introduced in July 2021 10 was reversed a few months later 11 because it was unpopular with patients and concerns had emerged about quality and safety (e.g. missed diagnoses, safeguarding challenges, over-investigation, over-treatment, and threats to the therapeutic relationship), digital inequalities, increased burden on the patient, and increased staff workload and stress 12,13 .…”

Section: Introductionmentioning

confidence: 99%

Remote care in UK general practice: baseline data on 11 case studies

et al. 2022

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Background: Accessing and receiving care remotely (by telephone, video or online) became the default option during the coronavirus disease 2019 (COVID-19) pandemic, but in-person care has unique benefits in some circumstances. We are studying UK general practices as they try to balance remote and in-person care, with recurrent waves of COVID-19 and various post-pandemic backlogs. Methods: Mixed-methods (mostly qualitative) case study across 11 general practices. Researchers-in-residence have built relationships with practices and become familiar with their contexts and activities; they are following their progress for two years via staff and patient interviews, documents and ethnography, and supporting improvement efforts through co-design. In this paper, we report baseline data. Results: Reflecting our maximum-variety sampling strategy, the 11 practices vary in size, setting, ethos, staffing, population demographics and digital maturity, but share common contextual features—notably system-level stressors such as high workload and staff shortages, and UK’s technical and regulatory infrastructure. We have identified both commonalities and differences between practices in terms of how they: 1] manage the ‘digital front door’ (access and triage) and balance demand and capacity; 2] strive for high standards of quality and safety; 3] ensure digital inclusion and mitigate wider inequalities; 4] support and train their staff (clinical and non-clinical), students and trainees; 5] select, install, pilot and use technologies and the digital infrastructure which support them; and 6] involve patients in their improvement efforts. Conclusions: General practices’ responses to pandemic-induced disruptive innovation appear unique and situated. We anticipate that by focusing on depth and detail, this longitudinal study will throw light on why a solution that works well in one practice does not work at all in another. As the study unfolds, we will explore how practices achieve timely diagnosis of urgent or serious illness and manage continuity of care, long-term conditions and complex needs.

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Clinical risk in remote consultations in general practice: findings from in-COVID-19 pandemic qualitative research

Cited by 44 publications

References 14 publications

UK newspapers ‘on the warpath’: media analysis of general practice remote consulting in 2021

UK newspapers ‘on the warpath’: media analysis of general practice remote consulting in 2021

Protocol: Remote care as the ‘new normal’? Multi-site case study in UK general practice

Remote care in UK general practice: baseline data on 11 case studies

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