Alternatives to the face-to-face consultation in general practice; focused ethnographic case study

Abstract
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 general practices 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 to the face-to-face consultation.
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 in eight UK general practices.
Method
Non-participant observation, informal conversations with staff, semi-structured interviews with staff and patients. 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 email with patients were not known about or followed. Patients reported benefits including convenience and access. Staff and some patients regarded the face-to-face 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.

Keywords
Remote consultation, Family Practice, general practice, electronic mail, telemedicine, focussed ethnography, qualitative research, workload, communication, telephone, internet

How this fits in
• What was previously known: enthusiasts have led the introduction of alternatives to the face-to-face consultation in general practice though uptake has been patchy and practices have concerns about being inundated by patients. Patients like them and find them convenient.
• What our research adds: by conducting observations as well as interviews with all staff groups and patients who have used an alternative to the face-to-face consultation we have obtained insights into the varied rationale for their introduction and expanded the evidence on how they work in practices with recent experience of trying to implement them.
• Relevance to clinicians: there is an expectation that practices will ‘go digital’ to help manage demand and we suggest that any decision should be a considered one, in particular thinking about the rationale for introduction, what the practice hopes to gain, and whether there is evidence that alternative consultation forms will achieve these aims.