Planning and Evaluating Remote Consultation Services: A New Conceptual Framework Incorporating Complexity and Practical Ethics

In the paper

“Two prominent themes in our data were organizations' digital maturity in providing remote consultations and the need for proactive measures to improve digital inclusion.”

In the paper

“There were tensions, for example, between quality and efficiency, between demand management and patient choice, and between the needs and preferences of some patients and those of other patients in the context of limited staffing and material constraints (e.g., availability of safe waiting areas which limited face-to-face appointments during the pandemic).”

In the paper

“The only available space for one (female) GP to consult from was the kitchen table, necessitating complex negotiations with other family members about access to the food supply.”

In the paper

“They talked about the need to be alert to the possibility of the “doorknob phenomenon” —that people sometimes seek a consultation for one reason but bring in the real reason late in the encounter, hence withholding key information at the triage stage.”

In the paper

“We have found that both during and beyond the pandemic, policymakers envisaged an efficient, safe and accessible remote consultation service delivered through state-of-the art digital technologies and implemented via rational allocation criteria and quality standards.”

• Also stated in: § Developing the Guiding Principles · hedged

  “Evidence from policy announcements and our elite policymaker interviews revealed a relatively confident vision of an efficient, safe and accessible remote consultation service delivered mostly through state-of-the art digital technologies and implemented via rational allocation criteria and quality standards.”

In the paper

“- Access to care, especially patients' difficulty getting the kind of appointment they wished and conflict with support staff associated with this;”

In the paper

“An initial plan to analyse quantitative data statistically was abandoned when it became clear that presenting our draft principles in deliberately contradictory pairs had led to confusion and irritation (which we discuss briefly in the Findings section).”

In the paper

“Clinicians described over-riding such systems (for example when triaging e-consultations) because they had a gut feeling that a seemingly minor aspect of the history could indicate serious illness (45) or because they had safety-netting concerns that a particular patient should be checked more frequently than the recommended interval.”

What the sources say

• Not checked yetcites [45] Smith, 2020, Understanding the role of GPs' gut feelings in diagnosing cancer in primary care: a systematic review and meta-analysis of existing evidence, Br J Gen Pract. source

In the paper

“Many staff—rightly or wrongly—still considered face-to-face consulting to be the “gold standard” professional norm:”

In the paper

“During the pandemic, some locality-based clinical commissioning groups became tied into commercial contracts with video software providers whose products were approved at speed at the height of the crisis and offered “free” or low-cost for the first year.”

In the paper

“Several examples from our dataset illustrated the subtleties of the reason for consulting and why rigid algorithms or allocation criteria may prove too brittle to guide practice.”

In the paper

“One GP expressed concern that a patient was consulting from the lavatory because this was the only quiet and private space available. Another described connecting to a teenager's bedroom where a parent may have been present but off camera.”

In the paper

“Learning from models of good practice elsewhere tended to be a positive experience, whereas public release of performance data—in which each organization or department is compared competitively with others (for example in the proportion of consultations undertaken remotely)—was viewed negatively by our participants.”

In the paper

“This had been our intention, but it was clear that whilst clinicians work comfortably with contradictory principles in their day to day work, they experienced strong cognitive dissonance when asked to confront them in a desktop exercise without a real, practical situation in mind.”

In the paper

“Additional ethical tensions related to staff well-being and redistribution of the work of caring (often shifting to the patient or lay carer).”

In the paper

“Our interviewees depicted these changes positively—indeed, they considered that the changes would have been impossible or much delayed without them—but they also expressed concern about what would happen when organizations returned to business as usual, since the longer-term trade-offs between convenience and regulatory control (e.g., data privacy) are unclear.”

In the paper

“However, our dataset included numerous examples of capacity constraints which limited organizations' abilities to undertake co-design work, provide a high degree of flexibility or provide sufficient face-to-face slots to accommodate all requests.”

In the paper

“The theme of digital inclusion recurred in our data.”

In the paper

“Examples of digital inclusion efforts in our dataset included flexibility to accommodate patient preferences (some teenagers, for example, preferred to consult with the video switched off; some parents preferred to video their child doing a task and send the video to the therapist rather than the child perform live to camera), signposting to local digital literacy programmes, and making it clear”

In the paper

“All but one of the 25 revised principles in round 2 were supported in principle by 80% or more respondents, but many had suggestions for changes in wording (e.g., be less paternalistic, reduce jargon, split a maxim into two).”

In the paper

“All but one of the 26 revised principles in round 3 were supported by 80% or more participants with only minor suggestions for further revisions to wording; the final item was supported by 71%, with several respondents all suggesting omission of a particular phrase.”

In the paper

“In contrast, our empirical data revealed that strategic decisions about setting up remote consultation services, allocation decisions for appointment type (phone, video, e-, face-to-face), and clinical decisions when consulting remotely were fraught with contradictions and tensions, leading to both large- and small-scale ethical dilemmas that were either unique to the remote modality or greatly”

In the paper

“Establishing and running remote consultation services is challenging politically (interest groups may gain or lose), organizationally (remote consulting requires implementation work and new roles and workflows), economically (costs and benefits are unevenly distributed across the system), technically (excellent care needs dependable links and high-quality audio and images)”

In the paper

“Clinical allocation criteria, perhaps built into algorithms, may suggest (though not determine) a type of appointment.”

In the paper

“Costs of technologies are typically unevenly distributed across the healthcare system.”

In the paper

“On 30th July 2020, it was announced that all healthcare consultations in the UK should henceforth be “remote by default,” not just during the pandemic but indefinitely (1).”

What the sources say

• Not checked yetcites [1] Hancock, 2020

In the paper

“As Hunter (39) has argued, clinical decisions are governed not by hard and fast rules but by shared rules of thumb or guiding principles which she calls maxims, some of which are contradictory (e.g., “ignore the anecdotal” but “listen to the patient's story”).”

What the sources say

• Not checked yetcites [39] Hunter, 1996, “Don't think zebras”: uncertainty, interpretation, and the place of paradox in clinical education, Theor Med. source

In the paper

“Whilst Hunter focused narrowly on clinical maxims, case-based ethical reasoning more broadly—whether, for example, to invoke child protection measures or ask a social prescriber to get involved in someone's life—operates along similar lines.”

In the paper

“The situational application of such guiding principles has an important time dimension.”

In the paper

“Importantly, both NASSS and the adaptation described here (PERCS) are explanatory frameworks to guide a holistic interpretation of a complex and evolving phenomenon. They do not offer predictive certainty and are not intended to be applied formulaically.”

In the paper

“Maxims, which tend to be passed on orally from more to less experienced practitioners, encapsulate shared understanding and wisdom; they suggest a potential way forward but are high-level enough to be flexibly applied.”

What the sources say

• Not checked yetcites [39] Hunter, 1996, “Don't think zebras”: uncertainty, interpretation, and the place of paradox in clinical education, Theor Med. source

In the paper

“To develop and refine some ethical principles to guide application of the PERCS framework, we used the Delphi method—a well-established semi-structured approach to working toward consensus among experts (41).”

What the sources say

• Not checked yetcites [41] Boulkedid, 2011, Using and reporting the Delphi method for selecting healthcare quality indicators: a systematic review, PLoS ONE. source

In the paper

“With time, one constellation of symptoms, signs, and contextual influences will evolve to a subtly different constellation, generating clues as to the nature of the illness and its likely regression or further progression.”

In the paper

“Some software products (e.g., accuRx) potentially allow the clinician to instantly convert a phone consultation to video in real time, thus avoiding double-handling, but products which lack this functionality require a new appointment.”

In the paper

“Telephone advice services, underpinned by advanced computer decision support systems, can be costly to set up and maintain and require new work skills to operate (32); their introduction may generate supply-induced demand (53).”

What the sources say

• Not checked yetcites [32] Turnbull, 2014, The work, workforce, technology and organisational implications of the ‘111' single point of access telephone number for urgent (non-emergency) care: a mixed-methods case study, Health Serv Delivery Res. source
• Not checked yetcites [53] Pope, 2017, Has the NHS 111 urgent care telephone service been a success? Case study and secondary data analysis in England, BMJ Open. source

In the paper

“More prosaically, consulting behavior patterns previously learnt in the context of the clinic must now be transposed to the home space, which may produce dissonance, as the following quote illustrates:”

In the paper

“All these factors may help explain why the patient seeks a particular mode of consultation—and also why a clinician or support staff member may decide that it is in the patient's best interests (or not) to be seen face-to-face, as the following quote illustrates:”

In the paper

“We recruited and obtained emailed consent from an initial sample of 69, though 19 of these did not attempt any items (mostly because they found the exercise too difficult).”

In the paper

“Telephone, for example, has less functionality video but is more dependable and familiar.”

In the paper

“Some reasons for consulting are clinician- or system-driven (e.g., invitations for screening or long-term condition monitoring).”

In the paper

“Advantages of this method include practicality (it can be done online, asynchronously, without specialist tools), anonymity (participants know the average group score but not individuals' scores), and iteration (through feedback, outliers are prompted to either defend their response to the group or change it) (42, 43).”

What the sources say

• Not checked yetcites [42] Khodyakov, 2020, Response changes in Delphi processes: why is it important to provide high-quality feedback to delphi participants?, J Clin Epidemiol source
• Not checked yetcites [43] Belton, 2019, Improving the practical application of the Delphi method in group-based judgment: a six-step prescription for a well-founded and defensible process, Technol Forecast Soc Change. source

In the paper

“Maxims and other high-level guiding principles require an understanding of the circumstances in which the rule should be applied rather than formulaic replication.”

In the paper

“Arguments against remote forms of care tended to be patient-focused, highlighting possible disbenefits such digital exclusion.”

In the paper

“Staff attitudes are grounded in professional norms and values including deeply-held concerns about quality and safety of care.”

In the paper

“The NASSS framework has been widely used across a range of settings for evaluating and explaining the fortunes of various kinds of health technology projects [see for example (18–20)] and draws on complexity theory (21).”

What the sources say

• Not checked yetcites [18] Greenhalgh, 2018, Analysing the role of complexity in explaining the fortunes of technology programmes: empirical application of the NASSS framework, BMC Med. source
• Not checked yetcites [19] Abimbola, 2019, The NASSS framework for ex post theorisation of technology-supported change in healthcare: worked example of the TORPEDO programme, BMC Med. source
• Not checked yetcites [20] Dyb, 2021, Adopt, adapt, or abandon technology-supported person-centred care initiatives: healthcare providers' beliefs matter, BMC Health Serv Res. source
• Not checked yetcites [21] Greenhalgh, 2018, Studying complexity in health services research: desperately seeking an overdue paradigm shift, BioMed source

In the paper

“NASSS explores the dynamic interaction between multiple domains (the technology, the people and so on) in a complex system and how these domains and their interdependencies have evolved—and are likely to evolve further—over time.”

What the sources say

• Not checked yetcites [17] Greenhalgh, 2017, Beyond adoption: a new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies, J Med Internet Res. source
• Not checked yetcites [21] Greenhalgh, 2018, Studying complexity in health services research: desperately seeking an overdue paradigm shift, BioMed source

In the paper

“Many of these challenges have an under-examined ethical dimension.”

In the paper

“Digital inclusion is high on the policy agenda in the UK and elsewhere (79, 80).”

What the sources say

• Not checked yetcites [79] 2020
• Not checked yetcites [80] NHS, 2020

In the paper

“These themes resonated with writing by feminist philosophers (89–92) on the ethics of care, including the hidden work and emotional labor of low-status workers such as receptionists and unpaid carers.”

What the sources say

• Not checked yetcites [89] Tronto, 1993
• Not checked yetcites [90] Fisher, 1990, Toward a feminist theory of caring
• Not checked yetcites [91] Held, 2006
• Not checked yetcites [92] Pols, 2015, Towards an empirical ethics in care: Relations with technologies in health care, Med Health Care Philos. source

In the paper

“Burden of treatment also includes the effort needed from the patient to access services (31, 93), which technologies (especially e-consultations) could potentially alleviate.”

What the sources say

• Not checked yetcites [31] Turnbull, 2019, A conceptual model of urgent care sense-making and help-seeking: a qualitative interview study of urgent care users in England, BMC Health Serv Res. source
• Not checked yetcites [93] May, 2014, Rethinking the patient: using Burden of Treatment Theory to understand the changing dynamics of illness, BMC Health Serv Res. source

In the paper

“Infrastructure also includes human elements (e.g., organizational roles, routines, and relationships), shared understandings and historical path-dependencies (such as legacy technologies and commercial contracts), and the regulatory and professional standards noted above (27, 37).”

What the sources say

• Not checked yetcites [27] Greenhalgh, 2019, Infrastructure revisited: an ethnographic case study of how health information infrastructure shapes and constrains technological innovation, J Med Internet Res. source
• Not checked yetcites [37] Star, 1999, The ethnography of infrastructure, Am Behav Sci. source

In the paper

“A related concept is what May et al. (93) have called burden of treatment—the additional burden placed on the patient when they are asked to “self-manage” —with the sickest and most vulnerable carrying the greatest burden.”

What the sources say

• Not checked yetcites [93] May, 2014, Rethinking the patient: using Burden of Treatment Theory to understand the changing dynamics of illness, BMC Health Serv Res. source

In the paper

“The evidence base for achieving greener health services by means of remote care is limited and contested, but one study suggests that a substantial reduction in carbon footprint could be made (66).”

What the sources say

• Not checked yetcites [66] Holmner, 2014, Carbon footprint of telemedicine solutions-unexplored opportunity for reducing carbon emissions in the health sector, PLoS ONE. source

In the paper

“Pols (92) has developed what she calls an empirical ethics of [technology-supported] care which considers technologies not as inanimate tools which make the clinical interaction more or less efficient (and as “cold” artifacts that contrast with “warm” human care) but as relational actors which, if creatively selected and “tinkered with” to fit specific situations, can enhance and support the”

What the sources say

• Not checked yetcites [92] Pols, 2015, Towards an empirical ethics in care: Relations with technologies in health care, Med Health Care Philos. source

In the paper

“Innovative organizations tend to be large, competently led and with clear strategic vision, functionally differentiated, non-hierarchical and with adequate slack (people and resources that can be channeled into new projects to get them up and running).”

What the sources say

• Not checked yetcites [62] Greenhalgh, 2004, Diffusion of innovations in service organizations: systematic review and recommendations, Milbank Q. source

In the paper

“As Gkeredakis et al. (4) have pointed out, during the pandemic a sense of urgency, relaxing of regulations and policy investment in technological solutions produced many new technological components but there was not time to strengthen either technical or human infrastructure, yet successful embedding and use of these novel solutions will be “contingent upon the openness, distributedness, recombin”

What the sources say

• Not checked yetcites Gkeredakis et al. (4) Gkeredakis, 2021, Crisis as opportunity, disruption and exposure: exploring emergent responses to crisis through digital technology, Inform Organ. source

In the paper

“Tudor Hart's (71) inverse care law states that people most in need of health care are least likely to seek it or receive it; the law reflects two mutually-reinforcing phenomena—worse health in deprived localities and barriers to accessing healthcare in those same localities (47, 48, 72, 73).”

What the sources say

• Not checked yetcites [71] Hart, 1971, The inverse care law, Lancet. source
• Not checked yetcites [47] Jansen, 2020, Socioeconomic inequalities in out-of-hours primary care use: an electronic health records linkage study, Eur J Public Health. source
• Not checked yetcites [48] Marmot, 2018, An inverse care law for our time, BMJ. source
• Not checked yetcites [72] Mercer, 2012, Multimorbidity and the inverse care law in primary care, BMJ. source
• Not checked yetcites [73] Rolewicz, 2020, Are the needs of people with multiple long-term conditions being met? Evidence from the 2018 General Practice Patient Survey, BMJ Open. source

In the paper

“NHS England, for example, recently announced a vision for a “net zero [carbon] NHS,” including a major contribution of new modalities for delivering care (65).”

What the sources say

• Not checked yetcites [65] NHS, 2021

In the paper

“Held's taxonomy (91) divides the ethics of care into personal (focusing on an individual's commitment and accountability to the person they are caring for), political (focusing on various kinds of inequality in caring—such as fairness, human rights, and inclusivity) and global (caring for the planet and its sustainability—and hence caring for future generations).”

What the sources say

• Not checked yetcites [91] Held, 2006

In the paper

“Beauchamp and Childress (87) later added four further principles based on behavioral norms—veracity (tell the truth), privacy (ensure no intruders or eavesdroppers), confidentiality, and fidelity (avoid conflicts of interest such as the potential for personal profit).”

What the sources say

• Not checked yetcites [87] Beauchamp, 2019, Principles of biomedical ethics: marking its fortieth anniversary, Am J Bioethics source

In the paper

“Normalization includes supporting staff to make sense of the new technology in the context of their work; engaging them to participate; coordinating their implementation efforts; and monitoring benefits and costs (23).”

What the sources say

• Not checked yetcites [23] May, 2009, Development of a theory of implementation and integration: normalization process theory, Implement Sci. source

In the paper

“These principles were originally proposed by Beauchamp (who leant toward a consequentialist or utilitarian position, focusing on outcomes of decisions for the patient and others) and Childress (a deontologist focusing more on the clinician's duties) (85), and extended to consider scope of application by Gillon (86).”

What the sources say

• Not checked yetcites [85] Beauchamp, 1979
• Not checked yetcites [86] Gillon, 1994, Medical ethics: four principles plus attention to scope, BMJ. source

In the paper

“These barriers are part of a wider digital shift whereby many aspects of life—insurance, banking, local government, education, travel, and holidays, and many more—are increasingly presented to the citizen, client or customer as “digital first,” thereby excluding (partially or wholly) those unable to access them in this way (75).”

What the sources say

• Not checked yetcites [75] Schou, 2019, Digital by default? A qualitative study of exclusion in digitalised welfare, Soc Policy Administr. source

In the paper

“whilst we obtained research ethics approval to video and audiotape clinical consultations, this aspect of the work has so far proved impossible in practice”

In the paper

“Overall, patients randomized to video did no worse clinically and were no less satisfied than those randomized to usual care, and that costs (where measured) were similar”

What the sources say

• Not checked yetcites [109] Chongmelaxme, 2019, The effects of telemedicine on asthma control and patients' quality of life in adults: a systematic review and meta-analysis, J Allergy Clin Immunol Pract. source
• Not checked yetcites [110] Gentry, 2019, Geriatric telepsychiatry: systematic review and policy considerations, Am J Geriatr Psychiatry. source
• Not checked yetcites [111] Hong, 2019, Effectiveness of tele-monitoring by patient severity and intervention type in chronic obstructive pulmonary disease patients: a systematic review and meta-analysis, Int J Nurs Stud. source
• Not checked yetcites [112] Kelson, 2019, Internet-delivered acceptance and commitment therapy for anxiety treatment: systematic review, J Med Internet Res. source
• Not checked yetcites [113] McFarland, 2019, The effect of telehealth versus usual care for home-care patients with long-term conditions: a systematic review, meta-analysis and qualitative synthesis, J Telemed Telecare. source
• Not checked yetcites [114] Thiyagarajan, 2020, Exploring patients' and clinicians' experiences of video consultations in primary care: a systematic scoping review, BJGP Open. source

In the paper

“The few detailed real-world studies in the literature suggest that efforts to implement remote consultation services even without an ongoing pandemic are logistically complex, resource-intensive and often stymied by technical and regulatory challenges (18, 26, 27, 115, 117, 118)”

What the sources say

• Not checked yetcites [18] Greenhalgh, 2018, Analysing the role of complexity in explaining the fortunes of technology programmes: empirical application of the NASSS framework, BMC Med. source
• Not checked yetcites [26] Greenhalgh, 2018, Real-world implementation of video outpatient consultations at macro, meso, and micro levels: mixed-method study, J Med Internet Res. source
• Not checked yetcites [27] Greenhalgh, 2019, Infrastructure revisited: an ethnographic case study of how health information infrastructure shapes and constrains technological innovation, J Med Internet Res. source
• Not checked yetcites [115] Donaghy, 2019, Acceptability, benefits, and challenges of video consulting: a qualitative study in primary care, Br J Gen Pract. source
• Not checked yetcites [117] Odendaal, 2020, Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis, Cochrane Database Syst Rev source
• Not checked yetcites [118] Wherton, 2020, Guidance on the introduction and use of video consultations during COVID-19: important lessons from qualitative research, BMJ Leader. source

In the paper

“several studies have suggested that double-handling may reduce efficiency (32, 98–102)”

What the sources say

• Not checked yetcites [32] Turnbull, 2014, The work, workforce, technology and organisational implications of the ‘111' single point of access telephone number for urgent (non-emergency) care: a mixed-methods case study, Health Serv Delivery Res. source
• Not checked yetcites [98] Thompson-Coon, 2013, Telephone consultations in place of face to face out-patient consultations for patients discharged from hospital following surgery: a systematic review, BMC Health Serv Res. source
• Not checked yetcites [99] Downes, 2017, Telephone consultations for general practice: a systematic review, Syst Rev. source
• Not checked yetcites [100] Campbell, 2014, Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost–consequence analysis, Lancet J. source
• Not checked yetcites [101] Newbould, 2019, A ‘telephone first' approach to demand management in English general practice: a multimethod evaluation, Health Serv Deliv Res. source
• Not checked yetcites [102] Salisbury, 2020, The impact of digital-first consultations on workload in general practice: modeling study, J Med Internet Res. source

In the paper

“almost all primary studies were underpowered and had highly-selected samples”

What the sources say

• Not checked yetcites [109] Chongmelaxme, 2019, The effects of telemedicine on asthma control and patients' quality of life in adults: a systematic review and meta-analysis, J Allergy Clin Immunol Pract. source
• Not checked yetcites [110] Gentry, 2019, Geriatric telepsychiatry: systematic review and policy considerations, Am J Geriatr Psychiatry. source
• Not checked yetcites [111] Hong, 2019, Effectiveness of tele-monitoring by patient severity and intervention type in chronic obstructive pulmonary disease patients: a systematic review and meta-analysis, Int J Nurs Stud. source
• Not checked yetcites [112] Kelson, 2019, Internet-delivered acceptance and commitment therapy for anxiety treatment: systematic review, J Med Internet Res. source
• Not checked yetcites [113] McFarland, 2019, The effect of telehealth versus usual care for home-care patients with long-term conditions: a systematic review, meta-analysis and qualitative synthesis, J Telemed Telecare. source
• Not checked yetcites [114] Thiyagarajan, 2020, Exploring patients' and clinicians' experiences of video consultations in primary care: a systematic scoping review, BJGP Open. source

In the paper

“Qualitative studies had indicated high patient and staff satisfaction but frequent technical problems (113–115)”

What the sources say

• Not checked yetcites [113] McFarland, 2019, The effect of telehealth versus usual care for home-care patients with long-term conditions: a systematic review, meta-analysis and qualitative synthesis, J Telemed Telecare. source
• Not checked yetcites [114] Thiyagarajan, 2020, Exploring patients' and clinicians' experiences of video consultations in primary care: a systematic scoping review, BJGP Open. source
• Not checked yetcites [115] Donaghy, 2019, Acceptability, benefits, and challenges of video consulting: a qualitative study in primary care, Br J Gen Pract. source

In the paper

“Observational studies documented a sharp increase in remote consultations (telephone, e- and video, in that order) during the first wave in the UK (14, 15)”

What the sources say

• Not checked yetcites [14] Murphy, 2021, Implementation of remote consulting in UK primary care following the COVID-19 pandemic: a mixed-methods longitudinal study, Br J Gen Pract. source
• Not checked yetcites [15] Joy, 2020, Reorganisation of primary care for older adults during COVID-19: a cross-sectional database study in the UK, Br J Gen Pract. source

In the paper

“There was very little research on e-consultations prior to the pandemic, and findings were limited (12, 103–107)”

What the sources say

• Not checked yetcites [12] Brant, 2016, Using alternatives to face-to-face consultations: a survey of prevalence and attitudes in general practice, Br J Gen Pract. source
• Not checked yetcites [103] Huxley, 2015, Digital communication between clinician and patient and the impact on marginalised groups: a realist review in general practice, Br J Gen Pract. source
• Not checked yetcites [104] Banks, 2018, Use of an electronic consultation system in primary care: a qualitative interview study, Br J Gen Pract. source
• Not checked yetcites [105] Huygens, 2018, Understanding the use of email consultation in primary care using a retrospective observational study with data of Dutch electronic health records, BMJ Open. source
• Not checked yetcites [106] Edwards, 2017, Use of a primary care online consultation system, by whom, when and why: evaluation of a pilot observational study in 36 general practices in South West England, BMJ Open. source
• Not checked yetcites [107] Marshall, 2018, Online consulting in general practice: making the move from disruptive innovation to mainstream service, BMJ. source

In the paper

“The Delphi exercise to develop guiding principles for applying the PERCS framework was undertaken on a relatively small sample”

In the paper

“PERCS is an explanatory framework, not a deterministic or predictive tool”

In the paper

“the combined empirical dataset which we used to refine and extend those frameworks was large and diverse; it included several pre-pandemic studies as well as a government-funded evaluation and two in-pandemic research studies, incorporating extensive primary data from surveys, ethnographic observations, interviews, focus groups, cross-sectoral workshops, and a Delphi panel”

In the paper

“Findings from our in-pandemic research on remote consultation services contrast sharply with research on such services undertaken before the pandemic which—in retrospect—was incomplete, skewed and lacking granularity”

In the paper

“these have been widely-used and stood the test of time”

What the sources say

• Not checked yetcites [17] Greenhalgh, 2017, Beyond adoption: a new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies, J Med Internet Res. source
• Not checked yetcites [62] Greenhalgh, 2004, Diffusion of innovations in service organizations: systematic review and recommendations, Milbank Q. source

In the paper

“One quantitative survey followed up 756 e-consultations in general practice and found that most generated either a telephone (32%) or face-to-face (38%) consultation (108)”

What the sources say

• Not checked yetcites [108] Farr, 2018, Implementing online consultations in primary care: a mixed-method evaluation extending normalisation process theory through service co-production, BMJ Open. source

In the paper

“Previous research on telephone consultations is surprisingly sparse and supports no firm conclusions”

What the sources say

• Not checked yetcites [32] Turnbull, 2014, The work, workforce, technology and organisational implications of the ‘111' single point of access telephone number for urgent (non-emergency) care: a mixed-methods case study, Health Serv Delivery Res. source
• Not checked yetcites [98] Thompson-Coon, 2013, Telephone consultations in place of face to face out-patient consultations for patients discharged from hospital following surgery: a systematic review, BMC Health Serv Res. source
• Not checked yetcites [99] Downes, 2017, Telephone consultations for general practice: a systematic review, Syst Rev. source
• Not checked yetcites [100] Campbell, 2014, Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost–consequence analysis, Lancet J. source
• Not checked yetcites [101] Newbould, 2019, A ‘telephone first' approach to demand management in English general practice: a multimethod evaluation, Health Serv Deliv Res. source
• Not checked yetcites [102] Salisbury, 2020, The impact of digital-first consultations on workload in general practice: modeling study, J Med Internet Res. source

In the paper

“The studies involving human participants were reviewed and approved by NHS East Midlands Leicester Central Research Ethics Committee (REC ref 20/EM0128; IRAS ID: 283196 and subsequent amendments)”

In the paper

“they later reported feeling tired and under pressure as well as concerned about the loss of in-person care, threats to the therapeutic relationship, potential for missed diagnoses especially in deprived and vulnerable groups, and a rising backlog of unmet need”

What the sources say

• Not checked yetcites [14] Murphy, 2021, Implementation of remote consulting in UK primary care following the COVID-19 pandemic: a mixed-methods longitudinal study, Br J Gen Pract. source
• Not checked yetcites [15] Joy, 2020, Reorganisation of primary care for older adults during COVID-19: a cross-sectional database study in the UK, Br J Gen Pract. source

In the paper

“Many interacting factors need to be taken into account, and the fortunes of remote consultation programs will unfold differently in different circumstances”

In the paper

“Other studies have described problems of increased antimicrobial prescribing (120), reduced ordering of diagnostic investigations (121) and delayed diagnosis of cancer (122, 123) attributed to the pandemic-related shift to remote consultations”

What the sources say

• Not checked yetcites [120] Han, 2020, Impact of remote consultations on antibiotic prescribing in primary health care: systematic review, J Med Internet Res. source
• Not checked yetcites [121] Crawford, 2021, Requests from primary care for chest X-ray and CA125 measurements during the COVID-19 emergency: an observational study, Clin Med. source
• Not checked yetcites [122] Hiom, 2020
• Not checked yetcites [123] Helsper, 2020, Cancer has not gone away: a primary care perspective to support a balanced approach for timely cancer diagnosis during COVID-19, Eur J Cancer Care source

In the paper

“In surveys of staff and patients, most described their experience of technology-mediated care as “positive” but also questioned whether remote clinical care was as good as face-to-face (3)”

What the sources say

• Not checked yetcites [3] Horton, 2021

In the paper

“The best kind of consultation for a particular patient at a particular time, taking account of the needs of other patients and staff, cannot be decided formulaically”

In the paper

“that staff experienced the shift as organizationally and professionally challenging but considered it justified for safety reasons”

What the sources say

• Not checked yetcites [14] Murphy, 2021, Implementation of remote consulting in UK primary care following the COVID-19 pandemic: a mixed-methods longitudinal study, Br J Gen Pract. source
• Not checked yetcites [15] Joy, 2020, Reorganisation of primary care for older adults during COVID-19: a cross-sectional database study in the UK, Br J Gen Pract. source