Findings from thematic analysis
In the primary datasets, five recurring themes, topics, and narrative devices were identified: reasons for the change; depictions of technology; war and revolution metaphors; the need for rapid change in the NHS; and trade-off between positive and negative impacts. These are summarised in Tables 2 and 3. Where a newspaper published more than one article on one day, articles have been distinguished by ‘(a)’ and ‘(b)’.
Table 2. Coding table for period 1 (2 March–31 May 2020)
Table 3. Coding table for period 2 (30 July–12 August 2020)
Reasons for the change
Most articles published at the beginning of March 2020 sought to explain why remote consultations were being introduced at a time of rapid change and uncertainty; most related to slowing the spread of the virus. Some focused on patients, depicting remote consultations as reducing ‘the risk of someone already infected with the virus spreading it further’ (Express, 11 March). Some articles explicitly advised, and even commanded, patients not to make in-person visits to their GP, as in ‘Ring GPs, don’t visit’ (Telegraph, 15 March).
Other explanations were GP-focused. Remote consultations were described not only as ‘a way of [GPs] protecting themselves’ (Guardian, 6 March) from the virus but also as a means of increasing efficiency of care, to ‘free GPs to deal with the extra workload created by the virus’ (Guardian, 6 March). However, almost nothing was said in the lay press about the workload associated with the task of effectively and rapidly embedding the technology in workflows or familiarising staff with the new system. A single article in the dataset reported one GP who felt that rather than increasing efficiency, his workload had increased so much that ‘he had 40 other patients to phone back’ (Daily Mail, 24 March).
The narrative of improved efficiency in remote primary care was occasionally reinforced in the period 2 dataset by reports of a Royal College of General Practitioners survey, which was depicted as having found that ‘seven in ten [GPs] said telephone appointments increased their efficiency’ (Daily Mail, July 30). It is noteworthy that this finding was taken from a report that predominantly questioned the remote-first policy,11 and that the Daily Mail chose not to convey the overall sense of the report.
The period 2 dataset included some retrospective explanations, with reasons appearing in the past tense. One article, which offered a negative overall assessment of the new remote-first policy going forward, nevertheless depicted it as having been justified when first introduced:
‘At the height of the COVID-19 epidemic it was understandable that GPs should try to avoid face-to-face contact where possible. It was vital the disease was contained and that doctors themselves had the best possible protection.’
(Express, 31 July)
The strong message communicated to the public was that the policy of defaulting to remote was justified then (since the threat of the pandemic was serious and pressing) but is no longer justified now (since the pandemic has subsided). Instead, later articles argued, there is no good reason to maintain remote as default. Rather, a return to face-to-face in some circumstances could be justified on the grounds of choice: clinicians and patients should ‘decide what works best for them’ (Express, 31 July).
Depictions of technology
Remote consulting was frequently depicted in the period 1 dataset as delivered via novel and bespoke technology, with an emphasis on innovation and private-sector entrepreneurship. Several commercial companies that had been offering remote consultations (in partnership with the NHS or privately) during the pandemic were showcased. In most cases, the narratives depicted technologies in active terms as the agents of change.
The GP Chief Medical Officer of LIVI, for example, announced that the company’s remote technology ‘allows GPs […] to care for people at home via digital consultations’ (Independent, 15 April). The language used conveys the idea of master and subordinate: the latter is incapable of acting without the permission and support of the former. The article includes firm and confident predictions with technology central to the achievement of improved outcomes, for example, ‘Digital healthcare will keep people at home and therefore save lives’. In contrast, GPs themselves were not depicted by any articles in the period 1 dataset as active agents or as saving any lives. A symbiotic relationship between GPs and digital health care was depicted in only one article (Voice, 9 April), with two surgeries in Newham ‘offering remote GP consultations in collaboration with Docly’, a text-based service described as working ‘in unison’ with practices. Rather than saving lives, its role is to ‘facilitate’ health care and ‘ease the burden on primary care’.
Although GPs who were not linked to digital healthcare companies were widely in favour of remote consultations, there was scepticism towards the technology firms. One GP, for example, described the firms as ‘innovative (or predatory, depending on your take on it)’ (Guardian, 11 March).
The narrative of bespoke, heroic technologies developed by an entrepreneurial private sector did not persist. In the period 2 dataset, no representatives from private health technology companies wrote articles or provided quotes, and only one such company (Doctorlink) was mentioned briefly (Independent, 31 July). Instead, the new government policy was often reported as best delivered by doctors using familiar, freely available, and non-bespoke technology (such as Zoom, Skype, and/or WhatsApp). Matt Hancock is reported as encouraging healthcare professionals ‘to speak with both colleagues and patients’ (Independent, 30 July) via WhatsApp. In period 2, data shows that agency is restored to GPs, with generic technologies facilitating, rather than delivering, patient care.
War and revolution metaphors
Military metaphors were evident in the period 1 dataset. One article, for example, entitled ‘GPs told to switch to digital consultations to combat COVID-19’ (Guardian, 6 March), paints the image of GPs as soldiers on the frontline and coronavirus as the enemy. The military metaphor is further developed into an enemy that is gaining ground, with GPs ‘fight [ing] the spread of coronavirus’ (Daily Mail, 10 March), while public health chiefs ‘battle to reduce the risk’ of further spread (Express, 11 March). In an article entitled ‘Digital front opens in war on disease […] ‘ (Times, 29 March), commercial start-ups are depicted as allied with doctors in a strategically-organised battle against COVID-19.
Another article talks not — as might be expected — of GPs (agents) deploying technologies (tools) but of the reverse: digital appointments helping ‘to deploy the workforce [GPs] more efficiently’ (Independent, 16 March), with technology explicitly superseding doctors in the military hierarchy.
The metaphor of revolution was also prominent in the period 1 dataset. The original, emergency move to remote consultations is described as having ‘revolutionised GP surgeries pretty much overnight’ (Telegraph, 25 May). However, while one article agrees that it was ‘a very rapid and necessary revolution’ (Guardian, 19 April), another suggests that the revolution is yet to happen (Independent, 15 April). This lack of consensus on whether the revolution is in the past or the future may reflect uncertainty about whether it is a technological revolution (achieved simply by installing new technology) or a service revolution (not achieved until the technology is actually in regular and unproblematic use).
The period 2 dataset paints a different picture. Despite Matt Hancock’s comparisons of the pandemic with a war in his speech,5 no military metaphors are mentioned in the articles, suggesting that the media considered the ‘war’ against COVID-19 to be over. Although the metaphor ‘crusade’ appears on one occasion, it is not against the virus, but is rather ‘ [Matt Hancock’s] crusade to introduce more digital technology to the NHS’ (Express, 31 July). Similarly, revolution was mentioned only once in the period 2 dataset, but not linked to the pandemic or the immediate response to it. By describing Matt Hancock’s suggestion that the NHS moves towards ‘Zoom medicine’ as ‘a bold, potentially revolutionary step’ (Telegraph (b), 31 July), the article places the revolution firmly in the future and shifts the agency from industry and clinicians to politics and policy.
The need for rapid change in the NHS
Articles in the period 1 dataset depict the speed at which remote consultations were implemented as ‘astonishing’ (Times, 4 April), ‘dizzying’ (Guardian, 11 March), and ‘dramatic’ (Guardian, 19 April). This sense of surprise partly reflects a widespread perception of the NHS, and general practice in particular, as inherently slow and reluctant to change. Leading change agents, such as Sir John Oldham, were quoted urging their more reluctant colleagues to seize the day — ‘now is the moment for my GP colleagues to embrace video consultations’ (Times, 10 March).
The Chair of Council of the Royal College of General Practitioners was widely quoted on this theme, for example, ‘it is coronavirus that has propelled primary healthcare into the digital age after years of dragging its feet’ (Telegraph, 25 May). The coverage suggests, on the one hand, that there was no real reason for the delay apart from inertia — but on the other, that in times of crisis primary care services can adapt at a remarkable pace.
Articles in the period 2 dataset develop this narrative by expanding on Matt Hancock’s comment5 that the NHS must not fall back into what are depicted as bad habits (such as, inefficient routines and practices that fail to maximise the efficiency gains of technology). One article describes the NHS generally as ‘resistant to change, over-bureaucratic and its administration is often technologically backwards’ (Telegraph (b), 31 July). Another article comments on the ‘archaic administration of […] doctors’ surgeries, which can often feel like places where the modern internet fears to tread’ and depicts general practice as in need of a ‘digital reckoning’ (Times (b), 31 July).
Trade-off between positive and negative impacts
Articles in both datasets talked of benefits and harms of remote consulting for both clinicians and patients. In period 1, GPs were reported as viewing the move as ‘sensible’ (Guardian, 6 March; Express, 14 March), and mentions positive consequences including improved safety, the ability for self-isolating GPs to work from home, and convenience. As one quoted GP put it, ‘digital healthcare, if done well, has a way of creating positive change’ (Voice, 9 April). While GPs were also reported as concerned about hypothetical missed symptoms and diagnoses, ‘problems that require relationships’ (Daily Mail, 2 May), and barriers to access, especially that the elderly ‘will struggle with replacement telephone consultations’ (Telegraph, 15 March), the trade-off was depicted as worthwhile, with benefits discussed more frequently and emphatically.
The trade-offs of remote consulting were viewed differently in the period 2 dataset. While some benefits, such as convenience and suitability for ‘simple conditions’ (Guardian (b), 30 July), were acknowledged, limitations were more numerous and discussed more often. The risk of missed diagnoses, threats to the therapeutic relationship, and concerns about digital exclusion were covered in more detail with additional examples (for example, articles discussing digital exclusion now included not just the elderly but also those with learning difficulties and low-income groups). Articles in the period 2 dataset explored a growing list of clinical situations where remote consulting would be impossible or inappropriate, such as blood tests, vaccinations, and physical examinations, and sensitive situations, such as gynaecological examinations, detection of abuse, and certain mental health conditions.
The clear shift over time from an overall positive trade-off to a contingent and sometimes negative one was still apparent but less marked in patients’ accounts. Both periods included both positive and negative accounts, though the latter were more common in period 2. In the period 1 dataset, patients without serious complaints described their experiences as ‘very simple and easy’ (Telegraph, 25 May, video consultation) and ‘the most painless doctor’s appointment of my life’ (Telegraph, 22 May, phone consultation). Those quoted in period 2 with minor complaints also described ‘a positive experience’ (Guardian (b), 30 July, phone consultation) and considered the encounter a ‘pleasure’ (Daily Mirror, 1 August, phone consultation).
But even in the early days of remote consultations, negative patient experiences, especially in those with more serious complaints, were reported. One patient in the period 1 dataset is quoted as saying his GP ‘missed my coronavirus symptoms’, leading (it was claimed) to his rapid deterioration and hospital admission (Telegraph, 25 May, phone consultation). Other stories in the period 2 dataset described an alleged missed cancer (Independent, 4 August, video consultation) and missed abdominal emergency (Daily Mail, 2 August, phone consultation); in the second example the patient’s wife is quoted saying ‘people will die if this lack of face-to-face consultations continues’.
