Change in consultation numbers
The quantitative findings are based on 350 966 registered patients in 21 practices (Table 1). In April 2019 there were 218 GP consultations per 1000 registered patients; 31% were by telephone, and no video consultations were recorded (Figure 1). In April 2020 this had reduced to 180 GP consultations per 1000 registered patients; 89% by telephone and 1% coded as video, increasing to 3% for patients aged >85 years (although GP coding practices may mean that some video consultations were coded as telephone consultations). Less than 1% of consultations coded by GPs were e-consultations. Consultation volumes increased by June/July 2020 back to similar levels as seen in June/July 2019.
Table 1. Characteristics of all patients registered in participating practices in July 2019
Figure 1. GP and nurse/paramedic consultations per 1000 registered patients, February to July 2019 and February to July 2020. Between 97% and 99% of consultations each month were face-to-face or telephone. Monthly percentages for home visits, e-consultations, and video (not shown) varied between 1% to 3% across all three types.
GP-to-patient SMS messages increased 3.1-fold, and nurse-to-patient 4.8-fold in April to July 2020 compared to 2019. In April to July 2019, 33% of SMS were sent on the same day the patient had a consultation. By April to July 2020 this had increased to 65% (see Supplementary Figure S1).
Table 2 shows changes from April to July 2019 to April to July 2020. There was an 11% reduction in GP consultations (IRR 0.89) and a 17% reduction for nurses/paramedics (IRR 0.83). GPs did almost three times more remote consultations than the previous year and nurses over five times more (IRR 2.76 and IRR 5.51, respectively). GP in-person consultations dropped to 16% of the previous year and nurses to just over 50% (IRR 0.16 and IRR 0.54, respectively).
Table 2. Changes in consulting rates in April to July 2020 compared to April to July 2019 overall, and stratified by patient characteristicsa
These changes were consistent across sex, IMD, and ethnicity groups (interaction P-values >0.05 for all outcome models), but differed by patient age, mental health status, and shielding status, for both GPs and nurses (Table 2).
Age
There was no significant change in total GP consultation rates in patients aged >70 years, and a decrease in all other age groups, in particular 5 to 17 years (IRR 0.65, P<0.001). The reduction in GP in-person consultations was less for patients who were ≥85 years (IRR 0.24, P<0.001) and pre-schoolers (IRR 0.24, P<0.001) than ages 5 to 84 years (IRR 0.12 to 0.19, all P<0.001). Nurses maintained a greater in-person focus on pre-school children (IRR 0.83, P = 0.03) with a larger drop in in-person nurse consultations for all other age groups (IRR 0.29 to 0.57, all P<0.001).
Mental health
Consultation rates in patients with poor baseline mental health increased between April to July 2019 and April to July 2020 for GPs (IRR 1.06, P = 0.02) and stayed constant for nurses (IRR 0.99, P = 0.89). GP and nurse consultation rates in patients with good mental health decreased (IRR 0.84 and IRR 0.83, respectively, P<0.001). People with good mental health had a greater reduction in nurse in-person consultations (IRR 0.54, P<0.001) than people with poor mental health (IRR 0.65, P<0.001; interaction P = 0.01).
Shielding
Consultation rates in shielding patients increased in April to July 2020 compared with April to July 2019 for both GPs (IRR 1.09, P = 0.004) and nurses (IRR 1.15, P = 0.03). Consultation rates for non-shielding patients decreased. In-person consultations reduced more in non-shielding patients than shielding patients (GP IR 0.16 versus 0.20, interaction P = 0.03; nurse IRR 0.53 versus 0.73, interaction P = 0.001).
Qualitative findings
Summary of changes through the four rounds
Changes through the four time-periods are described diagrammatically in Figure 2; using Normalisation Process Theory as a framework to explain the implementation of remote consulting.
Figure 2. Normalisation Process Theory model of remote consulting.
1Bistech = company that provided telephone call routing to enable some reception staff to work from home or sites closed to patients. DOH = Department of Health. F2F = face-to-face. VPN = Virtual Private Network (provides secure connection to a private network). VNC = Virtual Network Computing (provides remote control of a computer from another location).
Participants reported universal consensus on the need for remote consulting and strong buy-in to implementing it in March 2020. In Round 1 (May 2020), practice staff felt a strong sense of achievement in having worked so effectively with partners to implement the necessary changes.24 In Round 2, practices were restarting some routine services that were paused in Round 1. This increased volume was challenging because: face-to-face consultations took longer (because of infection control), many telephone consultations required more careful questioning than pre-COVID (because even complex problems were now routinely managed by phone), and video took time to connect.25 In Round 3, many participants reported fatigue from holding increased levels of clinical risk, partly because of remote consulting and partly because of the backlog in secondary care.26 In Round 4, practices reflected on what to retain post-pandemic. They were keen to avoid a return to unfiltered demand but, despite a suggestion by the Department of Health that remote consulting should be the preferred way of working,27 most GPs felt that remote consulting at current levels was unsustainable.28
Detailed findings are presented for each of the NPT constructs below.
Coherence: making sense of the reasons for remote consulting
Mirroring NHS England advice in March 2020 that face-to-face patient contact should be minimised, Round 1 interviews showed a strong consensus that remote consulting was imperative to protect patients and staff. In later interviews, as UK lockdown eased, this strong coherence reduced, due to lack of clear guidance:
‘When we started [March 2020] it was very clear that your primary goal was to not have people enter this building […] whereas now, [July 2020] there isn’t any clear NHS England message to guide on your threshold for bringing people in, so I think it’s hard for us to know what we should be doing’.
(GP, Health centre [HC]20, Round 4)
Cognitive participation: buy-in to remote consulting
Round 1 interviews demonstrated universal staff buy-in for rapidly implementing remote consulting:
‘We’ve had to [implement remote consulting] by necessity so again that’s taken out a lot of the onboarding, selling process and they just sort of got on with it like GPs do .’
(GP, HC20, Round 2)
Telephone, video, and SMS were seen as necessary to implement social distancing and as what patients wanted. However, this wholesale buy-in did not apply to e-consultations, which staff perceived as driven by a pre-existing national agenda:
‘We were told we had to do it [provide e-consultations] . There was no motivation at all, apart from the stick [national policy] ’.
(GP, HC19, Round 4)
Buy-in to remote consulting was strongly tied to the sense of coherence of remote consulting as a current necessity. Clinicians varied as to the extent to which they wanted to continue consulting remotely after the pandemic:
‘We’re doing it [move to remote consulting] because we have to do it, not because it’s how we choose to work.’
(GP, HC13, Round 1)
‘So certainly, I think the triage by phone and video consulting will be two areas that we will keep but tempered.’
(Practice manager, HC1, Round 1)
Collective action: putting remote consulting into action
From March 2020, guidance was regularly issued from various organisations on how services needed to change.29–31 A CCG-led collaboration collated the guidance and sent daily bulletins to practices. Most practices set up small teams to interpret, action, and cascade this within the practice:
‘Up until this week we were having a daily 9.00 am meeting of a lead doctor, a manager, a receptionist, an IT person and a lead nurse, just to […] discuss any Government or CCG, or any other guidelines which had come in overnight, and check on how we were implementing them.’
(GP, HC10, Round 1)
Practices closed online or walk-in advance consultation booking, implemented same-day total triage, joint GP patient lists, and established infrastructure to allow home working through call routing and remote EMIS access (Figure 2). E-consultation systems were introduced gradually to ensure practices could set-up and embed them properly, and technology for SMS photos and video links was implemented. GPs initially used their own phones and data. As international supply-chain problems eased, the CCG provided laptops, webcams, and improved WiFi. Taking such rapid wholescale action was possible because of the initial drop in demand:
‘It was very easy to turn around our system from being very face-to-face to telephone […] with lockdown the patient demand disappeared for various conditions and so that gave us a bit of room to breathe.’
(Practice manager, HC18, Round 2)
As demand increased, but COVID-19 cases in BNSSG remained low, practices adjusted systems, opening pre-bookable telephone appointments, reintroducing receptionist triage, and returning to individual GP patient lists.
Reflexive monitoring: positive appraisals of remote consulting
Imposing 90% remote consulting created wide recognition that many patients previously seen face-to-face could be safely consulted by telephone. Furthermore, information gathered through triage meant necessary face-to face time was more ‘focused and productive’ (GP, HC18, Round 2).
Some clinicians, previously resistant to telephone consulting, recognised that it was a skill which could improve with practice. Nurses found that telephone consulting worked well for chronic condition reviews, prioritising poorly controlled patients, and seeing patients face-to-face for physical aspects only. Telephone consulting gave GPs greater control of their working day and meant they could type and check information without the patient feeling that they were not listening. GPs noted that patients come to the point more quickly and raise fewer problems by phone:
‘I hope we’ll never go back to just whole mornings of patients booking by themselves, quite often when they don’t need to see a doctor, when it could have been dealt with in another way or by another person.’
(GP, HC9, Round 2)
Video consultation proved useful for dynamic assessment (such as gait and respiratory monitoring) and were particularly useful with children, to assess them visually and reassure the parent:
‘The [verbal] description doesn’t always match up with the clinical picture and being able to actually have a look, that’s very helpful’.
(GP, HC3, Round 1)
Nurses used video consultations to train patients and/or carers on wound care or administration of injectable long-acting reversible contraception. GPs used video consultations to connect with older people or vulnerable patients in nursing homes or when they were with an allied health professional.
Clinicians used accuRx to send information to patients via SMS before and after a consultation:
‘I’ll write quite detailed texts to patients who I’ve just spoken to, saying, “You might want to try this website” […] all you have to do is cut-and-paste a link and some people then have immediately got the website on their phone.’
(GP, HC19, Round 2)
SMS proved useful for fitness-to-work notes, contacting patients about prescriptions, and sending questionnaires to risk-stratify people with long-term conditions. Most GPs preferred a photograph-plus-telephone-consultation to video consultations for static problems that require visual assessment (for example, a rash):
‘Rather than initially setting up a video consultation [it’s better] to ask them to take a picture of it […] because the patient spends time getting a decent photo, and you’re not hanging on for each video consult for 5 or 10 minutes while you get the technology working.’
(GP, HC11, Round 1)
Most felt it was too early to appraise the impact of e-consultations. Some practices hoped that the response-window of e-consultations (for example, 48 hours) would enable them to spread demand more flexibly.
Reflexive monitoring: challenges with remote consulting
From June to July 2020, as consultation volumes and complexity increased, GPs found telephone consulting at high volumes to be more mentally intense and less satisfying:
‘Working from a long screen of lots of telephone calls, with holding lots of risks for a long time, and having then also removed what many GPs find the most enjoyable part of their job — talking and touching and sensing patients in the room — the day job has become a bit of a hard grind.’
(GP, HC20, Round 2)
Some felt an increased strain in making clinical decisions, prescribing, and holding more clinical risk over the phone:
‘I had someone [on the phone] with a bit of abdominal pain, chest tightness, anxious, pain in feet, PR [per rectum] bleeding, you just think “Gosh — where do I even start with this.” Yes, It can be a bit tricky over the phone.’
(GP, H16, Round 4)
Most GPs felt that, although they were seeing patients face-to-face when necessary, in the context of a pandemic, this depended on weighing up competing risks to the patient and practice. Practices with a large older, deprived, or immigrant population pointed out that non-verbal cues were more important in some groups of patients than others:
‘I work in a relatively deprived multi-ethnic area […] sometimes it’s more difficult to be able to take a very clear and reliable history over the telephone and be able to make safe management decisions.’
(GP, HC5, Round 1)
GPs had varying levels of IT problems with video consultations, highlighting that seamless technology is essential for successful implementation. While GPs had high initial expectations of video calls, as the pandemic eased, many felt that face-to-face was increasingly preferable to video for patients who needed visual assessment:
‘I think the initial excitement about video consulting […] there is quite a bit of faff around it and […] there is not that much that it adds. […] When we first started and absolutely not seeing patients and that was very useful, now I think probably if you needed a video, you might just think I might just see them [face-to-face] at this point.’
(GP, HC20, Round 4)
Other GPs pointed out that they also often needed to examine the patient and visualise close-up:
‘I kind of thought I would be doing more video by now, but […] I’m still doing mostly phone. I think I’m finding things that I want to see. I want to feel more than see, mostly.’
(GP, HC8, Round 4)
Some clinicians found it challenging to know when to switch to video and were concerned that they may have missed problems in telephone consultations because patients had not reported physical signs.
E-consultations registered by a clinician were <1% of all consultations in July 2020. The algorithm-based platform was introduced slowly as an alternative to telephone access. This allowed practices to pilot and refine the platform, but also meant that e-consultations were seen as an additional stream of work:
‘It’s like having more than one email account, isn’t it? You have got to check in all different places for incoming stuff [it’s] much more efficient to have everything coming into a single point.’
(GP, HC19, Round 4)
GPs also raised concerns about remote consultations that were commonly raised before COVID-19: first, that e-consultations would be used ‘inappropriately’;32 second, that all types of remote consultation would lead to ‘double doing’ (GP, HC8, Round 2);33 third, that SMS, e-consultations, and video would increase access for those with IT skills, and enforce already existing health inequities.4,34
