Satisfaction with remote consultations in primary care during COVID-19: a population survey of UK adults

Background Mode of access to primary care changed during the COVID-19 pandemic; remote consultations became more widespread. With remote consultations likely to continue in UK primary care, it is important to understand people’s perceptions of remote consultations and identify potential resulting inequalities. Aim To assess satisfaction with remote GP consultations in the UK during the COVID-19 pandemic and identify demographic variation in satisfaction levels. Design and setting A cross-sectional survey from the second phase of a large UK-based study, which was conducted during the COVID-19 pandemic. Method In total, 1426 adults who self-reported having sought help from their doctor in the past 6 months completed an online questionnaire (February to March 2021). Items included satisfaction with remote consultations and demographic variables. Associations were analysed using multivariable regression. Results A novel six-item scale of satisfaction with remote GP consultations had good psychometric properties. Participants with higher levels of education had significantly greater satisfaction with remote consultations than participants with mid-level qualifications (B = −0.82, 95% confidence interval [CI] = −1.41 to −0.23) or those with low or no qualifications (B = −1.65, 95% CI = −2.29 to −1.02). People living in Wales reported significantly higher satisfaction compared with those living in Scotland (B = −1.94, 95% CI = −3.11 to −0.78), although caution is warranted due to small group numbers. Conclusion These findings can inform the use and adaptation of remote consultations in primary care. Adults with lower educational levels may need additional support to improve their experience and ensure equitable care via remote consultations.


Introduction
Over 133 500 excess deaths occurred during the COVID-19 pandemic (March 2020 to December 2021) in England and Wales, with peaks of excess deaths occurring in April 2020 and January 2021. 1 Not only was there increased workload for the NHS during the COVID-19 pandemic, the mode of delivery and therefore mode of access for patients changed, with the use of remote consultations in primary care becoming widespread. 2,3[6] A review of pre-pandemic studies noted inequalities in use of remote primary care consultations. 7Women and younger people were more likely to use remote consultations, and people aged >85 years and non-immigrants were more likely to use telephone consultations. 7There was no clear pattern of association between other demographic or socioeconomic factors and remote primary care consultation usage. 7Although usage does not directly inform us about satisfaction with remote consultation, it may indicate preferences in pre-pandemic times when there was a choice about face-to-face or remote consultations.
At least some elements of remote GP consulting will likely continue beyond the pandemic.It is therefore important to consider patients' experiences of remote consulting along with potential inequalities that might be exacerbated.
The digital divide -the inequitable distribution of technology -has been highlighted, and its negative impact on health inequalities further fuelled by the pandemic. 8The increased use of remote consultations may have a greater impact on particular subgroups, such as individuals with limited access to the relevant technology 3,9 or with dementia. 10 rapid review of patients' experiences of remote primary care consultations during the pandemic identified both advantages and disadvantages of remote consultations perceived by patients. 11indings about satisfaction with and preferences for remote consultation differed between studies. 11Some studies showed positive associations between satisfaction with remote consultations and demographic factors such as younger age, 12,13 being female, 14,15 higher Background Mode of access to primary care changed during the COVID-19 pandemic; remote consultations became more widespread.With remote consultations likely to continue in UK primary care, it is important to understand people's perceptions of remote consultations and identify potential resulting inequalities.

Aim
To assess satisfaction with remote GP consultations in the UK during the COVID-19 pandemic and identify demographic variation in satisfaction levels.

Design and setting
A cross-sectional survey from the second phase of a large UK-based study, which was conducted during the COVID-19 pandemic.

Method
In total, 1426 adults who self-reported having sought help from their doctor in the past 6 months completed an online questionnaire (February to March 2021).Items included satisfaction with remote consultations and demographic variables.Associations were analysed using multivariable regression.

Results
A novel six-item scale of satisfaction with remote GP consultations had good psychometric properties.Participants with higher levels of education had significantly greater satisfaction with remote consultations than participants with mid-level qualifications (B = -0.82,95% confidence interval [CI] = -1.41 to -0.23) or those with low or no qualifications (B = -1.65,95% CI = -2.29 to -1.02).People living in Wales reported significantly higher satisfaction compared with those living in Scotland (B = -1.94,95% CI = -3.11 to -0.78), although caution is warranted due to small group numbers.
Against this backdrop, it is important to understand people's perceptions of remote consultations and identify potential inequalities.The present study therefore aimed to assess satisfaction with remote GP consultations in the UK population during the COVID-19 pandemic and explore demographic variation in satisfaction levels.

Method
Setting and participants Data for the present study were collected as part of a UK-based population survey conducted during the COVID-19 pandemic. 19Participants were invited to take part in the wider study between August and September 2020 (phase one) and again between February and March 2021 (phase two). 20Two UK-based population samples were recruited to complete an online questionnaire in both phases.Recruitment for the two samples was carried out via HealthWise Wales (HWW; a register for potential research participants) and social media for the COVID-19 Cancer Attitudes and Behaviours Study (CABS), and Dynata (an online panel provider commissioned by Cancer Research UK [CRUK]) for the COVID-19 Cancer Awareness Measure (COVID-CAM) data. 19,20For the CABS sample, potentially under-represented groups were targeted by specific recruitment strategies. 19For the COVID-CAM sample, quotas were placed on several characteristics to recruit a nationally representative and ethnically diverse sample. 19Eligibility criteria included being aged ≥18 years, living in the UK, and able to speak English.Questions on remote GP consultation were only included in the second phase of the wider study.

Measures
Data were recoded where appropriate to ensure that responses from both samples were comparable.Response options 'prefer not to say' and 'not applicable' were treated as missing.
Demographic information was collected in both surveys through a series of multiple-choice questions.This included gender, age, ethnic background, highest educational qualification, employment status, relationship status, disability, place of residence, and presence of health conditions.Age was collected directly in the CABS sample, but was computed for the COVID-CAM sample using date of birth combined into 10-year categories.Participants were asked whether they had a variety of specific health conditions that were combined into one variable identifying the total number of health conditions reported.
Satisfaction with remote GP consultations was measured using seven items (see Supplementary Table S1) that were adapted from a CRUK survey, 21 or developed responsively with stakeholders (via public/patient experiences and researchers' objectives) during the study and tested for acceptability with lay representatives. 19,22Each item had response options on a 4-point Likert scale from 'strongly disagree' to 'strongly agree', with the additional options of 'prefer not to say' and 'not applicable'.In the CABS sample, participants were only asked these seven items if they self-reported having sought help for a range of possible cancer symptoms (including vague/non-specific symptoms such as feeling tired all the time) during the preceding 6 months.Participants in the COVID-CAM sample who self-reported having tried to contact their GP practice in the last 6 months were included in the sample for analysis.Participants in both samples were asked the extent to which they agreed with each statement if they had received advice from a GP or doctor remotely (for example, a video or telephone call) for a health concern in the last 6 months.

How this fits in
Remote consultations became more widespread during the COVID-19 pandemic and continue to date.However, patterns of association between demographic characteristics and satisfaction with remote GP consultations during the pandemic were unclear.People with higher levels of educational qualification were found to have greater levels of satisfaction with remote GP consultations.Those with lower educational levels may benefit from further support with remote consultations.
(version 17).Descriptive statistics were used to characterise the individual and combined samples.Principal component analysis (PCA) with varimax rotation was used to identify the underlying factor structure of items measuring satisfaction with remote GP consultations.Items that loaded (>0.3) on the extracted components from PCA were examined for potential inclusion in the final measure Frequency distributions (accompanied by percentages) for items were examined for each sample (CABS/ COVID-CAM) and then combined (see Supplementary Table S1 for combined data for each item by demographic characteristics).t-tests and analysis of variance (ANOVA) (followed by post hoc Tukey tests) were used to examine differences in mean satisfaction scores by demographic factors.Multivariable linear regression analysis was conducted, including variables that were statistically significantly associated with satisfaction in univariable analyses.Each independent variable in the multivariable regression was identified as categorical, with the reference category being the group with the highest mean satisfaction score.

Participant characteristics
The sample was derived from 4978 people who responded in the second phase of the wider study (response rate from first phase sample: n = 4978/7543, 66.0%).Of these, 1426/4978 (28.6%) people self-reporting help-seeking from their doctor in the previous 6 months were included in the present study.Just over half of the participants were male (51.8%), and the majority of participants (92.6%) were of a White ethnic background (Table 1).Most participants were aged between 55 and 74 years (52.5%), with a further 16.1% aged between 45 and 54 years.Over 40% of the sample were employed and a further 42.7% were retired.Over a third (36.9%) were educated to degree level or higher, with another third (33.9%) having further or higher education but below degree level.

PCA of satisfaction with remote GP consulting items
The results of PCA indicated an initial two-component solution with eigenvalues >1 (Kaiser's criterion) accounting for 66.6% of the total variance (component 1: 51.2%, component 2: 15.4%).After varimax rotation, six out of seven items loaded (>0.3) onto component 1, two of which loaded onto both components (>0.3) but primarily onto component 1 (see Supplementary Table S2).Examination of the component plot showed that the only item that loaded exclusively (>0.3) onto component 2 ('In the future I would like to be offered the choice of a face-to-face consultation or remote consultation') appeared distinct from the others.Removing this item improved the internal consistency (α = 0.855; n = 1147 'complete cases') and PCA showed that 58.4% of the

Table 1 continued. Participant characteristics for the combined (n = 1426) and individual samples (CABS, n = 457; COVID-CAM, n = 969)
Business and Technology Education Council.CABS = COVID-19 Cancer Attitudes and Behaviours Study.COVID-CAM = COVID-19 CancerAwareness Measure.ONC = Ordinary National Certificate.a Participants were given a list: arthritis, cancer, circulation problems, chest problems, depression, diabetes, heart problems, high blood pressure, kidney problems, stroke, and/or other.b Data combined for ease of presentation.

Table 3 . Univariable and multivariable associations between satisfaction with remote GP consultations and demographic factors
Business and Technology Education Council.df= degrees of freedom.ONC = Ordinary National Certificate.SD = standard deviation.aTotal possible score range of 6 to 24 (higher score indicating higher satisfaction).bAsymptotically F distributed.Welch test reported because of heterogeneity of variances.Includes any 'mixed/multiple ethnic groups', 'Asian/Asian British', 'Black/African/Caribbean/Black British', and 'other ethnic group'.d Includes 'higher education qualification below degree level', 'ONC/ BTEC', and 'A-levels or Highers'.e Includes 'unemployed', 'still studying', 'full-time home maker', and 'disabled/ too ill to work'.f Participants were given a list: arthritis, cancer, circulation problems, chest problems, depression, diabetes, heart problems, high blood pressure, kidney problems, stroke, and/or other. c