Change in consultation numbers
The quantitative findings are based on 350,966 registered patients across the 21 practices (see Table 1). In April 2019 there were 218 GP consultations per 1000 registered patients, of which 31% were by telephone, and no video-consultations were recorded (see Figure 1). In April 2020, this had reduced to 180 GP consultations per 1000 registered patients; 89% were telephone and just over 1% were coded as video, increasing to 3% for patients over 85 (although GP coding practices may mean that some videos were coded as telephone). Less than 1% were e-consultations added by GPs. Consultation volumes increased by June/July 2020 to similar levels to June/July 2019.
SMS messages sent to patients by GPs increased 3.1-fold, and by nurses 4.8-fold in Apr-Jul 2020 compared to 2019. In Apr-Jul 2019, 33% of SMS were sent on the same day that the patient had a consultation. By Apr-Jul 2020 this had increased to 65%. (See Supplementary File 4)
Table 2 shows changes from Apr-Jul 2019 to Apr-Jul 2020. There was an 11% reduction in consulting overall for GPs (IRR 0.89) and a 17% reduction for nurses (IRR = 0.83). GPs did almost 3 times more remote consultations compared with the previous year (IRR = 2.76), while GP in-person consultations dropped to 16% of the previous year (IRR = 0.16). Nurses did over five times more remote consultations (IRR = 5.51) and in-person consultations dropped to just over 50% of the previous year (IRR = 0.54).
These changes were consistent across different gender, IMD and ethnicity groups (interaction p-values >0.05 for all three outcome models for both GPs and nurses), but differed by patient age, mental health status, and shielding status, for both GPs and nurses (Table 2). For patients aged 85+, those shielding, or with poor mental health, consultation rates were higher in April-July 2020 than in April-July 2019.
Age: There was an increase in total GP consultation rates in 85+ year-olds (IRR = 1.08, p = 0.03), no significant change in patients from 70-84 (IRR=0.95, p=0.20), and a decrease in all other age groups, in particular 5-17 years (IRR=0.65, p<0.001). The reduction in GP in-person consultations was less for patients who were 85+ (IRR = 0.24, p<0.001) or pre-schoolers (IRR = 0.23, p<0.001) than ages 5-84 (IRR=0.12 to 0.19, all p<0.001). Nurses maintained more of an in-person focus on pre-school children (IRR = 0.83, p=0.01) with a larger drop in in-person nurse consultations for all other age groups (IRR=0.29 to 0.56, all p<0.001). The biggest drop in overall nurse consulting was in children aged 5-17 years (IRR=0.62, p<0.001).
Mental Health: Consultation rates in patients with poor baseline mental health increased from April-July 2019 for GPs (IRR=1.07, p<0.001) and stayed constant for nurses (IRR=0.98, p=0.69). GP and nurse consultation rates in patients with good mental health decreased (IRR=0.84, p<0.001 and IRR=0.79, p<0.001, respectively). 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=0.64, p<0.001; interaction p=0.02).
Shielding: Consultation rates in shielding patients increased in April-July 2020 compared with April-July 2019 for both GPs (IRR=1.11, p<0.001) and for nurses (IRR=1.14, p=0.03). Consultation rates for non-shielding patients decreased (IRR=0.87, p<0.001 and 0.83, p=0.002, respectively). Patients not shielding had a greater reduction in in-person consultations than patients who were shielding (GP IRR 0.16 vs 0.20, interaction p=0.02; nurse IRR 0.53 vs 0.72, interaction p=0.001).
We conducted 87 interviews in four interview rounds between 13th May - 29th July 2020, with 41 participants: 21 GPs, 11 practice managers and 9 senior nurses/ advanced nurse practitioners (see supplementary file 1). Findings are presented for each of the NPT constructs.
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, HC20, Round 4)
Cognitive participation: Buy-in to remote consulting
Round 1 interviews demonstrated universal staff buy-in for rapidly implementing remote consulting:
Part of that is also us not having to persuade our reluctant staff to do it because actually we’ve had to 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 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
Infrastructure: The drop in consultation volumes released capacity in March/April 2020 to rapidly implement changes. Remote access technologies (e.g. virtual network computing, virtual private networks, re-routing of telephone calls) were used to allow shielding/self-isolating staff to work from home or in branch surgeries closed to patients (see Table 3). AccuRx functionality was upgraded to allow unlimited video links and photo transfer. As pandemic- blockages in international supply chains were cleared, GPs were provided with laptops, headsets and webcams.
Access Pathways: Practices closed online or walk-in consultation booking, leaving telephone (or e-consultations where implemented) as the only access pathway. Same-day telephone triage services were implemented and most practices adjusted appointment systems so that GPs worked off single patient lists, without fixed appointment times. Single lists worked for some GPs, but others found it relentless. Shielding and vulnerable patients were proactively followed up by GPs, nurses or social prescribers.
Changes made: In response to an increase in (non-COVID-19) demand some practices opened pre-bookable telephone appointments and moved back to individual GP lists. Total telephone triage, which meant that every patient received a GP callback, became less manageable, and many practices reintroduced elements of receptionist triage. Fixed time-slots were often reintroduced. Identifying a distinction between telephone consulting and telephone triage, practices introduced differing duration telephone appointment slots for different types of telephone consultation. (see Table 3)
E-consultation systems were “soft-launched” in study practices during the 4-month period of this project. Practices did not advertise the service widely to ensure practices could set-up and embed them properly.
Reflexive monitoring: appraising the consequences of the move to remote consulting
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.”
Some clinicians, who had been 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 conditions 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 (e.g. gait, 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, for example on wound care or administration of injectable long-acting reversible contraception. GPs used video-consultations to connect with elderly 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 (e.g. 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 five or ten 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 (e.g. 48 hours) would enable them to spread demand more flexibly.
Challenges with remote consulting:
From June-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 elderly, 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. While soft launches allowed practices to pilot and understand the impacts of e-consultations, they also had the consequence that e-consultations were partly 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 which were commonly raised before COVID-19; firstly that e-consultations would be used “inappropriately”20, secondly that all types of remote consultation would lead to “double doing”21; thirdly that SMS, e-consultations and video would increase access for those with IT skills, and enforce already existing health inequities.22 23
The government have constantly got it completely wrong about how many people are internet ready. I have long conversations all the time [with people who] haven’t got a computer at home or they have and they just haven’t got the foggiest about how to do anything other than watch Netflix on it (GP, HC21, Round 3)