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Background: Online consultation (OC) was previously promoted by the NHS to solve primary care workload challenges. Its implementation was sped up during the COVID-19 pandemic. Workload effects are widely debated. Using a job design perspective may enhance understandings of workload effect. Aim: To qualitatively interrogate the workload experiences of primary care staff involved in OC implementation, using the Job Characteristics Model (JCM) to enable the following: a clearer understanding of the primary care staff psychological experiences; and recommendations informing the design of digital implementations and continued use. Design & setting: A qualitative interview study of GP practices using OC within South West England. Method: Thirteen participants representing seven practices completed JCM-based semi-structured telephone interviews. An abductive theoretically driven thematic analysis was completed. Results: Participants experienced different tasks pre- and post-implementation of OC, and adapted differently to them. Differences included the following: contact modality change, some administrative staff felt removed from patient contact; and in perceived autonomy, some GPs valued increased workload control. Variation in workload experience was affected by job role and practice context, and the form of and rationale for implementation. Use of a psychological model (the JCM) allowed clearer consideration of the effects of change, as well as OC on workload. Conclusion: Psychological theory may be helpful in interpreting workload effects of technology implementation such as OC. Designing change to include consideration of technology effects, psychological experiences, differences across roles, and individual and practice contexts may be important for technology implementation and evaluation of its workload effects. [ABSTRACT FROM AUTHOR]

Background: Current National Health Service policy in England encourages enhanced digital access in primary care service provision. In this study, we investigate 'digital facilitation' - that range of processes, procedures and personnel which seeks to support National Health Service primary care patients in their uptake and use of online services., Objectives: Identify, characterise and explore the potential benefits and challenges associated with different models of digital facilitation currently in use in general practice which are aimed at improving patient access to online services in general practice in England. Use the resulting intelligence to design a framework for future evaluations of the effectiveness and cost effectiveness of such interventions. Explore how patients with mental health conditions experience digital facilitation and gauge their need for this support., Design: Observational mixed-methods study (literature review, surveys, ethnographic observation and interviews); formal synthesis of findings., Setting: General practice in four regions of England., Participants: Practice survey: 156 staff. Patient survey: 3051 patients. Mental health survey: 756 patients. General practitioner patient survey: 3 million responders. Ethnographic case-studies: 8 practices; interviews with 36 staff, 33 patients and 10 patients with a mental health condition. Stakeholder interviews: 19 participants., Intervention: Digital facilitation as undertaken in general practice., Main Outcome Measures: Patient and practice staff reported use of, and views of, digital facilitation., Data Sources: Surveys, qualitative research; national General Practitioner Patient Survey (2019-22)., Review Methods: Scoping-review methodology applied to academic and grey literature published 2015-20., Results: While we did find examples of digital facilitation in routine practice, these often involved using passive or reactive modes of support. The context of COVID, and the necessary acceleration (at that time) of the move to a digital-first model of primary care, shaped the way digital facilitation was delivered. There was lack of clarity over where the responsibility for facilitation efforts lay; it was viewed as the responsibility of 'others'. Patients living with mental health conditions had similar needs and experiences regarding digital facilitation to other patients., Limitations: The context of the COVID pandemic placed limitations on the project. Fewer practices responded to the practice survey than anticipated; reconfiguration of general practices to support COVID measures was a key consideration during non-participant observation with social distancing and other measures still in place during fieldwork., Conclusions: Digital facilitation, while not a widely recognised concept, is important in supporting the move to a National Health Service with enhanced digital opportunities and enhanced digital access. General practice staff are allocating resources to provide such efforts in general practices in England. The establishment of clear lines of responsibility, the development of digital tools and platforms that work for patients and practice staff, and investment in staff time and training are needed if digital facilitation is to support the intended digital revolution., Future Work: We did not find one single dominant or preferred model of digital facilitation which might reasonably be considered to form the basis of an intervention to be tested. Rather, there is a need to co-develop such an intervention with patients, general practice staff and relevant policy experts. We outline a framework for a future evaluation of such an intervention., Study Registration: This study is registered as ResearchRegistry6523 (www.researchregistry.com/browse-the-registry#home/?view_2_search=Di-Facto&view_2_page=1) and PROSPERO CRD42020189019 (www.crd.york.ac.uk/prospero/display_record.php?RecordID=189019)., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128268) and is published in full in Health and Social Care Delivery Research ; Vol. 12, No. 32. See the NIHR Funding and Awards website for further award information.

Background: Group consultations have been gaining ground as a novel approach to service delivery. When in-person care was restricted owing to COVID-19, general practice staff began delivering group consultations remotely over video. Aim: To examine how multiple interacting influences underpinned implementation and delivery of video group consultations (VGCs). Design and setting: Qualitative study in general practice in England. Method: a) 32 semi-structured interviews with patients, clinical, and non-clinical staff (from eight GP surgeries in total), NHS policymakers and programme managers, and other stakeholders; b) observation in relevant training and operational meetings; and c) three co-design workshops (21 participants). Thematic analysis was informed by the Planning and Evaluating Remote Consulting Services (PERCS) framework. Results: In the first year of the pandemic, VGCs focused on supporting those with long-term conditions or other shared health and social needs. Most patients welcomed clinical and peer input, and the opportunity to access their practice remotely during lockdown. However, not everyone agreed to engage in group-based care or was able to access IT equipment. At practice level, significant work was needed to deliver VGCs, such as setting up the digital infrastructure, gaining team buy-in, developing new patient-facing online facilitation roles, managing background operational processes, protecting online confidentiality, and ensuring professional indemnity cover. Training provided nationally was seen as instrumental in capacity building for VGC implementation. Conclusion: Small scale VGC implementation addressed unmet need during the pandemic. However, embedding VGCs in routine care requires rethinking of operational, infrastructural, and clinical processes. Additional research on costs and benefits at service and patient level is needed. [ABSTRACT FROM AUTHOR]

Background: Health service policy in many jurisdictions is driving greater investment into digital primary care services. While some patients and practices may benefit, there are concerns that not all are able or wish to access primary care services online. "Digital facilitation" is the "range of processes, procedures, and personnel seeking to support patients in their uptake and use of online services" and may address such concerns., Objective: As part of a multimethod research program, we undertook surveys of practice staff and patients to gain insight into the support being offered by practices and explore patients' experiences of this support., Methods: General practices from 4 regions of England were sent a questionnaire exploring the modes of digital facilitation offered, the personnel involved in its delivery, and views on the motivations and drivers for providing support. Moreover, 12,822 patients registered with 62 general practices (predominantly those providing practice survey responses) were sent a questionnaire exploring their experiences of any support offered by their practice to use online services., Results: Almost one-third of practices (156/500, 31.2%) responded to the practice survey, with most reporting using passive modes of digital facilitation (eg, display, leaflets, and SMS text messages) and few using active modes (eg, offering tablets or computers or using practice champions). However, 90.9% (130/143) reported providing ad hoc support. Practices agreed that it was the responsibility of both the practice (105/144, 72.9%) and the wider National Health Service (118/143, 82.5%) to support patients in using online services and that providing such support benefited the practice (126/144, 87.5%) and their patients (132/144, 91.7%). Nearly a quarter of the patients (3051/12,822, 23.8%) responded to the patient survey, with few (522/3051, 17.11% or less) reporting awareness of any modes of digital facilitation apart from text messages and emails (1205/3051, 39.5%) and only 13.36% (392/2935) reporting receiving support to use online services. Adjusted logistic regression analyses showed that older patients had a lower likelihood of 4 outcomes: being aware of, or of using, digital facilitation efforts, or being told about or being helped to use online services (all P<.05), particularly with regard to being helped to use online services (adjusted odds ratio for patients aged 85 years versus those aged 55-64 years: 0.08, 95% CI 0.02-0.36). However, ethnic minority participants or those for whom their first language was not English had positive associations with these outcomes., Conclusions: General practices recognize that patients would benefit from support to access online services. However, the support provided is often passive or ad hoc, and patients were seldom aware of digital facilitation efforts that their practice provided. There is potential to increase engagement with online primary care services by providing more support for all patients, particularly to provide targeted support for older patients., (©Rachel Winder, John L Campbell, Nurunnahar Akter, Abodunrin Q Aminu, Jeffrey Lambert, Emma Cockcroft, Chloe Thomas, Christopher E Clark, Carol Bryce, Jon Sussex, Helen Atherton, Christine Marriott, Gary Abel. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 07.08.2024.)

Background: The coronavirus (COVID-19) pandemic resulted in the rapid implementation of remote consultations to maintain musculoskeletal physiotherapy services. However, little is known about UK musculoskeletal physiotherapists' experiences of providing services during the COVID-19 pandemic., Objectives: To explore musculoskeletal physiotherapists' experiences of using remote consultations in one area of England during the COVID-19 pandemic., Design: Qualitative study using hermeneutic phenomenology based on the approach of Gadamer., Methods: Semi-structured interviews with twelve musculoskeletal physiotherapists were conducted online using Microsoft Teams. Data were analysed using frameworks based on the philosophical concepts of Gadamer's hermeneutics., Findings: Musculoskeletal physiotherapists' experience of using remote consultations during the COVID-19 pandemic was framed by three concepts: therapeutic relationship, transformational change, and uncertainty. These concepts are underpinned by four main themes capturing their experiences: (1) Disconnection: Difficulties building a rapport and reduced non-verbal communication affected building an effective therapeutic relationship, (2) Necessity: Transformation of services to remote consultations was positive, although technology and connectivity issues had a negative impact, (3) Loss of control: Diagnostic uncertainty, being unprepared, and experience affected physiotherapists' clinical practice, (4) Protection: Peer support and the use of technology facilitated a feeling of protection for physiotherapists., Conclusion: The findings of this study contribute to a better understanding of musculoskeletal physiotherapists' experience of using remote consultations during the COVID-19 pandemic. Implications for practice include the need to provide training for all musculoskeletal physiotherapists and undergraduates to enable the effective delivery of remote physiotherapy. Furthermore, digital infrastructure should be optimised to support future delivery of remote musculoskeletal physiotherapy services., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Online consultation systems (OCSs) allow patients to contact their healthcare teams online. Since 2020 they have been rapidly rolled out in primary care following policy initiatives and the COVID-19 pandemic. In-depth research of patients' experiences using OCSs is lacking., Aim: Explore patients' experiences of using an OCS., Design and Setting: Qualitative study in English GP practices using the Patchs OCS (www.Patchs.ai) from March 2020 to July 2022., Method: Thematic analysis of 25 patient interviews and 21 467 written comments from 11 851 patients who used the OCS from nine and 240 GP practices, respectively., Results: Patients cited benefits of using the OCS as speed, flexibility, and efficiency. Nevertheless, some patients desired a return to traditional consultation methods. GP practices often did not clearly advertise the OCS or use it as patients expected, which caused frustration. Patients reported advantages of having a written record of consultations and the opportunity to communicate detailed queries in free text. Views differed on how the OCS influenced clinical safety and discussions of sensitive topics. Patients who struggled to communicate in traditional consultations often preferred using the OCS, and male patients reported being more likely to use it., Conclusion: Globally, this is the largest in-depth study of patient experiences of an OCS. It contributes new knowledge that the patient experience of using OCSs can be influenced by previously unreported patient characteristics and the conditions they consult about. Further, it contributes recommendations on the design and implementation of the OCS in practice., (© The Authors.)

This article -- the second in their series -- looks at remote consultations, providing a summary of what they are in relation to patients with skin conditions and detailing the guidance that has been developed by the Dermatology National Outpatients Transformation Programme, which it is hoped will lead to more personalised care in the field. [ABSTRACT FROM AUTHOR]

Background: COVID-19 has accelerated remote healthcare provision in primary care, with changes potentially permanent. The implementation of remote provision of health care needs to be informed by vulnerable populations, such as people living with dementia.Aim: To understand the remote healthcare experiences of patients living with dementia and their family carers during the COVID-19 pandemic.Design and Setting: Qualitative interviews with community-based patients living with dementia and their carers were carried out between May-August 2020, while the COVID-19 pandemic was ongoing in England.Method: Semi-structured interviews were conducted remotely by telephone or video call with 30 patients living with dementia and 31 carers. Data were analysed using thematic analysis.Results: Three main themes were derived relating to: proactive care at the onset of COVID-19 restrictions; avoidance of healthcare settings and services; and difficulties with remote healthcare encounters. People living with dementia and their carers felt check-up calls were reassuring but limited in scope and content. Some avoided healthcare services, wishing to minimise COVID-19 risk or reduce NHS burden, or encountering technological barriers. Difficulties in remote consultations included lack of prompts to remember problems, dealing with new emerging difficulties, rescheduling/missed calls, and inclusion of the voice of the person with dementia.Conclusion: While remote consultations could be effective, proactive calls could be more structured around needs. Consideration should be given to replace non-verbal prompts to describe problems, particularly for new health concerns. In continuing remote consultations, it is important to facilitate engagement with patients living with dementia and their carers to ensure good practice. [ABSTRACT FROM AUTHOR]

Background: Videoconferencing has been proposed as a way of improving access to healthcare for older adults in care homes. Despite this, effective uptake of videoconferencing remains varied. This study evaluates a videoconferencing service for care home staff seeking support from healthcare professionals for the care of residents. The aim was to explore factors affecting the uptake and sustainability of videoconferencing in care homes, to establish what works for whom, in which circumstances and respects. The findings informed recommendations for commissioners and strategic managers on how best to implement videoconferencing for remote healthcare provision in care homes for older adults.Methods: Realist evaluation was used to develop, refine and test theories around the uptake and maintenance of videoconferencing in three care homes across Yorkshire and the Humber, England. The care homes were selected using maximum variation sampling regarding the extent to which they used videoconferencing. A developmental inquiry framework and realist interviews were used to identify Context, Mechanism and Outcome Configurations (CMOCs) regarding uptake and sustainability of the service. Participants included care home residents (aged > 65) and staff, relatives and strategic managers of care home chains. The interviews were an iterative process conducted alongside data analysis. Transcripts of audio recordings were entered into NVIVO 12, initially coded into themes, then hypotheses developed, refined and tested.Results: Outcomes were generated in relation to two main contextual factors, these were: (1) communication culture in the home and (2) the prior knowledge and experience that staff have of videoconferencing. The key facilitators identified were aspects of leadership, social links within the home and psychological safety which promoted shared learning and confidence in using the technology.Conclusions: Videoconferencing is a valuable tool, but successful implementation and sustainability are dependent on care home culture and staff training to promote confidence through positive and supported experiences. [ABSTRACT FROM AUTHOR]

Background: Personalised Care and Support Planning (PCSP) replaces conventional annual reviews for people with long-term conditions. It is designed to help healthcare professionals (HCPs) and patients engage in conversations as equals and collaboratively plan actions oriented to each patient's priorities, alongside biomedical concerns. Little is known about how the shift to remote consulting initiated with COVID-19 restrictions has impacted PCSP., Aim: To investigate HCPs' experiences of conducting PCSP conversations remotely and consider implications for the fulfilment of PCSP ambitions as remote consulting continues beyond COVID-19 restrictions., Methods: 19 semi-structured interviews with HCPs in England and Scotland; interpretive analysis., Results: HCPs' accounts made clear that COVID-19 restrictions impacted multiple aspects of PCSP delivery, not just the mode of conversation. Broader disruption to general practice systems for gathering and sharing information ahead of PCSP conversations, and moves to 'wide window' appointment times, made it harder for patients to be prepared for PCSP conversations. This constrained scope to achieve PCSP ambitions even with the best professional communication skills. Most remote PCSP conversations were conducted by telephone. In the absence of visual communication with patients, it was sometimes harder to achieve the ambitions of PCSP conversations, including to balance patient and professional agendas, fulfil key planning activities, and foster a relational ethos of equal, collaborative partnership. The challenges were particularly severe when working with new patients and people with complex clinical and social problems. Although options for telephone appointments now offer valued flexibility, sustained experience of struggling to achieve PCSP ambitions via remote consulting led some HCPs to lower their standards for judging a "good" PCSP conversation, and to diminished professional satisfaction., Conclusions: There are significant challenges to fulfilling the ambitions of PCSP via telephone, especially when preparatory support is limited. This study provides grounds for scepticism about how compatible telephone appointments can be with this person-centred model of working, especially for people who are socially disadvantaged and live with complex health conditions. These threats to the provision of person-centred support for people with long-term conditions warrant careful attention going forward if the PCSP model and its benefits are to be sustained., (© 2024. The Author(s).)

Objectives: To assess the relative productivity of primary medical services in England and the impact of the COVID-19 pandemic on productivity levels., Setting: Primary medical services for 59 million patients (98% of the population in England), in 101 clinical commissioning groups (CCGs), across two time periods: period 1, pre-pandemic, April to December 2019 and period 2, pandemic, April to December 2020., Methods: We use data envelopment analysis (DEA) to assess relative productivity with four input measures (the number of full-time equivalent general practitioners, nurses, other direct patient contact staff and administrators), and five output measures (face-to-face appointments, remote consultations, home visits, referrals to secondary care and prescriptions). Our units of analysis were CCGs. DEA assigns an efficiency score to a CCG, taking a value between 0 and 100%, by benchmarking it against the most productive CCGs. We use Tobit regression to examine the association between productivity and other factors., Results: The mean bias-corrected efficiency score of primary medical services in CCGs was 92.9% (interquartile range 92.0% to 95.7%) in period 1, falling to 90.6% (interquartile range 86.8% to 95.2%) in period 2. In period 1, CCGs with a higher proportion of registered patients aged over 65 years, higher levels of deprivation, lower levels of disease prevalence, higher nurse to GP ratios and higher GP to other direct patient contact staff ratios, achieved statistically significantly higher general practice efficiency scores (p < 0.05). In period 2, only the ratio of GP to other direct patient contact staff was associated with efficiency scores (p > 0.05)., Conclusions: Our analysis indicates only modest geographic variation in productivity of primary medical services when measured at the level of clinical commissioning groups and a small reduction in productivity during the pandemic. Further work to establish relative productivity of individual GP practices is warranted once sufficient data on appointment rates by GP practice is available., (© 2023. Crown.)

Background: General practice is an important place for patients experiencing or perpetrating domestic violence and abuse (DVA), and for their children to seek and receive help. While the incidence of DVA may have increased during the COVID- 19 pandemic, there has been a reduction in DVA identifications and referrals to specialist services from general practice. Concurrently there has been the imposition of lockdown measures and a shift to remote care in general practices in the UK., Aim: To understand the patient perspective of seeking and receiving help for DVA in general practice during the COVID-19 pandemic. This was then compared with experiences of general practice healthcare professionals., Design and Setting: A qualitative interview study in seven urban general practices in England and Wales, as part of a feasibility study of IRIS+, an integrated primary care DVA system-level training and support intervention., Method: Semi-structured interviews with 21 patients affected by DVA and 13 general practice healthcare professionals who had received IRIS+ training. Analysis involved a Framework approach., Results: Patients recounted positive experiences of seeking help for DVA in general practice during the pandemic. However, there have been perceived problems with the availability of general practice and a strong preference for face-to-face consultations, over remote consultations, for the opportunities of non- verbal communication. There were also concerns from healthcare professionals regarding the invisibility of children affected by DVA., Conclusion: Perspectives of patients and their families affected by DVA should be prioritised in general practice service planning, including during periods of transition and change., (© The Authors.)

Objective: Explore the experiences of patients and clinicians in rheumatology and cardiology outpatient clinics during the first year of the COVID-19 pandemic, focusing on the impact of remote consultations on interpersonal dynamics., Design: Qualitative study using semistructured interviews, conducted between February and June 2021., Setting: The rheumatology and cardiology departments of a general hospital in England, UK., Participants: All clinicians and a convenience sample of 100 patients in each department who had taken part in a remote consultation in the past month were invited to take part. Twenty-five interviews were conducted (13 with patients, 12 with clinicians)., Results: Three themes were developed through the analysis: adapting to the dynamics of remote consultations, impact on the patient's experience and impact on the clinician's experience. The majority of remote consultations experienced by both patients and clinicians had been via telephone. Both clinicians and patients found remote consultations to be more business-like and focused, with the absence of pauses restricting time for reflection. For patients with stable, well-managed conditions, remote consultations were felt to be appropriate and could be more convenient than in-person consultations. However, the loss of visual cues meant some patients felt they could not give a holistic view of their condition and limited clinicians' ability to gather and convey information. Clinicians adjusted their approach by asking more questions, checking understanding more frequently and expressing empathy verbally, but felt patients still shared fewer concerns remotely than in person; a perception with which patients concurred., Conclusions: These findings highlight the importance of ensuring, for each patient, that remote care is appropriate. Future research should focus on developing ways to support both clinicians and patients to gather and provide all information necessary during remote consultations, to enhance communication and trust., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Background: Following a large-scale, pandemic-driven shift to remote consulting in UK general practice in 2020, 2021 saw a partial return to in-person consultations. This occurred in the context of extreme workload pressures because of backlogs, staff shortages, and task shifting., Aim: To study media depictions of remote consultations in UK general practice at a time of system stress., Design and Setting: Thematic analysis of national newspaper articles about remote GP consultations from two time periods: 13-26 May 2021, following an NHS England letter, and 14-27 October 2021, following a government-backed directive, both stipulating a return to in-person consulting., Method: Articles were identified through, and retrieved from, LexisNexis. A coding system of themes and narrative devices was developed iteratively to inform data analysis., Results: In total, 25 articles reported on the letter and 75 on the directive. Newspaper coverage of remote consulting was strikingly negative. The right-leaning press in particular praised the return to in-person consultations, depicting remote care as creating access barriers and compromising safety. Two newspapers led national campaigns pressuring the government to require GPs to offer in-person consultations. GPs were quoted as reluctant to return to an 'in-person by default' service (as it would further pressurise a system already close to breaking point)., Conclusion: Remote consultations have become associated in the media with poor practice. Some newspapers were actively leading the 'war' on general practice rather than merely reporting on it. Proactive dialogue between practitioners and the media might help minimise polarisation and improve perceptions around general practice., (© The Authors.)

Background Provision of spirometry for chronic obstructive pulmonary disease (COPD) is a new requirement in primary care. Effective spirometry requires that tests and interpretations meet international criteria. Aim To assess the feasibility and usefulness of remote specialist reporting of primary care spirometry. Design of study Comparison of reporting by primary care clinicians and respiratory specialists of consecutive primary care spirometry tests. Setting South London primary care teams with patient lists ≥6000. Method Feasibility of remote reporting of spirometry was assessed by the frequency of electronic mailing of tests. Usefulness of remote reporting was defined by the frequency that specialist reports made a clinically significant addition. Usefulness was assessed by measuring agreement (κ) between primary care reports and those of specialists. Clinically significant disagreements were analysed with respect to test quality, diagnosis, and severity. Results Six practices emailed 312 tests over 3 months. Forty-nine tests sent without indices or curves (flow volume and time volume) were excluded. Mean age of patients tested was 65 years and 52% were female. Mean predicted forced expiratory volume in the first second (FEV1) was 69%. Clinically significant disagreements were identified in the interpretation of acceptability (quality) of 67/212 (32%) tests (κ = 0.07; 95% confidence interval [CI] = 0 to 0.24), of diagnosis in 49/168 (29%) tests (κ = 0.39; 95% CI = 0.25 to 0.55), and of severity in 62/191 (32%) tests (κ = 0.53; 95% CI = 0.43 to 0.63). Conclusion Remote reporting of primary care spirometry was feasible. Its usefulness was confirmed by the high rate of additional clinically significant information to the reports of primary care clinicians. The quality of primary care spirometry was so unsatisfactory that remote reporting of tests may be a means of establishing adequate spirometry. [ABSTRACT FROM AUTHOR]

Background:  In March 2020, the delivery of NHS general practice consultations was rapidly modified to mitigate against the spread of COVID-19. Remote triage and consultations became the default, with adapted models for face-to-face contact if clinically required. This study aimed to gain insight into public perception of these adaptations. Methods:  Two online surveys were developed, and conducted between August and September 2020. Survey A, open to anyone receiving the link to it, considered respondents' experiences of healthcare contacts since March 2020, and their understanding of the adapted delivery. Survey B, open to survey A respondents only, then considered how healthcare communication had been received and individual preferences for this. Survey participation was voluntary. Results:  The views and experiences of 150 members of the public were obtained. 105 had considered contacting general practice, although half avoided this or delayed doing so for longer than usual. While some patients did so 'to help the NHS', others experienced reduced access for a variety of reasons including COVID-19 safety concerns. Some however reported benefitting from remote consultation availability and regular texts/emails from their practice. 68% (102/150) of respondents were unaware that patients with COVID-19 were seen separately from other patients during general practice appointments. 27% of those in survey B who had avoided or delayed contact said they would have felt more comfortable contacting general practice had they known about this. Conclusions: Experience and use of the adapted general practice models varied. Some patients felt their access to healthcare was reduced, often due to technological requirements. For some who found attending face-to-face appointments difficult however, remote contact was advantageous. Most patients surveyed were unaware of the COVID-19 control measures in place during face-to-face general practice consultations. Assessment of adapted delivery model accessibility and clearer public messaging about the changes may help reduce inequalities., Competing Interests: No competing interests were disclosed., (Copyright: © 2021 Duncan LJ and Cheng KFD.)

Objective: To understand patients' views on a 'telephone-first' approach, in which all appointment requests in general practice are followed by a telephone call from the general practitioner (GP)., Design: Qualitative interviews with patients and carers., Setting: Twelve general practices in England., Participants: 43 patients, including 30 women, nine aged over 75 years, four parents of young children, five carers, five patients with hearing impairment and two whose first language was not English., Results: Patients expressed varied views, often strongly held, ranging from enthusiasm for to hostility towards the 'telephone-first' approach. The new system suited some patients, avoiding the need to come into the surgery but was problematic for others, for example, when it was difficult for someone working in an open plan office to take a call-back. A substantial proportion of negative comments were about the operation of the scheme itself rather than the principles behind it, for example, difficulty getting through on the phone or being unable to schedule when the GP would phone back. Some practices were able to operate the scheme in a way that met their patients' needs better than others and practices varied significantly in how they had implemented the approach., Conclusions: The 'telephone-first' approach appears to work well for some patients, but others find it much less acceptable. Some of the reported problems related to how the approach had been implemented rather than the 'telephone-first' approach in principle and suggests there may be potential for some of the challenges experienced by patients to be overcome., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY. Published by BMJ.)

Background: The receptionist is pivotal to the smooth running of general practice in the UK, communicating with patients and booking appointments., Aim: The authors aimed to explore the role of the receptionist in the implementation of new approaches to consultations in primary care., Design and Setting: The authors conducted a team-based focused ethnography. Three researchers observed eight general practices across England and Scotland between June 2015 and May 2016., Method: Interviews were conducted with 39 patients and 45 staff in the practices, all of which had adopted one or more methods (telephone, email, e-consultation, or internet video) for providing an alternative to face-to-face consultation., Results: Receptionists have a key role in facilitating patient awareness regarding new approaches to consultations in primary care, while at the same time ensuring that patients receive a consultation appropriate to their needs. In this study, receptionists' involvement in implementation and planning for the introduction of alternative approaches to face-to-face consultations was minimal, despite the expectation that they would be involved in delivery., Conclusion: A shared understanding within practices of the potential difficulties and extra work that might ensue for reception staff was lacking. This might contribute to the low uptake by patients of potentially important innovations in service delivery. Involvement of the wider practice team in planning and piloting changes, supporting team members through service reconfiguration, and providing an opportunity to discuss and contribute to modifications of any new system would ensure that reception staff are suitably prepared to support the introduction of a new approach to consultations., (© British Journal of General Practice 2018.)

Background: Public Health England (PHE) coordinates a suite of real-time national syndromic surveillance systems monitoring general practice, emergency department and remote health advice data. We describe the development and informal evaluation of a new syndromic surveillance system using NHS 111 remote health advice data., Methods: NHS 111 syndromic indicators were monitored daily at national and local level. Statistical models were applied to daily data to identify significant exceedances; statistical baselines were developed for each syndrome and area using a multi-level hierarchical mixed effects model., Results: Between November 2013 and October 2014, there were on average 19 095 NHS 111 calls each weekday and 43 084 each weekend day in the PHE dataset. There was a predominance of females using the service (57%); highest percentage of calls received was in the age group 1-4 years (14%). This system was used to monitor respiratory and gastrointestinal infections over the winter of 2013-14, the potential public health impact of severe flooding across parts of southern England and poor air quality episodes across England in April 2014., Conclusions: This new system complements and supplements the existing PHE syndromic surveillance systems and is now integrated into the routine daily processes that form this national syndromic surveillance service., (© Crown copyright 2016.)

Background: The majority of established telestroke services are based on "hub-and-spoke" models for providing acute clinical assessment and thrombolysis. We report results from the first year of the successful implementation of a locally based telemedicine network, without the need of 1 or more hub hospitals, across a largely rural landscape., Methods and Results: Following a successful pilot phase that demonstrated safety and feasibility, the East of England telestroke project was rolled out across 7 regional hospitals, covering an area of 7500 square miles and a population of 5.6 million to enable out-of-hours access to thrombolysis. Between November 2010 and November 2011, 142 telemedicine consultations were recorded out-of-hours. Seventy-four (52.11%) cases received thrombolysis. Median (IQR) onset-to-needle and door-to-needle times were 169 (141.5 to 201.5) minutes and 94 (72 to 113.5) minutes, respectively. Symptomatic hemorrhage rate was 7.3% and stroke mimic rate was 10.6%., Conclusions: We demonstrate the safety and effectiveness of a horizontal networking approach for stroke telemedicine, which may be applicable to areas where traditional "hub-and-spoke" models may not be geographically feasible.

Objective: To describe the process, efficacy and safety of intravenous thrombolysis for acute ischaemic stroke in an emergency department (ED) setting with remote specialist support through structured telephone consultation., Design: Retrospective case series., Setting: Three EDs within a single stroke service in northern England., Participants: Patients with acute stroke given intravenous thrombolytic therapy between 6 September 2007 and 1 October 2010., Outcome Measures: Combined death and dependency at 90 days (0-2 on the modified Rankin Scale for a good outcome vs 3-6 for a poor outcome), door-to-needle time, neurological impairment and presence of treatment related haemorrhage., Results: 192 patients received intravenous thrombolysis. 94/178 (53%) were treated after remote specialist assessment. Data available from 178 patients showed similar proportions with a good outcome after each mode of assessment (56% in person and 48% by telephone). The median door-to-needle time was 8 min faster in the group assessed in person (65 vs 73 min by telephone) but there was no difference in neurological outcome or symptomatic haemorrhage. After review in person, the stroke specialist tended to treat patients with a higher median modified Rankin Scale (1 vs 0 by telephone)., Conclusion: In a single stroke service the clinical outcomes of treatment with intravenous thrombolysis were similar whether assessment was performed after specialist review in person or via a telemedicine service consisting of ED staff training, telephone consultation and remote review of brain imaging by a stroke specialist.

Background: Early detection and management of dementia in primary care are difficult problems for practitioners. England's National Dementia Strategy 2009 seeks to improve these areas but there is limited evidence on how to achieve this most effectively., Aim: This review aims to identify and appraise empirical studies of interventions designed to improve the performance of primary care practitioners in these areas., Design: A narrative review of primary-care based studies., Method: Publications up to February 2010 were identified by searching the electronic databases MEDLINE, Embase, and PsycINFO, and bibliographies. The criterion for inclusion was that studies had to be of interventions aimed at improving detection or management of dementia in primary care. Exclusion criteria included studies in non-English publications, pharmacological interventions, and screening instrument studies. Quality was assessed using the PEDro (Physiotherapy Evidence Database) scale., Results: Fifteen studies were identified, of which 11 were randomised controlled trials. Eight reported educational interventions, and seven trialled service redesign, either by changing the service pathway or by introducing case management. Educationally, only facilitated sessions and decision-support software improved GPs' diagnosis of dementia, as did trials of service-pathway modification. Some of the case-management trials showed improved stakeholder satisfaction, decreased symptoms, and care that was more concordant with guidelines., Conclusion: The quality of the studies varied considerably. Educational interventions are effective when learners are able to set their own educational agenda. Although modifying the service pathway and using case management can assist in several aspects of dementia care, these would require the provision of extra resources, and their value is yet to be tested in different health systems.

Objective: To seek opinions from general dental practitioners in Calderdale and Kirklees (West Yorkshire) regarding an online orthodontic referral service and to establish the profile of dentists working in primary care who would refer patients online for a consultant orthodontist's opinion., Methodology: All 91 general dental practices in Calderdale and Kirklees in West Yorkshire were sent a piloted questionnaire enquiring into their orthodontic treatment and referral patterns, and also into their attitudes to the use of the Internet and related technologies. Three mailings were performed, followed by telephone contact with non-responders., Results: Usable responses were obtained from 119 general dental practitioners who worked in 71 practices (78%). Analysis of data showed that, when asked whether they would be interested in using teledentistry to obtain a consultant orthodontist's opinion online, 53/116 (46%) replied positively. The most frequently specified reason for this interest was that it would save time and would achieve a quicker opinion for a practitioner's treatment plan. These dentists were more likely to be familiar with the use of digital cameras, be using removable appliances, and currently be in the habit of referring orthodontic cases to consultants and specialists., Conclusions: Just under half of the dentists working in primary care in Calderdale and Kirklees who responded had a positive attitude towards the benefits of a teledentistry referral scheme. However, a substantial number remained undecided, possibly because they were unsure of their information technology (IT) skills. A further pilot study is planned. It will enquire into the feasibility of carrying out such an exercise across West Yorkshire.

Objective: We describe the impact of a remote patient monitoring (RPM) system implemented in residential care homes., Methods: The service was designed to support the staff in managing patients that presented with non-specific symptoms. The system allows vital signs to be transmitted to a central server. The medical professional may then observe the data and provide advice to the staff on optimum management. Our system has been evaluated for 18 months and largely provided routine measurements., Results: During this period, three residents presented with non specific symptoms that were investigated using the RPM system. One patient had symptoms over a weekend, and the problem remained unresolved on Monday. The resident continued to only complain of feeling unwell, but reported no specific symptoms. Vital signs data were then sent and the doctor consulted. The electrocardiogram (ECG) showed significant ST segment changes. Repetitive measurements of the ECG, heart rate, and oxygen saturation of the blood (SpO2) were made every 5 minutes. The resident had a history angina and CHF. The staff was asked to give the patient aspirin and anti-angina drug. The ECG was seen to resolve after 40 minutes, but the SpO2 was falling. The decision to send to hospital was taken at this point. Two further patients with significant ECG changes were observed during the period of the project, and again both were asymptomatic, but in these cases the condition resolved and hospital admission was avoided. Feedback from users has been very positive. Staff found that the system gave them support to make better informed decisions on patient management, especially when determining whether to admit the person to hospital when reaching end of life. Further comments were that the system also proved useful to reassure relatives during these final stages., Conclusion: Our project demonstrated that significant cardiac events occur in the elderly population of residential homes without symptoms; and that RPM can be used by non medical staff to manage asymptomatic patients in the community.

Objective: To determine patient perceptions of joint teleconsultations (JTC), with particular reference to reasons underlying, and factors contributing to, patient satisfaction and dissatisfaction with this mode of health delivery., Background: Telemedicine has been welcomed as one way of improving health-care delivery, by improving patient access to secondary care and specialist services hence widening patient choice, particularly for patients outside major conurbations. However, a recent systematic review found currently available data on patient satisfaction with telemedicine to be methodologically flawed. Qualitative evaluations offer the opportunity to elucidate the details of patient satisfaction with this mode of health-care delivery., Design: Qualitative study using semi-structured interviews., Setting and Participants: Purposive sample of 28 participants of a major randomized controlled trial (Virtual Outreach study) of JTC conducted in one urban and one rural area in Britain., Intervention: Joint teleconferenced consultations with the patient, patient's general practitioner (GP), and a hospital specialist. The patient and GP were sited in the local practice, while the hospital specialist was in the hospital outpatient department, and the two parties were connected by an ISDN2 link and video-conferencing software., Main Outcome Measures: Patient experiences of JTC, with particular reference to reasons underlying, and factors contributing to, overall satisfaction or dissatisfaction., Results: Two major themes were identified: customer care and doctor-patient interaction. Patients appreciated the customer care aspects of JTC, particularly the enhanced convenience, reduced costs and improved punctuality associated with JTC. However, there were divergent views about the doctor-patient interactions with some patients expressing a sense of alienation arising from the use of technology, and problems with doctor-patient communication., Conclusions: These data add significantly to the existing literature on patient satisfaction with telemedicine, by elucidating the factors underlying overall satisfaction scores and hence have implications for future service delivery and implementation of telemedicine.

We conducted an evaluation of joint teleconsultations involving specialists, general practitioners (GPs) and their patients. Semistructured interviews (n = 39) and focus groups (2 groups with specialists; 6 groups with GPs) were used to collect data to explore participants' views on the educational aspect of joint teleconsultations, and to seek examples of learning that had taken place. The results showed that the teleconsultation was a complex situation in which some learning took place for the generalists, but overall participants were disappointed. Three themes emerged that could enhance the educational potential in future: generalists' reasons for referral as an influence on perceived learning; lack of clarity among clinicians regarding their role and conduct; and the presence of patients as an inhibitor in doctor-doctor interactions.

It has been suggested that joint teleconsultations can improve communication at the primary-secondary care interface. We examined data from a qualitative analysis of social interactions in teleconsultations between specialists and general practitioners. The primary interaction was between specialists and patients. The general practitioners mostly adopted a 'back seat role', listening and observing, but not becoming actively involved. Teleconsultations create a number of interactional difficulties, which are likely to impede implementation and sustainability.

It seems likely that the development of effective diabetes education for patients, carers and staff would prove highly cost-effective. Diabetes-e is an electronic diabetes encyclopaedia designed to provide comprehensive education to patients, carers (e.g. family, schools, care homes) and health professionals (specialist and non-specialist). In addition, educational media such as information leaflets (that can be printed during a consultation), streaming educational video and slide resource packs are available. Self-assessment questionnaires with feedback guide further education and facilitate targeted continuing professional development (CPD) for health professionals. The prototype has been developed with a particular emphasis on patient input. It is anticipated that Diabetes-e will be implemented across Central Nottinghamshire, including training of key personnel, by the end of 2005. The project has already gone live for insulin commencement.

Objectives: To examine the perceptions that those working in primary care have about the purpose and impact that telephone triage by nurses may have on their clinical roles and identities., Methods: Twenty-six semi-structured interviews were carried out with general practitioners (GPs), practice nurses and practice managers from a purposive sample of nine practices in one health district in the North West of England. Analysis drew on the techniques of constant comparison and discourse analysis., Results: Four themes emerged from the data: justifying triage - the respondents justify the introduction of telephone triage by emphasising the managerial benefits of controlling access and by suggesting the benefits this may bring to the patient-clinician relationship; categorising patients - patients are categorised and allocated on the basis of their biomedical diagnoses to the nurses or GPs in the practice; changing roles and identities - the hierarchy of patients and conditions created by allocating patients in this way strengthens and extends the professional hierarchy within a practice; and achieving a balance between conflicting aims - there is tension between the managerial need to triage patients according to their biomedical diagnosis and the aspirations that health care professionals have to personal and patient-centred care., Conclusion: Telephone triage by nurses may be effective at managing patient access to GPs but the need to categorise patients according to biomedical and managerial criteria needs to be balanced against the professional roles and identities that those working in general practice aspire to.

Background: The current model of general practitioner referral of patients to hospital specialists in the UK is sometimes associated with unnecessary duplication of investigations and treatments. We aimed to compare joint teleconsultations between general practitioners, specialists, and patients (virtual outreach) with standard outpatient referral., Methods: Virtual outreach services were established in London and Shrewsbury. The general practitioners referred 3170 patients, of whom 2094 consented to participate in the study and were eligible for inclusion. 1051 patients were randomly assigned virtual outreach, and 1043 standard outpatient appointments. We followed up the patients for 6 months after their index consultation. The primary outcome measure was the offer of a follow-up outpatient appointment. Analysis was by intention to treat., Findings: More patients in the virtual outreach group than the standard group were offered a follow-up appointment (502 [52%] vs 400 [41%], odds ratio 1.52 [95% CI 1.27-1.82], p<0.0001). Significant differences in effects were observed between the two sites (p=0.009) and across different specialties (p<0.0001). Virtual outreach increased the offers of follow-up appointments more in Shrewsbury than in London, and more in ear, nose, and throat surgery and orthopaedics than in the other specialties. Fewer tests and investigations were ordered in the virtual outreach group by an average of 0.79 per patient (0.37-1.21, p=0.0002). Patients' satisfaction (analysed per protocol) was greater after a virtual outreach consultation than after a standard outpatient consultation (mean difference 0.33 scale points [95% CI 0.23-0.43], p<0.0001), with no heterogeneity between specialties or sites., Interpretation: The trial showed that allocation of patients to virtual outreach consultations is variably associated with increased offers of follow-up appointments according to site and specialty, but leads to significant increases in patients' satisfaction and substantial reductions in tests and investigations. Efficient operation of such services will require appropriate selection of patients, significant service reorganisation, and provision of logistical support.

Objective: To investigate GDP opinions of the current referral system and to investigate the need and demand for telemedicine in oral surgery referrals., Design: Postal questionnaire., Setting: 400 GDPs in Greater Manchester., Results: 84% participation rate. 48% were not satisfied overall with the service of their current specialist oral surgery referral site. The principal reason was the length of the waiting time for consultation and treatment. Distance for patients to travel to the specialist unit was also of concern, even though most patients (89%) travelled short distances (return journey of twelve miles or less). 23% of respondents wished to improve their ability to communicate with the oral surgeon and 70% wanted involvement in the patient consultation. Both of these requirements were more likely in younger practitioners., Conclusion: There is a need and demand for change in the referral system for oral surgery specialist care. Telemedicine could conceivably be one way to improve access to specialist oral surgery care.

The introduction of nurse telephone triage for patients requesting same-day attention in a GP practice has reduced the number of appointments and home visits for these patients. Patients welcome the opportunity to speak to a health professional when they telephone. The practice has found the scheme a useful method of demand management and hopes to expand it.

The objective of this multicentre study was to undertake a systematic comparison of face-to-face consultations and teleconsultations performed using low-cost videoconferencing equipment. One hundred and twenty-six patients were enrolled by their general practitioners across three sites. Each patient underwent a teleconsultation with a distant dermatologist followed by a traditional face-to-face consultation with a dermatologist. The main outcome measures were diagnostic concordance rates, management plans and patient and doctor satisfaction. One hundred and fifty-five diagnoses were identified by the face-to-face consultations from the sample of 126 patients. Identical diagnoses were recorded from both types of consultation in 59% of cases. Teledermatology consultations missed a secondary diagnosis in 6% of cases and were unable to make a useful diagnosis in 11% of cases. Wrong diagnoses were made by the teledermatologist in 4% of cases. Dermatologists were able to make a definitive diagnosis by face-to-face consultations in significantly more cases than by teleconsultations (P = 0.001). Where both types of consultation resulted in a single diagnosis there was a high level of agreement (kappa = 0.96, lower 95% confidence limit 0.91-1.00). Overall follow-up rates from both types of consultation were almost identical. Fifty per cent of patients seen could have been managed using a single videoconferenced teleconsultation without any requirement for further specialist intervention. Patients reported high levels of satisfaction with the teleconsultations. General practitioners reported that 75% of the teleconsultations were of educational benefit. This study illustrates the potential of telemedicine to diagnose and manage dermatology cases referred from primary care. Once the problem of image quality has been addressed, further studies will be required to investigate the cost-effectiveness of a teledermatology service and the potential consequences for the provision of dermatological services in the U.K.

Objective: To evaluate the efficacy and acceptability of a self-help program for mild-to-moderate depression that combined treatment booklets and telephone calls to a computer-aided Interactive Voice Response (IVR) system., Method: In an open trial, 41 patients from Boston, Massachusetts; Madison, Wisconsin; and London, England, used COPE, a 12-week self-help system for depression. COPE consisted of an introductory videotape and 9 booklets accompanied by 11 telephone calls to an IVR system that made self-help recommendations to patients based on information they entered., Results: All 41 patients successfully completed the self-assessment in the booklets and telephone calls; 28 (68%) also completed the 12-week self-help program. Hamilton Rating Scale for Depression (HAM-D) and Work and Social Adjustment scores improved significantly (41% and 42% mean reduction in the intent-to-treat sample, respectively, p < .001). Eighteen (64%) of the 28 completers were considered responders on the basis of > or = 50% reduction in their HAM-D scores. There was a higher percentage of completers in the pooled U.S. sites (82% vs. 43%), and U.S. completers improved more than those in the United Kingdom (73% vs. 43% were responders). Most (68%) of the calls were made outside usual office hours, Monday-Friday, 9:00 a.m. to 5:00 p.m. Expectation of effectiveness and time spent making COPE calls (more treatment modules) correlated positively with improvement over 12 weeks. Mean call length for completers was 14 minutes., Conclusion: A self-help system comprised of a computer-aided telephone system and a series of booklets was used successfully by people with mild-to-moderate depression. These preliminary results are encouraging for people who cannot otherwise access ongoing, in-person therapy.

Teledermatology is no longer a futuristic curiosity; several general practices across the UK are now preparing to be electronically linked to other medical services for the purposes of referral and telediagnosis. Further, digital imaging in dermatology has been the subject of considerable research in recent years, largely because of its application to telemedicine. Indeed in the UK, geographically isolated general practices in North Powys have already demonstrated the effective delivery of dermatological expertise through a video-conferencing link to a consultant dermatologist at Aberystwyth Hospital, thereby reducing the need for patients or the consultant to travel long distances.