Remote care in UK general practice: baseline data on 11 case studies [version 2; peer review: 2 approved].

Background: Accessing and receiving care remotely (by telephone, video or online) became the default option during the coronavirus disease 2019 (COVID-19) pandemic, but in-person care has unique benefits in some circumstances. We are studying UK general practices as they try to balance remote and in-person care, with recurrent waves of COVID-19 and various post-pandemic backlogs. Methods: Mixed-methods (mostly qualitative) case study across 11 general practices. Researchers-in-residence have built relationships with practices and become familiar with their contexts and activities; they are following their progress for two years via staff and patient interviews, documents and ethnography, and supporting improvement efforts through co-design. In this paper, we report baseline data. Results: Reflecting our maximum-variety sampling strategy, the 11 practices vary in size, setting, ethos, staffing, population demographics and digital maturity, but share common contextual features-notably system-level stressors such as high workload and staff shortages, and UK's technical and regulatory infrastructure. We have identified both commonalities and differences between practices in terms of how they: 1] manage the 'digital front door' (access and triage) and balance demand and capacity; 2] strive for high standards of quality and safety; 3] ensure digital inclusion and mitigate wider inequalities; 4] support and train their staff (clinical and non-clinical), students and trainees; 5] select, install, pilot and use technologies and the digital infrastructure which support them; and 6] involve patients in their improvement efforts. Conclusions: General practices' responses to pandemic-induced disruptive innovation appear unique and situated. We anticipate that by focusing on depth and detail, this longitudinal study will throw light on why a solution that works well in one practice does not work at all in another. As the study unfolds, we will explore how practices achieve timely diagnosis of urgent or serious illness and manage continuity of care, long-term conditions and complex needs.

Clinical risk in remote consultations in general practice: findings from in-COVID-19 pandemic qualitative research.

BACKGROUND: The COVID-19 pandemic-related rise in remote consulting raises questions about the nature and type of risks in remote general practice. AIM: To develop an empirically based and theory-informed taxonomy of risks associated with remote consultations. DESIGN & SETTING: Qualitative sub-study of data selected from the wider datasets of three large, multi-site, mixed-method studies of remote care in general practice before and during the COVID-19 pandemic in the UK. METHOD: Semi-structured interviews and focus groups, with a total of 176 clinicians and 43 patients. Data were analysed thematically, taking account of an existing framework of domains of clinical risk. RESULTS: The COVID-19 pandemic brought changes to estates (for example, how waiting rooms were used), access pathways, technologies, and interpersonal interactions. Six domains of risk were evident in relation to the following: (1) practice set-up and organisation (including digital inequalities of access, technology failure, and reduced service efficiency); (2) communication and the clinical relationship (including a shift to more transactional consultations); (3) quality of clinical care (including missed diagnoses, safeguarding challenges, over-investigation, and over-treatment); (4) increased burden on the patient (for example, to self-examine and navigate between services); (5) reduced opportunities for screening and managing the social determinants of health; and (6) workforce (including increased clinician stress and fewer opportunities for learning). CONCLUSION: Notwithstanding potential benefits, if remote consultations are to work safely, risks must be actively mitigated by measures that include digital inclusion strategies, enhanced safety-netting, and training and support for staff.

Desperately Seeking Intersectionality in Digital Health Disparity Research: Narrative Review to Inform a Richer Theorization of Multiple Disadvantage.

BACKGROUND: Digital consultations between patients and clinicians increased markedly during the COVID-19 pandemic, raising questions about equity. OBJECTIVE: This study aimed to review the literature on how multiple disadvantage-specifically, older age, lower socioeconomic status, and limited English proficiency-has been conceptualized, theorized, and studied empirically in relation to digital consultations. We focused mainly on video consultations as they have wider disparities than telephone consultations and relevant data on e-consultations are sparse. METHODS: Using keyword and snowball searching, we identified relevant papers published between 2012 and 2022 using Ovid MEDLINE, Web of Science, Google Scholar, and PubMed. The first search was completed in July 2022. Papers meeting the inclusion criteria were analyzed thematically and summarized, and their key findings were tabulated using the Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative Research criteria. Explanations for digital disparities were critically examined, and a search was undertaken in October 2022 to identify theoretical lenses on multiple disadvantage. RESULTS: Of 663 articles from the initial search, 27 (4.1%) met our inclusion criteria. In total, 37% (10/27) were commentaries, and 63% (17/27) were peer-reviewed empirical studies (11/27, 41% quantitative; 5/27, 19% qualitative; 1/27, 4% mixed methods; 1/27, 4% systematic reviews; and 1/27, 4% narrative reviews). Empirical studies were mostly small, rapidly conducted, and briefly reported. Most studies (25/27, 93%) identified marked digital disparities but lacked a strong theoretical lens. Proposed solutions focused on identifying and removing barriers, but the authors generally overlooked the pervasive impact of multiple layers of disadvantage. The data set included no theoretically informed studies that examined how different dimensions of disadvantage combined to affect digital health disparities. In our subsequent search, we identified 3 theoretical approaches that might help account for these digital disparities. Fundamental cause theory by Link and Phelan addresses why the association between socioeconomic status and health is pervasive and persists over time. Digital capital theory by Ragnedda and Ruiu explains how people mobilize resources to participate in digitally mediated activities and services. Intersectionality theory by Crenshaw states that systems of oppression are inherently bound together, creating singular social experiences for people who bear the force of multiple adverse social structures. CONCLUSIONS: A limitation of our initial sample was the sparse and undertheorized nature of the primary literature. The lack of attention to how digital health disparities emerge and play out both within and across categories of disadvantage means that solutions proposed to date may be oversimplistic and insufficient. Theories of multiple disadvantage have bearing on digital health, and there may be others of relevance besides those discussed in this paper. We call for greater interdisciplinary dialogue between theoretical research on multiple disadvantage and empirical studies on digital health disparities.

The Role of Information Infrastructures in Scaling up Video Consultations During COVID-19: Mixed Methods Case Study Into Opportunity, Disruption, and Exposure.

BACKGROUND: Until COVID-19, implementation and uptake of video consultations in health care was slow. However, the pandemic created a "burning platform" for scaling up such services. As health care organizations look to expand and maintain the use of video in the "new normal," it is important to understand infrastructural influences and changes that emerged during the pandemic and that may influence sustainability going forward. OBJECTIVE: This study aims to draw lessons from 4 National Health Service (NHS) organizations on how information infrastructures shaped, and were shaped by, the rapid scale-up of video consultations during COVID-19. METHODS: A mixed methods case study of 4 NHS trusts in England was conducted before and during the pandemic. Data comprised 90 interviews with 49 participants (eg, clinicians, managers, administrators, and IT support), ethnographic field notes, and video consultation activity data. We sought examples of infrastructural features and challenges related to the rapid scale-up of video. Analysis was guided by Gkeredakis et al's 3 perspectives on crisis and digital change: as opportunity (for accelerated innovation and removal of barriers to experimentation), disruption (to organizational practices, generating new dependencies and risks), and exposure (of vulnerabilities in both people and infrastructure). RESULTS: Before COVID-19, there was a strong policy push for video consultations as a way of delivering health care efficiently. However, the spread of video was slow, and adopting clinicians described their use as ad hoc rather than business as usual. When the pandemic hit, video was rapidly scaled up. The most rapid increase in use was during the first month of the pandemic (March-April 2020), from an average of 8 video consultations per week to 171 per week at each site. Uptake continued to increase during the pandemic, averaging approximately 800 video consultations per week by March 2021. From an opportunity perspective, participants talked about changes to institutional elements of infrastructure, which had historically restricted the introduction and use of video. This was supported by an "organizing vision" for video, bringing legitimacy and support. Perspectives on disruption centered on changes to social, technical, and material work environments and the emergence of new patterns of action. Retaining positive elements of such change required a judicious balance between managerial (top-down) and emergent (bottom-up) approaches. Perspectives on exposure foregrounded social and technical impediments to video consulting. This highlighted the need to attend to the materiality and dependability of the installed base, as well as the social and cultural context of use. CONCLUSIONS: For sustained adoption at scale, health care organizations need to enable incremental systemic change and flexibility through agile governance and knowledge transfer pathways, support process multiplicity within virtual clinic workflows, attend to the materiality and dependability of the IT infrastructure within and beyond organizational boundaries, and maintain an overall narrative within which the continued use of video can be framed.

Theorising the shift to video consulting in the UK during the COVID-19 pandemic: Analysis of a mixed methods study using practice theory.

We studied video consulting in the National Health Service during 2020-2021 through video interviews, an online survey and online discussions with people who had provided and participated in such consultations. Video consulting had previously been used for selected groups in limited settings in the UK. The pandemic created a seismic shift in the context for remote consulting, in which video transformed from a niche technology typically introduced by individual clinicians committed to innovation and quality improvement to offering what many felt was the only safe way to deliver certain types of healthcare. A new practice emerged: a co-constitution of technology and healthcare made possible by new configurations of equipment, connectivity and physical spaces. Despite heterogeneous service settings and previous experiences of video consulting, we found certain kinds of common changes had made video consulting possible. We used practice theory to analyse these changes, interpreting the commonalities found in our data as changes in purpose, material arrangements and a relaxing of rules about security, confidentiality and location of consultations. The practice of video consulting was equivocal. Accounts of, and preferences for, video consulting varied as did the extent to which it was sustained after initial take-up. People made sense of video consulting in different ways, ranging from interpreting video as offering a new modality of healthcare for the future to a sub-optimal, temporary alternative to in-person care. Despite these variations, video consulting became a recognisable social phenomenon, albeit neither universally adopted nor consistently sustained. The nature of this social change offers new perspectives on processes of implementation and spread and scale-up. Our findings have important implications for the future of video consulting. We emphasise the necessity for viable material arrangements and a continued shared interpretation of the meaning of video consulting for the practice to continue.

Telepsychiatry: learning from the pandemic.

This article draws on research and clinical experience to discuss how and when to use video consultations in mental health settings. The appropriateness and impact of virtual consultations are influenced by the patient's clinical needs and social context, as well as by service-level socio-technical and logistical factors.

Achieving Spread, Scale Up and Sustainability of Video Consulting Services During the COVID-19 Pandemic? Findings From a Comparative Case Study of Policy Implementation in England, Wales, Scotland and Northern Ireland.

Requirements for physical distancing as a result of COVID-19 and the need to reduce the risk of infection prompted policy supporting rapid roll out of video consulting across the four nations of the UK-England, Northern Ireland, Scotland and Wales. Drawing on three studies of the accelerated implementation and uptake of video consulting across the four nations, we present a comparative and interpretive policy analysis of the spread and scale-up of video consulting during the pandemic. Data include interviews with 59 national level stakeholders, 55 health and social care staff and 30 patients, 20 national documents, responses to a UK-wide survey of NHS staff and analysis of routine activity data. Sampling ensured variations in geography, clinical context and adoption progress across the combined dataset. Comparative analysis was guided by theory on policy implementation and crisis management. The pandemic provided a "burning platform" prompting UK-wide policy supporting the use of video consulting in health care as a critical means of managing the risk of infection and a standard mode of provision. This policy push facilitated interest in video consulting across the UK. There was, however, marked variation in how this was put into practice across the four nations. Pre-existing infrastructure, policies and incentives for video consulting in Scotland, combined with a collaborative system-level approach, a program dedicated to developing video-based services and resourcing and supporting staff to deliver them enabled widespread buy-in and rapid spread. In England, Wales and Northern Ireland, pre-existing support for digital health (e.g., hardware, incentives) and virtual care, combined with reduced regulation and "light touch" procurement managed to override some (but by no means all) cultural barriers and professional resistance to implementing digital change. In Northern Ireland and Wales, limited infrastructure muted spread. In all three countries, significant effort at system level to develop, review and run video consulting programs enabled a substantial number of providers to change their practice, albeit variably across settings. Across all four nations ongoing uncertainty, potential restructuring and tightening of regulations, along with difficulties inherent in addressing inequalities in digital access, raise questions about the longer-term sustainability of changes to-date.

Expanding Video Consultation Services at Pace and Scale in Scotland During the COVID-19 Pandemic: National Mixed Methods Case Study.

BACKGROUND: Scotland-a country of 5.5 million people-has a rugged geography with many outlying islands, creating access challenges for many citizens. The government has long sought to mitigate these through a range of measures including an ambitious technology-enabled care program. A strategy to develop a nationwide video consultation service began in 2017. Our mixed methods evaluation was commissioned in mid-2019 and extended to cover the pandemic response in 2020. OBJECTIVE: To draw lessons from a national evaluation of the introduction, spread, and scale-up of Scotland's video consultation services both before and during the pandemic. METHODS: Data sources comprised 223 interviews (with patients, staff, technology providers, and policymakers), 60 hours of ethnographic observation (including in-person visits to remote settings), patient and staff satisfaction surveys (n=20,349), professional and public engagement questionnaires (n=5400), uptake statistics, and local and national documents. Fieldwork during the pandemic was of necessity conducted remotely. Data were analyzed thematically and theorized using the Planning and Evaluating Remote Consultation Services (PERCS) framework which considers multiple influences interacting dynamically and unfolding over time. RESULTS: By the time the pandemic hit, there had been considerable investment in material and technological infrastructure, staff training, and professional and public engagement. Scotland was thus uniquely well placed to expand its video consultation services at pace and scale. Within 4 months (March-June 2020), the number of video consultations increased from about 330 to 17,000 per week nationally. While not everything went smoothly, video was used for a much wider range of clinical problems, vastly extending the prepandemic focus on outpatient monitoring of chronic stable conditions. The technology was generally considered dependable and easy to use. In most cases (14,677/18,817, 78%), patients reported no technical problems during their postconsultation survey. Health care organizations' general innovativeness and digital maturity had a strong bearing on their ability to introduce, routinize, and expand video consultation services. CONCLUSIONS: The national-level groundwork before the pandemic allowed many services to rapidly extend the use of video consultations during the pandemic, supported by a strong strategic vision, a well-resourced quality improvement model, dependable technology, and multiple opportunities for staff to try out the video option. Scotland provides an important national case study from which other countries may learn.

Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework.

BACKGROUND: COVID-19 has thrust video consulting into the limelight, as health care practitioners worldwide shift to delivering care remotely. Evidence suggests that video consulting is acceptable, safe, and effective in selected conditions and settings. However, research to date has mostly focused on initial adoption, with limited consideration of how video consulting can be mainstreamed and sustained. OBJECTIVE: This study sought to do the following: (1) review and synthesize reported opportunities, challenges, and lessons learned in the scale-up, spread, and sustainability of video consultations, and (2) identify transferable insights that can inform policy and practice. METHODS: We identified papers through systematic searches in PubMed, CINAHL, and Web of Science. Included articles reported on synchronous, video-based consultations that had spread to more than one setting beyond an initial pilot or feasibility stage, and were published since 2010. We used the Nonadoption, Abandonment, and challenges to the Scale-up, Spread, and Sustainability (NASSS) framework to synthesize findings relating to 7 domains: an understanding of the health condition(s) for which video consultations were being used, the material properties of the technological platform and relevant peripherals, the value proposition for patients and developers, the role of the adopter system, organizational factors, wider macro-level considerations, and emergence over time. RESULTS: We identified 13 papers describing 10 different video consultation services in 6 regions, covering the following: (1) video-to-home services, connecting providers directly to the patient; (2) hub-and-spoke models, connecting a provider at a central hub to a patient at a rural center; and (3) large-scale top-down evaluations scaled up or spread across a national health administration. Services covered rehabilitation, geriatrics, cancer surgery, diabetes, and mental health, as well as general specialist care and primary care. Potential enablers of spread and scale-up included embedded leadership and the presence of a telehealth champion, appropriate reimbursement mechanisms, user-friendly technology, pre-existing staff relationships, and adaptation (of technology and services) over time. Challenges tended to be related to service development, such as the absence of a long-term strategic plan, resistance to change, cost and reimbursement issues, and the technical experience of staff. There was limited articulation of the challenges to scale-up and spread of video consultations. This was combined with a lack of theorization, with papers tending to view spread and scale-up as the sum of multiple technical implementations, rather than theorizing the distinct processes required to achieve widespread adoption. CONCLUSIONS: There remains a significant lack of evidence that can support the spread and scale-up of video consulting. Given the recent pace of change due to COVID-19, a more definitive evidence base is urgently needed to support global efforts and match enthusiasm for extending use.