Unintended consequences of online consultations: a qualitative study in UK primary care

Background: Health services are increasingly using digital tools to deliver care and online consultations are being widely adopted in primary care settings. The intended consequences of online consultations are to increase patient access to care and increase the efficiency of care. Aim: To identify and understand the unintended consequences of online consultations in primary care. Design and Setting: Qualitative interview study in eight general practices using online consultation tools in South West and North West England. Method: Thematic analysis of semi-structured interviews with 19 patients and 18 general practice staff. Results: We identified consequences of online consultations that restricted patient access to care by making it difficult for some patients to communicate effectively with a GP and disadvantaging digitally-excluded patients. This stemmed from patient uncertainty about how their queries were dealt with and whether practices used online consultations as their preferred method for patients to contact the practice. We identified consequences that limited increases in practice efficiency by creating additional work, isolation and dissatisfaction for some staff. Conclusion: Unintended consequences often present operational challenges that are foreseeable and partly preventable. However these challenges must be recognised and solutions resourced sufficiently. Not everyone may benefit and local decisions will need to be made about trade-offs. Bespoke process change is critical to making effective use of online consultation tools. Unintended consequences also present clinical challenges that result from asynchronous communication. Online consultation tools favour simple, well-formulated, information exchange that leads to diffuse relationships and a more transactional style of medicine.

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Unintended consequences of patient online access to health records: a qualitative study in UK primary care

10.21203/rs.3.rs-1256673/v1 ◽

2022 ◽

Author(s):

Andrew Turner ◽

Rebecca Morris ◽

Lorraine McDonagh ◽

Fiona L. Hamilton ◽

Sarah Blake ◽

...

Keyword(s):

Primary Care ◽

Health Care ◽

Unintended Consequences ◽

Patient Access ◽

North West ◽

Individual Interviews ◽

Access To Health ◽

Online Access ◽

Default Position ◽

The Right

Abstract BackgroundHealth systems around the world are seeking to harness digital tools to promote patient autonomy and increase the efficiency of care. One example of this policy in England is online patient access to full medical records in primary care. Since April 2019, all NHS England patients have had the right to access their full medical record prospectively, and full record access has been the “default position” since April 2020.AimTo identify and understand the unintended consequences of online patient access their medical record.Design and SettingQualitative interview study in 10 general practices in South West and North West England.MethodSemi-structured individual interviews with 13 patients and 16 general practice staff with experience of patient online access to health records.ResultsOnline access generated unintended consequences that negatively impacted patients’ understanding of their health care, for example patients discovering surprising information or information that was difficult to interpret. Online access impacted GPs’ documentation practices, such as when GPs pre-emptively attempted to minimise potential misunderstandings to aid patient understanding of their health care, in other cases, negatively impacting the quality of the records and patient safety when GPs avoided documenting their speculations or concerns. Contrary to assumptions that practice workload would be reduced, online access introduced extra work, such as managing and monitoring access and taking measures to prevent possible harm to patients.ConclusionThe unintended consequences described by both staff and patients show that to achieve the intended consequences set out in NHS policy additional work is necessary to prepare records for sharing and prepare patients about what to expect. It is crucial that practices are adequately supported and resourced to manage the unintended consequences of online access now that it is the default position.

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Understanding barriers and facilitators to compliance with UK social distancing guidelines during the COVID-19 pandemic: A qualitative interview study

10.31234/osf.io/k4wqh ◽

2021 ◽

Author(s):

Alexandra Burton ◽

Alison McKinlay ◽

Joanna Dawes ◽

Anna Roberts ◽

Wendy Fynn ◽

...

Keyword(s):

Social Support ◽

Emotional Support ◽

Unintended Consequences ◽

Control Measures ◽

Barriers And Facilitators ◽

Structured Interviews ◽

Social Distancing ◽

Shared Spaces ◽

Qualitative Interview Study ◽

Motivation Model

ObjectivesWhen followed, there is evidence that social distancing measures play a major role in reducing the transmission of viruses such as COVID-19. However, not all individuals follow the guidance. This study aimed to explore barriers and facilitators to compliance with United Kingdom social distancing guidelines during the COVID-19 pandemic.MethodSemi-structured interviews with 116 adults. Data were analysed using reflexive thematic analysis and themes mapped to domains of the Capability, Opportunity and Motivation Model of Behaviour (COM-B).Main Outcome MeasuresWe identified 12 themes affecting compliance to UK social distancing guidelines.ResultsBarriers to compliance included inconsistent rules, caring responsibilities, fatigue, unintended consequences of control measures, and the need for emotional support. Facilitators were informational support and social responsibility. Six themes acted both as a barrier or facilitator: lived environment and shared spaces, beliefs about consequences of non-compliance, influence of others, practical social support, and trust in government. Conclusions Participants experienced a range of barriers and facilitators to compliance, often dependent on individual circumstances. Reflective motivation, psychological capability and social opportunity were important drivers for compliance. Measures that enable social support alongside strategies that help maintain motivation to comply, provide clear guidance and optimise social cohesion should be promoted.

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Operational failures and how they influence the work of GPs: a qualitative study in primary care

British Journal of General Practice ◽

10.3399/bjgp20x713009 ◽

2020 ◽

Vol 70 (700) ◽

pp. e825-e832

Author(s):

Carol Sinnott ◽

Alexandros Georgiadis ◽

Mary Dixon-Woods

Keyword(s):

Primary Care ◽

Work Environment ◽

Information Transfer ◽

Healthcare Providers ◽

Comparison Method ◽

Care Work ◽

System Level ◽

Structured Interviews ◽

Qualitative Interview Study ◽

Operational Failures

BackgroundOperational failures, defined as inadequacies or errors in the information, supplies, or equipment needed for patient care, are known to be highly consequential in hospital environments. Despite their likely relevance for GPs’ experiences of work, they remain under-explored in primary care.AimTo identify operational failures in the primary care work environment and to examine how they influence GPs’ work.Design and settingQualitative interview study in the East of England.MethodSemi-structured interviews were conducted with GPs (n = 21). Data analysis was based on the constant comparison method.ResultsGPs reported a large burden of operational failures, many of them related to information transfer with external healthcare providers, practice technology, and organisation of work within practices. Faced with operational failures, GPs undertook ‘compensatory labour’ to fulfil their duties of coordinating and safeguarding patients’ care. Dealing with operational failures imposed significant additional strain in the context of already stretched daily schedules, but this work remained largely invisible. In part, this was because GPs acted to fix problems in the here-and-now rather than referring them to source, and they characteristically did not report operational failures at system level. They also identified challenges in making process improvements at practice level, including medicolegal uncertainties about delegation.ConclusionOperational failures in primary care matter for GPs and their experience of work. Compensatory labour is burdensome with an unintended consequence of rendering these failures largely invisible. Recognition of the significance of operational failures should stimulate efforts to make the primary care work environment more attractive.

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How to engage French professionals to undertake social responsibility at a local level?

European Journal of Public Health ◽

10.1093/eurpub/ckz186.361 ◽

2019 ◽

Vol 29 (Supplement_4) ◽

Author(s):

S Gautier ◽

Y Bourgueil

Keyword(s):

Primary Care ◽

Access To Care ◽

Health Professionals ◽

Local Level ◽

Radical Change ◽

Team Work ◽

Professional Commitment ◽

Fee For Service ◽

Structured Interviews ◽

Integration Of Care

Abstract Background In France, primary care is organised according to the principles of private practice: independent providers, payment by fee for service, freedom of settlement... Successive reforms have introduced more regulation i.e. gatekeeping role for GPs, better recognition of professional groups, new forms of payment and promotion of team work and multi-professional practices. Today, the concept of Health Territorial and Professional Communities (HTPC) is becoming a key element of health care reform encouraging primary care professionals to meet with specialists and social workers at a larger level than practice. HTPC should address issues such as access to services, coordination of care and promoting of preventive actions toward populations. This implies change in the roles, skills, methods and resources needed on both professional and regulatory sides. This study explores levers of the professional commitment in the HTPC and resources necessary for it. Methods We conducted a qualitative multiple case study in three French regions. Data was collected from thirty semi-structured interviews with key national informants, regional regulators and health professionals themselves. Results Professional commitment emerges at a local level on a territory defined by the collaboration practices and habits following a bottom-up process. The integration of care relies on the size of the HTPC which allows them to know each other and to work together to improve access to care and patient’s disease management. In order to achieve that, professionals claim to have access to administrative health data and to be able to analyze it. They need to develop news skills in management and group animation. The function and training of coordination professionals appear to be essential. Conclusions The professional commitment in HTPC relies on professional empowerment toward collective activities. This requires autonomy, skills and new roles both for professionals and regulatory authorities. Key messages French government relies on professionals’ investment at the territorial level by implementing HTPC to guarantee access to care and respond to population needs in primary care. HTPC implementation implies radical change for the professionals to undertake social and populational responsibility for which public health professionals should help to meet the challenge.

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Electronic transmission of prescriptions in primary care: transformation, timing and teamwork

Journal of Primary Health Care ◽

10.1071/hc21050 ◽

2021 ◽

Vol 13 (4) ◽

pp. 340

Author(s):

Chloë Campbell ◽

Caroline Morris ◽

Lynn McBain

Keyword(s):

Primary Care ◽

New Zealand ◽

General Practitioners ◽

Community Pharmacists ◽

Unintended Consequences ◽

Structured Interviews ◽

Interprofessional Communication ◽

Potential Benefits ◽

Handwritten Signature ◽

Purposive Sample

ABSTRACTINTRODUCTIONDuring the coronavirus disease 2019 (COVID-19) pandemic lockdown in New Zealand in March 2020, there was a rapid shift to virtual consultations in primary care. This change was supported by system adjustments to enable electronic transmission of prescriptions without a handwritten signature if they met certain security criteria. International research suggests potential for unintended consequences with such changes, so it is important to understand the effect on professional practice in New Zealand general practice and community pharmacy.AIMThe purpose of this study was to undertake a preliminary exploration of the experiences of New Zealand general practitioners and community pharmacists when prescriptions are transmitted electronically directly from prescriber to pharmacy.METHODSSemi-structured interviews with a purposive sample of four pharmacists and four general practitioners gathered qualitative data about their experiences of the shift to electronic transmission of prescriptions. Participants’ perceptions of effect on professional workflow, interprofessional interactions between general practitioners and pharmacists, and interactions with patients were explored. Interviews were audio-recorded, and the data analysed thematically using an inductive approach.RESULTSFour themes were identified: workflow transformation; mixed impact on interactions with patients; juggling timing and expectations; and new avenues for interprofessional communication (with some cul-de-sacs).DISCUSSIONBoth general practitioners and pharmacists experienced transformational changes to workflow. This was positive for general practitioners due to saved time and increased work flexibility. Pharmacists noted potential benefits but also some challenges. To fully reap teamwork benefits, more work is needed on managing the timing issues and patient expectations, and to refine the new modes of communication between health-care practitioners.

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COVID-19 at the Deep End: A Qualitative Interview Study of Primary Care Staff Working in the Most Deprived Areas of England during the COVID-19 Pandemic

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18168689 ◽

2021 ◽

Vol 18 (16) ◽

pp. 8689

Author(s):

Claire Norman ◽

Josephine M. Wildman ◽

Sarah Sowden

Keyword(s):

Primary Care ◽

Low Income ◽

Care Staff ◽

Snowball Sampling ◽

Structured Interviews ◽

Social Prescribing ◽

Qualitative Interview Study ◽

The Impact ◽

Primary Care Staff ◽

Deprived Areas

COVID-19 is disproportionately impacting people in low-income communities. Primary care staff in deprived areas have unique insights into the challenges posed by the pandemic. This study explores the impact of COVID-19 from the perspective of primary care practitioners in the most deprived region of England. Deep End general practices serve communities in the region’s most socioeconomically disadvantaged areas. This study used semi-structured interviews followed by thematic analysis. In total, 15 participants were interviewed (11 General Practitioners (GPs), 2 social prescribing link workers and 2 nurses) with Deep End careers ranging from 3 months to 31 years. Participants were recruited via purposive and snowball sampling. Interviews were conducted using video-conferencing software. Data were analysed using thematic content analysis through a social determinants of health lens. Our results are categorised into four themes: the immediate health risks of COVID-19 on patients and practices; factors likely to exacerbate existing deprivation; the role of social prescribing during COVID-19; wider implications for remote consulting. We add qualitative understanding to existing quantitative data, showing patients from low socioeconomic backgrounds have worse outcomes from COVID-19. Deep End practitioners have valuable insights into the impact of social distancing restrictions and remote consulting on patients’ health and wellbeing. Their experiences should guide future pandemic response measures and any move to “digital first” primary care to ensure that existing inequalities are not worsened.

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Learning from the introduction of ‘skill-mix’ changes in general practice: a qualitative process evaluation

British Journal of General Practice ◽

10.3399/bjgp18x696701 ◽

2018 ◽

Vol 68 (suppl 1) ◽

pp. bjgp18X696701

Author(s):

Pauline Nelson ◽

Anne-Marie Martindale ◽

Anne McBride ◽

Damian Hodgson

Keyword(s):

Primary Care ◽

General Practice ◽

Process Evaluation ◽

Unintended Consequences ◽

Active Management ◽

Early Adopter ◽

Snowball Sampling ◽

Structured Interviews ◽

Skill Mix ◽

Qualitative Process Evaluation

Background‘Skill-mix’ change (changing mix of staff roles or introducing new ways of working) is increasingly promoted to relieve pressure in general practice teams. As part of a primary care workforce strategy, one locality in Greater Manchester is seeking to integrate three ‘non-medical’ roles – Advanced Practitioners (APs), Physician Associates (PAs) and Clinical Pharmacists (CPs) – to work alongside practice staff.AimA qualitative process evaluation studied the integration of these roles to: establish the aims and priorities of the new services; understand and compare the ways in which the roles are being established with identification of measurable impacts and unintended consequences.MethodA rapid scoping review of the primary care skill-mix literature was conducted to inform the evaluation. Purposive and ‘snowball’ sampling enabled semi-structured interviews (12) and focus groups (2) to be conducted with 27 key individuals (workforce/training leads for the new services; APs/PAs/CPs; GPs/practice managers), before being transcribed, anonymised and analysed thematically with a combination of a priori and grounded codes. Analysis of relevant service/training plans supplemented interview/focus group data.ResultsA number of organisational and operational factors affecting implementation success in early adopter sites were identified including: the intended scope and function of new roles with corresponding implications for measuring impacts; leadership/active management of workforce changes; appropriate training and education; inter-professional tensions; regulatory provisions, and sustainability.ConclusionThere is variation in how the three skill-mix initiatives are being implemented in early adopter sites, with implications for success. Key considerations for introducing skill-mix changes in general practice are being identified.

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Nasal balloon autoinflation for glue ear in primary care: a qualitative interview study

British Journal of General Practice ◽

10.3399/bjgp18x700217 ◽

2018 ◽

Vol 69 (678) ◽

pp. e24-e32

Author(s):

Jane Vennik ◽

Ian Williamson ◽

Caroline Eyles ◽

Hazel Everitt ◽

Michael Moore

Keyword(s):

Primary Care ◽

Low Cost ◽

Daily Routine ◽

Structured Interviews ◽

Early Management ◽

Practice Nurses ◽

Holistic Treatment ◽

Qualitative Interview Study ◽

Cost Treatment ◽

Glue Ear

BackgroundNasal balloon autoinflation is an effective, non-surgical treatment for symptomatic children with glue ear, although uptake is variable and evidence about acceptability and feasibility is limited.AimTo explore parent and healthcare professional views and experiences of nasal balloon autoinflation for children with glue ear in primary care.Design and settingQualitative study using semi-structured interviews with a maximum-variety sample of parents, GPs, and practice nurses. The study took place between February 2013 and September 2014.MethodSemi-structured face-to-face and telephone interviews were audiorecorded, transcribed verbatim, and analysed using inductive thematic analysis.ResultsIn all, 14 parents, 31 GPs, and 19 nurses were included in the study. Parents described the nasal balloon as a natural, holistic treatment that was both acceptable and appealing to children. GPs and nurses perceived the method to be a low-cost, low-risk strategy, applicable to the primary care setting. Good instruction and demonstration ensured children mastered the technique and engaged with the treatment, but uncertainties were raised about training provision and potential impact on the GP consultation. Making nasal balloon autoinflation part of a child’s daily routine enhances compliance, but difficulties can arise if children are unwell or refuse to cooperate.ConclusionNasal balloon autoinflation is an acceptable, low-cost treatment option for children with glue ear in primary care. Provision of educational materials and demonstration of the method are likely to promote uptake and compliance. Wider use of the nasal balloon has the potential to enhance early management, and may help to fill the management gap arising from forthcoming changes to care pathways.

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General practitioners’ perceptions towards the use of digital health services for citizens in primary care: a qualitative interview study

BMJ Open ◽

10.1136/bmjopen-2018-028251 ◽

2019 ◽

Vol 9 (5) ◽

pp. e028251 ◽

Cited By ~ 14

Author(s):

Asbjørn Johansen Fagerlund ◽

Inger Marie Holm ◽

Paolo Zanaboni

Keyword(s):

Primary Care ◽

Health Services ◽

General Practitioners ◽

Computer Literacy ◽

Large Scale ◽

Digital Health ◽

The Elderly ◽

Structured Interviews ◽

Electronic Prescription ◽

Qualitative Interview Study

ObjectivesTo explore general practitioners’ (GPs) perceptions towards use of four digital health services for citizens: an electronic booking service to make reservations with the GP; an electronic prescription service to request renewal of maintenance drugs; a service for text-based non-clinical enquiries to the GP office and a service for text-based electronic consultation (e-consultation) with the GP.DesignA qualitative study based on semi-structured interviews.SettingPrimary care.ParticipantsNine GPs who were early adopters of the four services were interviewed.MethodOne moderator presented topics using open-ended questions, facilitated the discussion and followed up with further questions. Phone interviews were conducted, audio recorded and transcribed verbatim. Qualitative data were analysed using the framework method.ResultsThe use of digital services in primary care in Norway is growing, although the use of text-based e-consultations is still limited. Most GPs were positive about all four services, but there was still some scepticism regarding their effects. Advantages for GP offices included reduced phone load, increased efficiency, released time for medical assessments, less crowded waiting rooms and more precise communication. Benefits for patients were increased flexibility, autonomy and time and money savings. Children, the elderly and people with low computer literacy might still need traditional alternatives.ConclusionsMore defined and standardised routines, as well as more evidence of the effects, are necessary for large-scale adoption.

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Delivering a primary care-based social prescribing initiative: a qualitative study of the benefits and challenges

British Journal of General Practice ◽

10.3399/bjgp18x696617 ◽

2018 ◽

Vol 68 (672) ◽

pp. e487-e494 ◽

Cited By ~ 14

Author(s):

Kathryn Skivington ◽

Mathew Smith ◽

Nai Rui Chng ◽

Mhairi Mackenzie ◽

Sally Wyke ◽

...

Keyword(s):

Primary Care ◽

Case Management ◽

Case Manager ◽

Structured Interviews ◽

Social Prescribing ◽

Community Organisation ◽

Health Goals ◽

Community Organisations ◽

Ability To Act ◽

Qualitative Interview Study

BackgroundSocial prescribing is a collaborative approach to improve inter-sectoral working between primary health care and community organisations. The Links Worker Programme (LWP) is a social prescribing initiative in areas of high deprivation in Glasgow, Scotland, that is designed to mitigate the negative impacts of the social determinants of health.AimTo investigate issues relevant to implementing a social prescribing programme to improve inter-sectoral working to achieve public health goals.Design and settingQualitative interview study with community organisation representatives and community links practitioners (CLPs) in LWP areas.MethodAudiorecordings of semi-structured interviews with 30 community organisation representatives and six CLPs were transcribed verbatim and analysed thematically.ResultsParticipants identified some benefits of collaborative working, particularly the CLPs’ ability to act as a case manager for patients, and their position in GP practices, which operated as a bridge between organisations. However, benefits were seen to flow from new relationships between individuals in community organisations and CLPs, rather than more generally with the practice as a whole. Challenges to the LWP were related to capacity and funding for community organisations in the context of austerity. The capacity of CLPs was also an issue given that their role involved time-consuming, intensive case management.ConclusionAlthough the LWP appears to be a fruitful approach to collaborative case management, integration initiatives such as social prescribing cannot be seen as ‘magic bullets’. In the context of economic austerity, such approaches may not achieve their potential unless funding is available for community organisations to continue to provide services and make and maintain their links with primary care.

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