Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study

• Published in: Health services and delivery research 2018-06, Vol.6 (21), p.1-136
• Main Authors: Shaw, Sara, Wherton, Joseph, Vijayaraghavan, Shanti, Morris, Joanne, Bhattacharya, Satya, Hanson, Philippa, Campbell-Richards, Desirée, Ramoutar, Seendy, Collard, Anna, Hodkinson, Isabel, Greenhalgh, Trisha
• Format: Article
• Language: English
• Subjects: diabetes; ethnography; interviews; mixed-methods; organisational routines; remote video consultations; roter interaction analysis system; skypetm; sociotechnical systems; strong structuration theory; virtual consultations
• ISSN: 2050-4349; 2050-4357
• DOI: 10.3310/hsdr06210

Background: There is much enthusiasm from clinicians, industry and the government to utilise digital technologies and introduce alternatives to face-to-face consultations. Objective(s): To define good practice and inform digital technology implementation in relation to remote consultations via Skype™ (Microsoft Corporation, Redmond, WA, USA) and similar technologies. Design: Multilevel mixed-methods study of remote video consultations (micro level) embedded in an organisational case study (meso level), taking account of the national context and wider influences (macro level). Setting: Three contrasting clinical settings (Diabetes, Antenatal Diabetes and Cancer Surgery) in a NHS acute trust. Data collection and analysis: Macro level – interviews with 12 national-level stakeholders combined with document analysis. Meso level – longitudinal organisational ethnography comprising over 300 hours of observations, 24 staff interviews and analysis of 16 documents. Micro level – 30 video-recorded remote consultations; 17 matched audio-recorded face-to-face consultations. Interview and ethnographic data were analysed thematically and theorised using strong structuration theory. Consultations were transcribed verbatim and analysed using the Roter interaction analysis system (RIAS), producing descriptive statistics on different kinds of talk and interaction. Results: Policy-makers viewed remote video consultations as a way of delivering health care efficiently in the context of rising rates of chronic illness and growing demand for services. However, the reality of establishing such services in a busy and financially stretched NHS acute trust proved to be far more complex and expensive than anticipated. Embedding new models of care took much time and many resources, and required multiple workarounds. Considerable ongoing effort was needed to adapt and align structures, processes and people within clinics and across the organisation. For practical and safety reasons, virtual consultations were not appropriate for every patient or every consultation. By the end of this study, between 2% and 20% of all consultations were being undertaken remotely in participating clinics. Technical challenges in setting up such consultations were typically minor, but potentially prohibitive. When clinical, technical and practical preconditions were met, virtual consultations appeared to be safe and were popular with both patients and staff. Compared with face-to-face consultations, virtua