Planning and Evaluating Remote Consultation Services: A New Conceptual Framework Incorporating Complexity and Practical Ethics

As 'remote by default' becomes the norm for healthcare consultations, this study presents a new framework, Planning and Evaluation Remote Consultation Services (PERCS), to evaluate primary care services.

Journal article

Published: 02/09/2021

Open journal article

A study published by Frontiers in Digital Health authored by Nuffield Department of Primary Care Health Sciences, University of Oxford, Nuffield Trust and Plymouth Institute of Health and Care Research, University of Plymouth. 

Journal article information

  • Journal of publication: Frontiers in Digital Health
  • Nuffield Trust contributors: Dr Rebecca Rosen and Claudia Leone
  • All authors: Trisha Greenhalgh , Sara E. Shaw, Richard Byng, Stuart Faulkner, Teresa Finlay, Emily Grundy, Laiba Husain, Gemma Hughes, Lucy Moore, Chrysanthi Papoutsi, Catherine Pope, Sarah Rybczynska-Bunt, Alexander Rushforth, Joseph Wherton, Sietse Wieringa and Gary
  • Volume: 3
  • Issue: 726095
Abstract

Establishing and running remote consultation services is challenging politically (interest groups may gain or lose), organizationally (remote consulting requires implementation work and new roles and workflows), economically (costs and benefits are unevenly distributed across the system), technically (excellent care needs dependable links and high-quality audio and images), relationally (interpersonal interactions are altered), and clinically (patients are unique, some examinations require contact, and clinicians have deeply-held habits, dispositions and norms). Many of these challenges have an under-examined ethical dimension. In this paper, we present a novel framework, Planning and Evaluating Remote Consultation Services (PERCS), built from a literature review and ongoing research. PERCS has 7 domains—the reason for consulting, the patient, the clinical relationship, the home and family, technologies, staff, the healthcare organization, and the wider system—and considers how these domains interact and evolve over time as a complex system. It focuses attention on the organization's digital maturity and digital inclusion efforts. We have found that both during and beyond the pandemic, policymakers envisaged an efficient, safe and accessible remote consultation service delivered through state-of-the art digital technologies and implemented via rational allocation criteria and quality standards. In contrast, our empirical data reveal that strategic decisions about establishing remote consultation services, allocation decisions for appointment type (phone, video, e-, face-to-face), and clinical decisions when consulting remotely are fraught with contradictions and tensions—for example, between demand management and patient choice—leading to both large- and small-scale ethical dilemmas for managers, support staff, and clinicians. These dilemmas cannot be resolved by standard operating procedures or algorithms. Rather, they must be managed by attending to here-and-now practicalities and emergent narratives, drawing on guiding principles applied with contextual judgement. We complement the PERCS framework with a set of principles for informing its application in practice, including education of professionals and patients.

Funding

This research was funded from the following sources: Scottish Government (Technology Enabled Care Programme), National Institute for Health Research (BRC-1215-20008), UK Research and Innovation via ESRC (ES/V010069/1), Wellcome Trust (WT104830MA), and The Health Foundation, an independent charity committed to bringing about better healthcare for people in the UK (2133488). Additional support was provided to RB by the NIHR through the Peninsula Applied Research Collaboration (PenARC).