Before introducing an alternative to a face-to-face consultation then you may wish to think about the following:

Getting it “right” is dependent on your rationale for using an alternative to a face-to-face consultation? Is it for convenience for patients, improved patient access or to manage demand? It is also dependent on ensuring that the alternative to a face-to-face consultation(s) you have decided to introduce are suitable for your practice and its demographics. Click for links to Who is it for? and For what purpose?

Successful Introduction

All the practice staff are key to ensuring that the introduction of an alternative to a face-to-face consultation is successful. Patients need to be aware of the offer of an alternative to a face-to-face consultation and the reception staff are key to ensuring that patients are informed and that alternatives are offered to patients seeking an appointment.

Have all the changes required across the practice been discussed and acknowledged? What will be the impact on differing staff groups? More information on this can be found here. You also need to consider what will happen if there are staff resistant to the introduction of an alternative to a face-to-face consultation. A way of ensuring that there is practice wide adoption of the alternative to a face-to-face consultation is to agree rules of engagement, discuss widely and create protocols. This will provide guidance for all the staff and may also indicate areas where there may be extra workload.

You may know of other local practices or Clinical Commissioning Groups (CCGs) that are using or have used similar approaches so it might be worth speaking to them to hear about what worked and what didn’t, particularly if you share a similar patient population.

However, these alternatives to face to face consultation undergo a process of continuous refinement and formalisation happens over time therefore retaining flexibility in how the new approach is provided allows for control over use.

Technological support/infrastructure

When considering introducing an alternative to a face-to-face consultation it is important to think about your existing infrastructure. Will you be able to draw upon an existing facility currently used for communication between healthcare professionals for example telephone, email and Skype etc.? Are you going to have to alter the current infrastructure – for instance have you got enough phone lines, both incoming and outgoing lines? Will there be a financial cost associated with this? What level of technical support will you need and who will be providing it. Will it be NHS IT services, if so have you spoken to them about the introduction? If you are using a software company what level of support will they provide and is there an additional cost? Will the CCG/health board support you? And crucially, what are the contingency arrangements for technology failure?

Unforeseen Consequences

Many forms of an alternative to a face-to-face consultation can also lead to hidden work unless a clear record of what is done is made. It is therefore essential that alternatives are scheduled into existing practice. We observed email and phone consultations being conducted during breaks and before or after the usual clinic times therefore leading to extra work that wasn’t being accounted for.

In addition, identifying when an encounter is an alternative to a face-to-face consultation can be problematic, particularly if it is seen as a quick patient follow-up, responding to a patient request or a simple piece of administrative work, therefore it is crucial that the practice agrees a method of acknowledging and recording these encounters. It will also enable you to audit whether an alternative to a face-to-face consultation has achieved your objectives. More information on how will we know it has worked can be found here. In addition, if the alternative to a face-to-face consultation is not integrated into the current system this can lead to additional work for staff, it is therefore worth thinking about how the consultation can be incorporated into the patient record.

If patients are unclear about how or when to use an alternative to a face-to-face consultation this can lead to additional calls for clarification. Therefore ensuring that the patients are well prepared and informed is key. More information can be found here. Further, the use of an alternative to a face-to-face consultation may result in repeated consultations, i.e. followed up by either a face-to-face consultation or another an alternative type of consultation. This is not necessarily a failure on the use of an alternative to a face-to-face consultation but may suggest that it saves less time than anticipated.

There is often a fear that patients may use an alternative to a face-to-face consultation ‘inappropriately’. Whilst there is little evidence for this, patients may repurpose the ways in which new forms of consultation are used and not use them in the way that it is intended. It is therefore key to establish boundaries with patients, agree rules of engagement, devise protocols and provide clear information for patients about the use of an alternative to a face-to-face consultation.

Wider impact

Alternatives to face to face consultation can be used to increase access to care, for patients who cannot currently get a face to face consultation. Or they can be used to restrict access to care in order to focus the GPs time on people who need it most. If the introduction of an alternative to a face-to-face consultation reduces access for patients then the wider impact of this must be considered. Are there patients who need to see a doctor not getting through, are patients going elsewhere such as hospital emergency departments etc.? Is this pushing primary care work into secondary care?

Additional Costs

Alongside the cost of the initial investment (and some forms of consultation will require more initial investment than others), consider that there may be hidden costs, such as the additional cost of calling back patients that have used an e-consult, providing additional phone lines, ring-fencing time for staff to manage any extra workload that the alternative to a face-to-face consultation might entail. Is the investment dependent on a large number of patients using the system, if so how are you going to promote and encourage its use and have you budgeted for this? The introduction of an alternative to a face-to-face consultation might require additional training, but this is not always invested in, so have you considered the cost of providing training and the time that you may need to cover staff who are receiving the training?

Safety and security

One of the concerns often heard about the use of an alternative to a face-to-face consultation is the issues of safety and security. It is important that information and clinical governance are considered and that the practice follows guidelines. It is also crucial that systems are in place for the secure storage of emails, audio or digital files relating to an alternative to a face-to-face consultation. We have provided some useful guidance below: 

• NHSmail: a secure email service approved by the Department of Health for sharing patient identifiable and sensitive information
• Academy of Medical Royal Colleges – i-care: Information, Communication and Technology in the NHS
• Academy of Medical Royal Colleges – Ehealth Competency Framework
• GMC guidance on – Prescribing Guidance: Remote Prescribing via Telephone, Video-link or Online
• Email Consultations in Healthcare
• Health and Social Care Information Centre
• Medical Protection – Risk alert: Technology in general practice
• RCGP – Health Informatics Group