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.

There are a number of reasons for the perceived lack of relationship between LOS and health outcomes. Clearly reducing days of care at the low-intensity end of a hospital stay may not necessarily affect health outcomes. There is a case to be made for tailoring care more exactly to an individual's needs by looking at the actual components of care rather than the place of care--within or outside hospital walls.

The number of large-scale general practice provider collaborations is growing in England.  Expectations of what they will achieve are significant.  Trade-offs exist between mandated/voluntary collaborations; networks/single organisations; and different governance structures.  Better Improved clinica outcomes and cost savings do not automatically result from 'scaling-up'.  Policy-makers should move in this direction with caution, informed by ongoing evaluation.

Background: Fewer than 1% of UK general practice consultations occur by video. Aim: To explain why video consultations are not more widely used in general practice. Design and setting: Analysis of a sub-sample of data from three mixed-method case studies of remote consultation services in various UK settings 2019-2021. Methods: The dataset included interviews and focus groups with 121 participants from primary care (33 patients, 55 GPs, 11 other clinicians, 9 managers, 4 support staff, 4 national policymakers, 5 technology industry). Data were transcribed, coded thematically and then analysed using the Planning and Evaluating Remote Consultations (PERCS) Framework. Results: With few exceptions, video consultations were either never adopted or soon abandoned in general practice despite a strong policy push, short-term removal of regulatory and financial barriers and advances in functionality, dependability and usability of video technologies (though some products remained “fiddly” and unreliable). The relative advantage of video was perceived as minimal for most of the case load of general practice, since many presenting problems could be sorted adequately and safely by telephone and in-person assessment was considered necessary for the remainder. Some patients found video appointments convenient, appropriate and reassuring but others found therapeutic presence was only achieved in person. Video sometimes added value for out-of-hours and nursing home consultations and statutory functions (e.g. death certification). Conclusion: Efforts to introduce video consultations in general practice should focus on situations where this modality has a clear relative advantage (e.g. strong patient or clinician preference, remote localities, out-of-hours services, nursing homes).