Expanding video consultation services at pace and scale in Scotland during the Covid-19 pandemic: A national mixed-method case study.

Wherton, Joseph; Greenhalgh, Trisha; Shaw, Sara E

BACKGROUND Scotland-a country of 5.5 million people-has a rugged geography with many outlying islands, creating access challenges for many citizens. The government has long sought to mitigate these through a range of measures including an ambitious technology-enabled care (TEC) program. A strategy to develop a nationwide video consultation service began in 2017. Our mixed-method evaluation was commissioned in mid-2019 and extended to cover the pandemic response in 2020. OBJECTIVE To draw lessons from a national evaluation of the introduction, spread and scale-up of Scotland's video consultation services both before and during the pandemic. METHODS Data sources comprised 223 interviews (with patients, staff, technology providers and policymakers), 60 hours of ethnographic observation (including in-person visits to remote settings), patient and staff satisfaction surveys (N=20,349), professional and public engagement questionnaires (N=5400), uptake statistics and local and national documents. Fieldwork during the pandemic was of necessity conducted remotely. Data were analyzed thematically and theorized using the PERCS (Planning and Evaluating Remote Consultation Services) framework which considers multiple influences interacting dynamically and unfolding over time. RESULTS By the time the pandemic hit, there had been considerable investment in material and technological infrastructure, staff training, and professional and public engagement. Scotland was thus uniquely well placed to expand its video consultation services at pace and scale. Within four months (March-June 2020), the number of video consultations increased from about 330 to 17,000 per week nationally. While not everything went smoothly, video was used for a much wider range of clinical problems, vastly extending the pre-pandemic focus on outpatient monitoring of chronic stable conditions. The technology was generally considered dependable and easy to use. In most cases (78%, 14,677/18,817), patients reported no technical problems during their post-consultation survey. Healthcare organizations' general innovativeness and digital maturity had a strong bearing on their ability to introduce, routinize, and expand video consultation services. CONCLUSIONS The national-level groundwork before the pandemic allowed many services to rapidly extend the use video consultation during the pandemic, supported by a strong strategic vision, a well-resourced quality improvement model, dependable technology and multiple opportunities for staff to try out the video option. Scotland provides an important national case study from which other countries may learn. CLINICALTRIAL Not applicable.