Background
Aotearoa/New Zealand has a strong first-contact primary care system where most general practices operate as small businesses. Currently, the Government pays a fixed amount per quarter for people enrolled in a general practice via weighted capitation payments, with higher payments made for population groups with higher health needs, for those on lower incomes, and for practices offering lower cost care. Standard consultations are typically free for children aged under 14 years. Patients aged 14 years and over are charged co-payments of varying amounts for services, which act as significant barriers to access, particularly for Māori, Pacific peoples and those on lower incomes. A typical charge for an adult is between $50 and $65 dollars; some practices in high deprivation areas are able to charge less. A separate accident compensation scheme subsidies accident-related care, with practices funded on a fee-for-service basis, with subsidies also adjusted for need, income and the offering of lower cost care [9]. |
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What type of contact patients had with general practices during lockdown;
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Positive and negative patient experiences of telehealth during lockdown; and
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How patients would like to use telehealth in the future.
Methods
Development and content
Recruitment and data collection
Online survey
Interviews
Data analysis
Quantitative survey data
Qualitative survey and interview data
Results
Sample characteristics
Survey sample
Characteristic | Survey respondents (n = 1010) % | Interviewees (n = 38) % |
---|---|---|
Age group (years) | ||
18–34 | 22.4 | 18 |
35–44 | 20.4 | 16 |
45–54 | 25.0 | 32 |
55–64 | 17.5 | 8 |
65+ | 14.7 | 26 |
Gender | ||
Female | 84.5 | 63 |
Male | 14.2 | 37 |
Othera,b | 1.3 | – |
Prioritised ethnicity (in priority order) | ||
Māori | 10.2 | 16 |
Pacific peoples | 1.8 | 8 |
Asian | 3.4 | 11 |
New Zealand European/Other | 84.5 | 66 |
Current work status | ||
In paid employment as before COVID-19 | 58.9 | 58 |
In paid employment with reduced pay due to COVID-19 | 10.9 | 8 |
In paid employment but not being paid due to COVID-19 | 2.6 | – |
Unemployed and looking for a job | 3.1 | – |
Not in paid employment and not looking for a job | 24.3 | 34 |
Struggle to pay for basic living costs | ||
Agree/Strongly agree | 7.5 | |
Neither | 10.7 | |
Disagree/Strongly disagree | 81.9 | |
Self-rated health | ||
Excellent | 12.1 | |
Very good | 38.7 | |
Good | 32.4 | |
Fair | 13.9 | |
Poor | 3.0 | |
Presence of one or more long term health conditions | 60.9 | |
Presence of disability | 12.6 | |
Grouped District Health Board (DHB) regionb | ||
Northern region | 20.7 | 18 |
Midland region | 11.9 | 8 |
Central region | 44.1 | 53 |
South Island | 23.4 | 21 |
Interview sample
Survey quantitative results
Contacts with general practice
Experience and satisfaction with telehealth
Characteristic | Satisfieda with telephone consultation (n = 454) % | Satisfieda with in person visit (n = 309) % |
---|---|---|
Overall | 86 | 92 |
Age group (years) | ||
18–34 | 88 | 93 |
35–44 | 80 | 86 |
45–54 | 86 | 93 |
55–64 | 89 | 89 |
65+ | 89 | 96 |
Gender | ||
Female | 87 | 91 |
Male | 82 | 92 |
Otherb | 57c | 83c |
Prioritised ethnicity (in priority order) | ||
Māori | 82 | 90 |
Pacific peoples | 86c | 80c |
Asian | 60c | 80c |
New Zealand European/Other | 88 | 92 |
DHB region | ||
Northern region | 82 | 90 |
Midlands region | 75 | 82 |
Central region | 88 | 90 |
South Island | 91 | 99 |
Current work status | ||
In paid employment as before COVID-19 | 88 | 92 |
In paid employment with reduced pay due to COVID-19 | 82 | 88 |
In paid employment but not being paid due to COVID-19 | 90c | 100c |
Unemployed and looking for a job | 69c | 75c |
Not in paid employment and not looking | 86 | 82 |
Long term health condition(s) | ||
Yes | 87 | 91 |
No | 84 | 91 |
Disability | ||
Yes | 92 | 89 |
No | 85 | 92 |
Self-rated health | ||
Excellent | 95 | 94 |
Very good | 87 | 95 |
Good | 86 | 90 |
Fair | 83 | 91 |
Poor | 61 | 58c |
Struggle to pay for basic living costs over past seven days | ||
Strongly agree or agree | 86 | 88 |
Neither agree nor disagree | 69 | 90 |
Strongly disagree or disagree | 89 | 92 |
Quality measure | Consult type | ||
---|---|---|---|
Telephone (n = 528) % | Video (n = 46) % | In-person (n = 337) % | |
Did your doctor or nurse …a | |||
listen to what you had to say | 98 | 98 | 97 |
- Yes, but not as well as in-person | 20 | – | n/a |
spend enough time with you | 95 | 98 | 95 |
- Yes, but not as well as in-person | 23 | – | n/a |
treat you with kindness | 98 | 98 | 97 |
- Yes, but not as well as in-person | 10 | – | n/a |
explain things to you in a way that was easy to understand | 97 | 98 | 98 |
- Yes, but not as well as in-person | 12 | – | n/a |
Future interest in telehealth
Qualitative results
Convenience
Paradoxically, lockdown itself led to better access and more convenient care for some survey respondents due to an overall decrease in demand, so that many practices had more appointments available, could respond more promptly and had more time to spend with patients.It did not bother me at all that I couldn't see the doctor - she knows me and my health background so this was not a barrier at all. (S: F, 45–54)
Conversely, some found care more difficult to access, particularly if contacting practices by telephone and at the start of lockdown when many practices deactivated their patient online portals and patients were required to phone rather than book appointments online.So, BC [Before Corona] the most recent wait was 6 weeks, but on average it was at least 2-3 weeks, that’s when it was pretty good. During Corona... I rang and I had a phone appointment the next day. (I: F, 45–54)
Patients noticed that during lockdown they were not required to have an in-person visit for routine issues like repeat prescriptions, and that such visits pre-lockdown were not only inconvenient but unnecessary. This meant the convenience of well-functioning telehealth could improve access to primary care, including for groups that have previously not engaged as much with health services.The online portal was shut down at start of pandemic so the only way to access GP appointment or repeat prescription was to ring. … I found it aggravating having to ring for a repeat prescription and wait ages. (S: F, 55–64)
I didn’t have to go and take time off work to go to the general practice... So that’s where the convenience comes in; it makes the consult more efficient and perhaps it would encourage me, as a male, to actually go. (I: M, 65+)
Need to be seen in-person
Within the lockdown context, respondents recognised the tension between the need to be seen and the benefits from keeping them and others safe from infection through physical distancing. Respondents adapted to the lockdown telehealth imperative by using ‘workarounds’ such as sending photos, emailing home blood pressure readings, and moving between phone and video consultations for visual assessment, in which case, video consultations had advantages over the telephone. On occasion, pragmatic, but less-than-ideal management of issues occurred.My condition was something that needed to be seen, even though I had photos sent and I described and showed it on video. I think it would have been a lot better if she could have seen it and felt it. (I: F, 25–34)
It was difficult to get a diagnosis for an illness I had due to being unable to be seen in person or get a sample tested … I had to take antibiotics "just in case" it was a bacterial infection even though this was undetermined. (S: F, 25–34)
Relationships
I've got a good relationship with my doctor too, and I think she trusts my description of what might be going on. This made the telephone consultation really easy. (S: F, 45–54)
A pre-existing relationship, however, was not sufficient for a successful consultation when clinicians did not pay attention to establishing rapport within the telehealth environment. On the other hand, even when the respondent did not have a pre-existing relationship with the clinician, consultations could still be successful if the clinician created rapport.I would prefer to do phone or video [consultation] with my own doctor than see a different doctor. (I: F, 45–54)
Some patients found telehealth less rushed, more focused and personal, even providing space to talk more freely than usual. Patients valued being reassured and having a calm, unhurried telehealth consultation in which they felt heard, with all their concerns addressed. Demonstrating active listening was even more important when visual cues were not available. For others, telehealth felt abrupt and impersonal, even if the clinician at the other end was known to the patient.It [phone consultation] was quite comfortable even though I’ve never done it before, and I didn’t know the doctor, but she was very kind very caring, and it came through in the call. (I: F, 45–54)
It’s kind of a bit more dismissive on the phone, you know … I just don’t feel comfortable. I just feel like it’s more human [in-person] than on the phone. (I: F, 35–44)
Technological barriers
The introduction of online payments was disconcerting for some, especially those in older age groups who were unused to online banking. Concerns were also raised at how some people could be excluded from accessing general practices by telehealth due to lack of support, resources or infrastructure. Respondents felt some level of support could be provided by the health service (e.g. advice and assistance in preparing for a video consultation), but suggested inadequate resources and infrastructure pointed to deeper societal inequities (e.g. poverty, differences in rural and urban access to technological services).I would rather face-to-face. Not telephone. My hearing is not good, partly deaf. (I: M, 65+)
...some whānau [family] don’t have the finances for the technology needed to access online support or the know how to even navigate the internet. (S: F, 45–54)
Concerns about security and privacy were infrequent and mostly related to the fact that many telehealth consultations were taking place in a home environment, which may be unusually full of people, some of whom the patient might not want to overhear what was said....where they were [remote rural area], couldn’t get the internet and sometimes couldn’t get cell service. (I: F, 55–64)
Sometimes people are not comfortable discussing health issues from within their homes (lack of privacy, unsafe environment to discuss concerns etc.) (S: F, 18–24)
Views on value
For some patients, it felt inappropriate for telehealth to be charged the same as an in-person visit when they could not be examined thoroughly and their issue was not resolved. Reservations also arose over whether short telehealth consultations should be charged the same as a lengthy in-person visit and whether a telehealth consultation for an issue that then required an in-person visit should be charged twice.I got charged the same amount as normal … I got the same service as normal, so I guess it’s fine, but I guess the doctor did the same amount of work. (I: M, 45–54)
I was shocked I was charged $56.50 for a phone consult that lasted 10 minutes and did not include an examination of the affected area. (S: F, 45–54)
Patient preferences
Individual preference for a type of interaction could override what might be judged appropriate based only on the health concern. Some patients wanted to be seen regardless of the concern, because touch, examination and social contact were more important to them than convenience. Others thought the option of telehealth was important because it could save time and money....if I was getting prescriptions from [doctor] this kind of format into the future would be absolutely fine. But if she needed to check my glands ... that becomes a little bit more difficult. (I: F, 45–54)
Patients’s preferences for either telephone or video consultations were also highly individualised and context-dependent. For some, setting up video consultations was more stressful and difficult than telephone calls, which could be done from bed or wherever they happened to be at the time. Others relished the opportunity to connect digitally. Ultimately, patients wanted choice that was appropriately aligned with their needs and preferences.I hope that phone and video consultations remain an option long term as it is much quicker for routine things that don't require a physical examination. With travel and waiting time, I have to allow an hour for a GP appointment. The phone consult was done in 10 minutes. (S: F, 45–54)
The biggest thing for me I guess is as a patient or client to somehow know that there was still a choice around what way I want to connect with my GP. (I: M, 25–34)