Background
Primary healthcare is provided from the community by a broad range of health professionals and aims to reduce the causes, development and severity of diseases by providing treatment and education including the promotion of self-care.1 2 Within Aotearoa New Zealand (NZ), most primary healthcare services and funding models are provided by clinicians working within general practice, such as doctors, nurses and nurse practitioners. The NZ health system is, in the majority, tax funded, but most consumers are required to make copayments for services rendered within general practice.
Telehealth (care at a distance using information and communications technologies)1 became the most practical option for general practice consultations in NZ during COVID-19 alert levels 3 and 42 after 23 March 2020. Telehealth was not a frequently or routinely used consultation modality in primary care, and specifically in general practice, up to this point in NZ.
Traditional telehealth research highlights that, in comparison with in-person consultations, telehealth has lower costs for both consumer and provider and that there is no difference in service utilisation or disease progression for people with long term conditions,3 along with the convenience of phone or video consultations. However, the introduction of video for telehealth (as opposed to the phone) has been accompanied by disruption in processes, and concerns in clinical quality and accountability, and patient privacy.3 4
The priority in NZ, at the onset of the pandemic, was to limit exposure to and possible spread of COVID-19 while accessing and/or providing care. Within days, general practices set up telehealth processes (and associated software), and patients were triaged into video and/or phone appointments or in-person appointments, where physical examinations of patients were required and could be done safely.3
Continuity of care, as a process measure of access to care, remained a priority during this time. Continuity of care is the longitudinal therapeutic relationship between a clinician and patient,5 which is essential for patient-centred6 and person-focused care.7 Consumer experience research describes how patients prefer continuity of care with the same provider, are unaware when a telehealth option is available and tend to revert to ‘how we’ve always done things’ when under pressure.8 Person-focused care recognises the longitudinal relationship between clinician and patient that incorporates multiple interactions about a combination of long-term and short-term health issues over time.7 This approach, in turn, assumes the inclusion of different modes of interaction, such as in-person clinic visits, video and phone discussions and consultations, email/secure message correspondence and patient portal interactions.
Penchansky and Thomas9 describe access to care in terms of dimensions of accessibility, availability, affordability, service design, acceptability, implementation and design. Saurman10 adds awareness (knowing that a service is available) as the final dimension. Telehealth is one way to enable access to care but could potentially also become a barrier in terms of equity,11 where one assumes the availability of technologies and skills to be able to participate in, for example, a video consultation. The International Covenant on Economic, Social and Cultural Rights treaty12 outlines the right to equitable healthcare. NZ has an obligation under Te Tiriti o Waitangi (the Treaty of Waitangi) to ensure that improved health is equitably accessed for both Māori and non-Māori.11 13 Changes resulting from the introduction of telehealth must consider whether the new processes will result in improved health outcomes and be accessible equitably. With these considerations in mind, upscaling telehealth from sudden unplanned emergency use to business as usual requires understanding of the consumer experience in the postemergency COVID-19 period.
The intention of consumers and providers of general practice services to use telehealth technology after having experienced it is important to understand for future adoption of video and/or phone during consultations. The Unified Theory of Acceptance and Use of Technology (UTAUT)14 asserts that if there is perceived ease of use, perceived usefulness and positive social norm (peer support for adoption), one can predict user acceptance. To make sense of the intent to use theory (UTAUT), we will contextualise the findings in the theory of access to care by Penchansky and Thomas.9