Scotland the brave: A national case study of rapid scale-up of remote video consultation services in the Covid-19 pandemic (Preprint)
Wherton J., Greenhalgh T., Shaw SE.
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 evaluate 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), local and national documents, and process data such as uptake statistics, patient and staff satisfaction surveys, and patient enablement scores. Fieldwork during the pandemic was of necessity conducted remotely. Data were analysed thematically and theorised using our newly-developed PERCS (Planning and Evaluating Remote Consultation Services) framework which considers multiple influences interacting dynamically and unfolding over time. RESULTS Video consultation services pre-pandemic were patchy, with just two of Scotland’s 14 regions (where enthusiasts were based) accounting for most activity. By 2019, a national program to extend the service was well under way, driven by an ethos of collaborative quality improvement, reducing inequalities and achieving cross-government low-carbon goals. 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, resulting in a dramatic increase in number of services using video and consultations conducted. While not everything went smoothly, video consultations became available as business-as-usual for a much wider range of clinical problems, vastly extending the pre-pandemic focus on outpatient monitoring of chronic stable conditions. CONCLUSIONS Scotland provides an important national case study from which other countries may learn. CLINICALTRIAL Not applicable.