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This study aims to define good practice and inform its implementation in relation to clinician-patient consultations via Skype and similar virtual media.

Why is this RESEARCH important?:

Remote video consultations between clinician and patient are technically possible and increasingly acceptable. They are being introduced in some settings alongside (and occasionally replacing) face-to-face or telephone consultations. There are a number of video communication tools available, such as Skype, that offer potential advantages to patients (who are spared the cost and inconvenience of travel) and the healthcare system (e.g. they may be more cost-effective). But fears have been expressed that they may be clinically risky and/or less acceptable to patients or staff, and they bring significant technical, logistical and regulatory challenges.

Therefore, it is important to know how the dynamic in the consultation will change if carried out via video-based communication tools, as opposed to face-to-face, and what variables may mediate that change. It is also important to understand how such tools influence and relate to organisational systems and processes so that they can be appropriately embedded and sustained within routine care practice.


This was a mixed-method study of video outpatient consultations (via Skype) based in two clinical settings (diabetes and cancer surgery) in a National Health Service (NHS) acute trust in London, UK. The research consisted of in-depth studies of real consultations (micro-level) embedded in an organisational case study (meso-level), and review of the national context (macro-level).

At the micro level, we studied the clinician and patient interaction during Skype consultations. We used audio, video and screen capture to produce rich multimodal data on 30 virtual consultations conducted via Skype. We supplemented this with audio recordings of 17 matched, face-to-face recordings, allowing us to make comparisons across face-to-face and virtual consultations. This analysis was supported using the Roter Interaction Analysis System (RIAS) to code and analyse different kinds of talk.

At the meso level, we mapped the administrative and clinical processes that needed to change to implement and support Skype consultations. Data was collected through interviews and observations of work practices, documents, charts and other artefacts used by staff.

At the macro level, we conducted interviews with national stakeholders to understand the national-level context for the introduction of virtual consultations in NHS organisations, and what measures might incentivise and make these easier.

The project also included an action research component, in which we worked with local senior managers across different departments to understand and implement the organisational change required to support the use of virtual consultations.


When clinical, technical, and practical preconditions were met, video consultations appeared safe and were popular with some patients and staff. Compared with face-to-face consultations for similar conditions, video consultations were very slightly shorter and patients did slightly more talking. Video consultations appeared to work better when the clinician and patient already knew and trusted each other.

In the context of a strong policy push and industry interest to develop digital alternatives to the traditional consultation there are, in reality, multiple challenges to embedding virtual consultation services within routine practice in the NHS. In particular, establishing video outpatient services in a busy and financially stretched hospital setting took considerable and ongoing effort to coordinate and mutually adapt and align structures, processes and people. We found that inter-organisational collaboration and sharing of knowledge and practices appears to be critical to service development.


There is great potential for the use of video-based communication tools, such as Skype, for remote consultations between patient and clinician. This could improve patients’ access to healthcare professionals and increase their levels of engagement and confidence to manage health conditions.

We have developed significant expertise, standard operating procedures, information governance and technical guidance documents for setting up and running virtual clinics. We are continuing to work with our project partners to roll-out virtual consultations within the trust and extend the model to other trusts across the UK.

For more information and resources, visit the VOCAL project website:



Further information:

Full project title:
VOCAL: Virtual Online Consultations - Advantages and Limitations: A qualitative study of micro, meso and macro level interactions.

Length of project:
March 2015 – February 2017


DREAMS Study: Diabetes Review, Engagement and Management via Skype
VOCAL Project Website 








External collaborators:

Queen Mary University of London, UK:

  • Emma Byrne, Research Fellow, Barts and the London School of Medicine and Dentistry, London

Barts Health NHS Trust, London, UK:

  • Shanti Vijayaraghavan, Consultant Diabetologist
  • Satya Bhattacharya, Consultant Surgeon
  • Desirée Campbell-Richards, Research Nurse
  • Charles Gutteridge, Consultant Haematologist and Clinical Information Officer
  • Philippa Hanson, Consultant in Diabetes and Endocrinology
  • Anna Collard, Research Consultant
  • Joanne Morris, Project Manager
  • Seendy Ramoutar, Clinical Nurse Specialist

Tower Hamlets Clinical Commissioning Group, London, UK:

  • Isabel Hodkinson, Principal Clinical Lead