Sample characteristics
Survey sample
The survey respondents were mostly female, with more Europeans and fewer older adults than expected (Table 2). The highest proportion of responses came from localities related to the research team’s institutions (Wellington and Otago, with an associated city), due to the snow-balling recruitment strategy, which started survey dissemination through the researchers’ networks. We compared the survey sample with results from the nationally representative New Zealand Health Survey [see ‘Additional file 2’]. A large proportion of survey respondents reported having a chronic health condition, which may have been due to the broad definition in the question (‘any health conditions that mean you have to contact a GP clinic/health centre on an on-going basis’). Conversely, fewer respondents reported having a disability than would be expected from other estimates (19), which may be because we did not ask about specific disabilities, such as hearing or sight impairment, but asked for a subjective assessment (‘do you think of yourself as disabled?’).
Only 3.1% of survey respondents were unemployed, compared with the national unemployment rate of 4.2% in the period before lock-down.(20) However, more respondents (7.5%) reported struggling to pay for basic living costs, compared with between 4–6% from a weekly survey at the same time, which asked the same question.(21)
Interview sample
Since the interviewees were recruited from the survey, they were also more likely to be from the Wellington and Otago regions (Table 2). In contrast to the survey respondents, however, interviewees were more likely to be older and 34% were not employed or seeking work. They may have had more time and willingness to undertake an interview. We stratified potential interviewees by gender using the names they supplied since the survey respondents were disproportionately female. We were unable to target any other demographic as the contact details for interviewees could not be linked back to survey data.
Table 2
Demographics of survey respondents and interviewees
Characteristic
|
Survey respondents
n = 1,010
%
|
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
|
Other1,2
|
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) region2
|
|
|
Northern region
|
20.7
|
18
|
Midland region
|
11.9
|
8
|
Central region
|
44.1
|
53
|
South Island
|
23.4
|
21
|
1 Those who answered "gender diverse" or "prefer not to say" were grouped together because of small numbers; 2Northern region = Northland, Waitematā, Auckland and Counties Manukau DHBs; Midland region = Waikato, Bay of Plenty, Tairāwhiti, Lakes, Taranaki DHBs; Central region = Whanganui, Hawke’s Bay, MidCentral, Wairarapa, Hutt, Capital and Coast DHBs; South Island = Nelson-Marlborough, West Coast, Canterbury, South Canterbury, Southern DHBs
|
Survey quantitative results
Contacts with general practice
Of the 1,010 survey respondents, 86% (866) had contacted general practice during lockdown (others may have wanted to but did not, as the survey also asked about reasons for delaying seeking health care). For those who made contact, the top methods (multiple options were allowed) were by telephone (85%), through an online patient portal or website (30%), by visiting the clinic (26%) or by email (15%). Almost all of those who used text and instant messaging (32 responses) also used one of the other methods. Contact method did not vary by age or gender. Those with one or more long-term health conditions reported a higher use of online patient portals/website, email and visiting the clinic. Just over half (54%) of those who made contact did so on more than one occasion during lockdown (up until the time they completed the survey).
The most common reasons for contacting general practices (multiple reasons allowed) were for routine or non-urgent issues (42%) including vaccinations and medical certificates; repeat prescriptions (41%); an urgent or persistent issue (39%) such as injury, infection and pain; or chronic health conditions (25%). Known or suspected COVID-19 infection was a cause for contact for 10% of respondents.
Experience and satisfaction with telehealth
Survey respondents who had contacted general practices were asked in more detail about their experiences of telehealth and in-person consultations during lockdown. Of those who had any kind of consultation, 61% (528) had a telephone consultation, 5% (46) had a video consultation and 39% (337) had an in-person visit. Respondents who had telephone consultations had very similar sociodemographic characteristics to those who had in-person visits. Video consultations were too few to compare by patient characteristics.
Most respondents accessed telehealth for themselves, but 14% were for a child or another person (e.g. an older family member). Most consultations were with a doctor (84%). Only 17% had experience of telehealth before the lockdown. Consultations commonly cost the same as a regular visit (43% for telephone and 46% of video consultations), with only 14% of telephone consultations charged at a lower rate. Around 22% of telehealth consultations were free (e.g. for accidents or children aged under 14 years, which are covered by specific government funding). The cost was not known or reported for 18% of telephone and 26% of video consultations. From the qualitative data, this may have been because patients were not told/did not ask about the cost before the consultation, they could not remember, or they had not yet received an invoice.
Overall satisfaction with telehealth was high, at 91% for video and 86% for telephone consultations, but was slightly lower than in-person visits (92%) (Table 3). Some of the difference in satisfaction between telehealth and in-person visits related to how well practice staff were reported to ‘spend enough time with you’ and ‘listen to what you had to say’ (Table 4). In addition, some respondents expressed concern about not being seen, with 29% of respondents who had telephone consultations and 36% of respondents who had video consultations being moderately, very, or extremely, concerned that they could not be physically examined.
Table 3
Type of consult and satisfaction by survey respondent characteristics
Characteristic
|
Satisfied1 with telephone consultation
n = 454
%
|
Satisfied1 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
|
Other2
|
573
|
833
|
Prioritised ethnicity (in priority order)
|
|
|
Māori
|
82
|
90
|
Pacific peoples
|
863
|
803
|
Asian
|
603
|
803
|
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
|
903
|
1003
|
Unemployed and looking for a job
|
693
|
753
|
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
|
583
|
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
|
1Satisfied = Very satisfied or satisfied; 2Those who answered "gender diverse" or "prefer not to say" were grouped together because of small numbers; 3Based on < 10 responses
|
Table 4
Quality measures of interaction with the health professional by consultation type
Quality measure
|
Consult type
|
Telephone
n = 528
%
|
Video
n = 46
%
|
In-person
n = 337
%
|
Did your doctor or nurse…1
|
|
|
|
…listen to what you had to say
- Yes, but not as well as in-person
|
98
20
|
98
-
|
97
n/a
|
…spend enough time with you
- Yes, but not as well as in-person
|
95
23
|
98
-
|
95
n/a
|
…treat you with kindness
- Yes, but not as well as in-person
|
98
10
|
98
-
|
97
n/a
|
…explain things to you in a way that was easy to understand
- Yes, but not as well as in-person
|
97
12
|
98
-
|
98
n/a
|
1Combined responses for ‘Yes, just as well as in-person’ and ‘Yes, but not as well as in-person’ (telephone/video); ‘Yes’ (In-person); responses for ‘Yes, but not as well as in-person’ not provided for video consultations due to small numbers
|
Future interest in telehealth
Survey respondents who had contact with general practice during lockdown were asked whether they were aware of telehealth methods before lockdown: 12% were aware of video consultations and 48% of telephone consultations. All respondents were asked what telehealth services they would like in the future; 80% wanted telephone and 69% wanted video consultations, indicating a willingness to retain these approaches to delivering health care. These future preferences did not vary markedly by age, gender, ethnicity, presence of health conditions or disability.
Qualitative results
Themes from the qualitative data (interviews and survey open-ended questions) related to three of Levesque et al’s ‘patient ability’ dimensions of the access to health care framework (10): convenience (ability to reach), views on value (ability to pay) and relationships, technology and the need to be seen (ability to engage). These themes were also consistent with research on how telehealth works to support self-management: relationships, fit (convenience and technology) and visibility (the need to be seen).(22)
In general, and consistent with the high satisfaction ratings from the survey, positive feedback on telehealth was more common than negative feedback. However, respondents reported mixed experiences for all types of consultations (telehealth and in-person). The themes from the interviews are discussed below, in order of how frequently they arose from the patients’ feedback.
1. Convenience
Many respondents mentioned the convenience of telehealth consultations, in terms of saving time and money, and reducing stress, travel, employment disruption and exposure to infection (with COVID-19 and other pathogens). Respondents highlighted the ease of having consultations that fitted around their day, with the “hassle of lots of waiting time and the usual transport issues (including parking)”(S: M, 55–64) being avoided and “all my health needs [being] met whilst in the comfort of my home”(S: M, 35–44). The convenience of telehealth mostly outweighed concerns about not being seen or examined when the health issue was relatively routine or familiar and when there was an existing trusted relationship with the health provider.
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)
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.
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)
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.
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)
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.
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+)
2. Need to be seen in-person
Physical examination and observations were considered essential for some health concerns (e.g. IUD removal or a prostate check) and to give peace-of-mind and confidence. As a result, telephone and video consultations raised concerns for some participants about not being seen or adequately examined. Respondents indicated that telehealth worked especially well for non-urgent issues that did not require physical assessment, conditions that were familiar or where the patient knew what was wrong. Acute, new issues or more complex issues could be more difficult, especially if physical signs had to be elicited over the phone.
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)
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.
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)
3. Relationships
Successful telehealth consultations required mutual trust between patient and clinician, which was easier when there was a pre-existing relationship. Consultations with clinicians who knew their medical history was reassuring and, for many, the telehealth experience was just like a regular consultation. For those who highly valued continuity of care, connecting with a known, trusted doctor was more important than having an in-person visit.
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)
I would prefer to do phone or video [consultation] with my own doctor than see a different doctor. (I: 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.
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)
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’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)
4. Technological barriers
Technological barriers to telehealth included connectivity problems including poor internet access or cellphone service, lack of phone credit or data, and patient or clinician lack of familiarity with online tools. Respondents felt that better use of video technology should have reduced the need for in-person visits, but this did not always eventuate, with reports of insufficient broadband speed or unstable internet connection, poor image resolution and poorly angled cameras. Poor sound quality could present a problem for anyone, but telephone consultations could be impossible for those who were hard of hearing.
I would rather face-to-face. Not telephone. My hearing is not good, partly deaf. (I: M, 65+)
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).
...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)
...where they were [remote rural area], couldn’t get the internet and sometimes couldn’t get cell service. (I: F, 55–64)
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.
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)
5. Views on value
Cost was not mentioned in survey responses as frequently as the previous themes. Payment for telehealth varied between general practices. Often patients were not advised about the charges or method of payment before consultations and clinicians themselves could be uncertain about the fee and how the payment would be arranged. Patients conveyed clear views on what was value for money, depending on the time spent with them and service provided. They were willing to pay the same fee as an in-person visit for telehealth, as long as it seemed commensurate with an in-person visit and met their health needs.
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)
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 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)
6. Patient preferences
Patient preferences for telehealth were also influenced by personal factors. Patients carefully judged when they were comfortable with telehealth and when they wanted to be seen in-person. Partly, this was due to the health issues they were presenting with. They weighed up considerations such as symptom severity, the likelihood of needing a physical examination and whether they could explain themselves more clearly in-person.
...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)
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.
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)
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.
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)