Implementing online consultations in primary care: a mixed method evaluation extending normalisation process theory through service co-production

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Objectives: To examine patient and staff views, experiences and acceptability of a UK primary care online consultation system and ask how the system and its implementation may be improved.

Design: Mixed method evaluation of a primary care e-consultation system.
Setting: Primary care practices in south-west England.

Methods: Qualitative interviews with 23 practice staff in 6 practices. Patient survey data for 756 e-consultations from 36 practices, with free text survey comments from 512 patients, were analysed thematically. Anonymised patients’ records were abstracted for 485 e-consultations from 8 practices, including consultation types and outcomes. Descriptive statistics were used to analyse quantitative data. Analysis of implementation and usage of the e-consultation system was informed by: (a) normalisation process theory, (b) a framework that illustrates how e-consultations were co-produced, and (c) patients’ and staff touchpoints.

Results: We found different expectations between patients and staff on how to use e-consultations ‘appropriately’. Whilst some patients used the system to try and save time for themselves and their GPs, some used e-consultations when they could not get a timely face-to-face appointment. Most e-consultations resulted in either follow-on phone (32%) or face-to-face appointments (38%) and GPs felt that this duplicated their workload. Patient satisfaction of the system was high, but a minority were dissatisfied with practice communication about their e-consultation.

Conclusions: Where both patients and staff interact with technology, it is in effect ‘co-implemented’. How patients used e-consultations impacted upon practice staff’s experiences and appraisal of the system. Overall, the e-consultation system studied could improve access for some patients, but in its current form, it was not perceived by practices as creating sufficient efficiencies to warrant financial investment. We illustrate how this e-consultation system and its implementation can be improved, through mapping the co-production of e-consultations through touchpoints.
Original languageEnglish
Article numbere019966
Number of pages12
JournalBMJ Open
Issue number3
Early online date19 Mar 2018
Publication statusPublished - Mar 2018


  • Co-production
  • e-health
  • telemedicine
  • normalisation process theory
  • online consultations
  • primary care
  • touchpoints


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