Remote Consultations in General Practice in Ireland: Who Is Missing Out?

Abstract

Introduction

: This research examines the characteristics associated with the use of remote consultations in general practice in Ireland during and after the COVID-19 pandemic.

Methods

: The analysis uses three waves of a nationally representative cross-sectional survey of health in Ireland (“Healthy Ireland” survey), relating to the years 2020/2021, 2021/2022, and 2022/2023. The sample includes people aged 15 and over who reported seeing a general practitioner (GP) in the 4 weeks prior to the survey. The outcome variable (“remote consultation”) captures whether a respondent reported that their most recent GP consultation took place via telephone or video (“remote consultation”). Logistic regression analysis was used to assess the relationship between the likelihood of having a remote consultation and a range of potential explanatory variables including age, gender, insurance status, and socioeconomic status.

Results

: There was a significant decrease in the percentage of respondents reporting remote consultations over the period of analysis, from 39% in 2020/2021 to 10% in 2022/2023. In later periods, being female (odds ratio [OR] = 1.47 [1.04, 2.09]), having private health insurance (OR = 1.76 [1.13, 2.73]), and having a long-term health condition (OR = 1.53 [0.98, 2.39]) were positively associated with the probability of reporting a remote consultation, while being in an older age group (OR = 0.29 [0.13, 0.62]) was negatively associated with the likelihood of a remote consultation.

Discussion

: The high prevalence of remote consultations during the COVID-19 pandemic was not maintained in the postpandemic period. Policymakers should consider the reasons for this and consider the gendered, age-based, and insurance-based disparities in remote consultation utilization in the development and promotion of digital health care.

Introduction

While the remote provision of health care services through electronic and telecommunications technology has increased over the past couple of decades, the COVID-19 pandemic is widely considered a catalyst in stimulating the implementation of telemedicine in health institutions and health care settings.^1,2 Remote consultations have the potential to provide several benefits, such as timesaving for patients, reductions in travel costs and carbon emissions, increases in convenience and efficiency, and support for hybrid work models for health care professionals.^3
–5 However, remote consultations are not without their limitations, including a potential detraction from face-to-face communication often deemed central to the provision of high-quality health care services and a reliance on access to the internet or communication technology.^1,6

A range of individual characteristics have been found to be associated with the likelihood of having a remote consultation including age,^7

–10 gender,^7,10,11 race/ethnicity,^7

–12 insurance status,^8,10,12 and the patient’s first language.^7,8,11 However, the direction of association between individuals’ characteristics and the likelihood of a remote consultation is not always consistent across studies. For example, one study found that females were less likely to have a remote consultation for cardiovascular care,¹¹ while two other studies found that females were more likely to have a remote consultation for family medicine and outpatient encounters,^7,10 suggesting that the differences might be related to the types of health or health care setting included in the different studies.

A systematic review of studies examining inequalities in general practice remote consultations found that across 13 studies, women, nonimmigrants, and older patients were more likely to use telephone consultations; while internet-based consultations were likely to be used more by younger, affluent, and educated groups.¹³ The authors suggest that older patients may be more likely to benefit from face-to-face consultations, and that their use of telephone consultations may reflect an imposition caused by mobility issues and limited general practitioner (GP) resources to facilitate their visits. Gendered differences may reflect preferences or patterns of disease, while lower use among immigrants may be explained by language barriers, a lack of familiarity with new health systems, and perceived exclusion from health care.

In Ireland, a number of policy documents have discussed the potential for remote consultations in the delivery of health care services,^3,14 and usage increased significantly during the COVID-19 pandemic.¹⁵ However, the potential for remote consultations and telehealth more generally to exacerbate health inequalities (through furthering inequalities in accessing health care) has also been recognized in Irish government documents,³ and it has been proposed that research into telehealth implementation and utilization is required to better understand these potential inequalities. A study relating to 2020 (the height of the COVID-19 pandemic) found that particular groups of older people were more likely to have availed of a remote consultations than others, including those with more chronic conditions, poorer mental health, and those with private health insurance (PHI).¹⁶ It is not clear, however, how relevant these findings are beyond the COVID-19 pandemic and associated restrictions (see next section for discussion of the Irish health care system and COVID-19-related restrictions).

The aim of this research was to examine the characteristics associated with the use of remote consultations in Ireland in the period during and after the COVID-19 pandemic. For context, the next section provides a brief overview of the Irish health care system and the impact of the COVID-19 pandemic on accessing health care services.

THE IRISH HEALTH CARE SYSTEM

There are two main categories of entitlement to publicly financed health care services in Ireland. Those in Category I (medical cardholders) are entitled to largely free public health care services including GP care. Those in Category II are entitled to subsidized public hospital services and prescription medicines but pay the full cost of GP services. A third category—GP visit card holders—are entitled to free GP visits but otherwise have the same entitlements as Category II individuals. Eligibility for a medical/GP visit card is assessed primarily on the basis of an income means test, with the threshold for GP visit cards higher than for the medical card. All individuals over 70 years of age and under 8 years of age are entitled to a GP visit card.

In 2022, approximately 30% of the population had a medical card and 11% had a GP visit card.¹⁷ Cardholders are required to register with a particular GP, with GPs reimbursed by the state via the General Medical Services scheme. For private patients, GP practices are largely reimbursed on a fee-for-service basis from individual patients, with the fee determined by individual practices. Also, in 2022, 45% of the population was covered by PHI.¹⁷ While traditionally PHI was mainly used to provide cover for hospital services, more recently PHI companies have increasingly financed and provided primary care services (including GP services) both in-person and remotely.

In 2020 and 2021, due to the COVID-19 pandemic, a range of restrictions on movement were implemented in Ireland. While travel to attend medical appointments was permitted,¹⁸ GPs had been, since March 2020, providing a majority of their consultations remotely (via video link or over the phone).¹⁹ As of March 2020, most people who wanted a COVID-19 test required a GP referral, with most of these referrals provided through remote consultations. Until December 2022, GPs were renumerated €30 for each such remote consultation, regardless of a patient’s eligibility status. Additionally, a payment of €25 was paid to GPs for remote consultations, not related to COVID-19, which were intended to assess the need for a patient’s attendance at the practice premises. This fee applied only to remote consultations for cardholders and stopped in September 2020. Pandemic-related restrictions eased over the course of 2021 and 2022, and by the end of the study period, no restrictions relating to COVID-19 were in place in Ireland.

Methods

DATA

Data for the analysis were derived from the Healthy Ireland Survey (HIS). The HIS is a nationally representative, annually repeated, cross-sectional survey of people aged 15 or over living in the community in Ireland.²⁰ To date, eight waves of the survey have been completed (data collection for Wave 6 was interrupted by the COVID-19 pandemic and was therefore not completed. As such, the HIS to date comprises of Waves 1–5 and then Waves 7–9). The sample size is in the region of 7,500 per wave. The analysis in this article relates to Wave 7 (2020/2021), Wave 8 (2021/2022), and Wave 9 (2022/2023), all of which were undertaken by telephone. A two-stage telephone random digit dial approach was used to identify respondents, with an overall response rate of 40% (percentage of known eligible telephone numbers that are contacted that fully complete a survey interview).²⁰ In each wave, the final sample is weighted by sex, age, education, working status of the respondent, and region to maximize its representatives of the general population. The HIS includes a range of health-related topics and has been previously used to undertake a number of health-related research studies.^21
–23 The survey is approved by the Research Ethics Committee of the Royal College of Physicians of Ireland.²⁰

OUTCOMES

In each of the three waves, survey respondents that reported that they had at least one GP visit in the previous 4 weeks were asked: “Thinking of your most recent consultation with a GP, where did the consultation take place?” The following response options are provided:

In a GP surgery/health clinic

Over the phone

Online video consult

In my home

In a hospital (Wave 8 only)

Other

Refused

For the purpose of this analysis, a binary outcome variable was created, which took the value 1 if the respondent reported that their most recent consultation took place over the phone or online video consult, and 0 otherwise.

A range of explanatory variables were chosen with respect to the national and international literature on the utilization of remote consultation (Table 1). The explanatory variables were selected based on a review of national and international literature on the utilization of remote consultations. For some variables (self-reported health, education, employment, country of birth, and social class), categories were aggregated to account for small numbers of respondents (Table 1). For example, while there are nine potential responses to the question on the highest level of education completed, this was aggregated to two categories for this analysis (less than degree, degree, or more).

Table 1.

Number of Respondents Reporting a General Practitioner Consultation in the 4 Weeks Preceding the Survey, with the Proportion of Those Whose Consultations Took Place Remotely in Parentheses for the Total Population and Particular Subgroups

	2020–2021	2021–2022	2022–2023
Total	1,428 (39%)	1,632 (15%)	1,735 (10%)
Gender
Male	621 (38%)	748 (12%)	766 (8%)
Female	807 (40%)	884 (17%)	969 (12%)
Age
15–29	153 (38%)	183 (17%)	186 (15%)
30–49	472 (45%)	555 (16%)	544 (12%)
50–64	404 (38%)	443 (17%)	516 (9%)
65+	399 (31%)	451 (11%)	489 (6%)
Card status
Medical or GP visit card	676 (39%)	770 (13%)	783 (9%)
No card	752 (39%)	862 (18%)	952 (11%)
PHI
Yes	789 (38%)	871 (17%)	896 (13%)
No	639 (40%)	761 (14%)	839 (9%)
Self-reported health
Good/very good	1,033 (39%)	1,175 (17%)	1,201 (10%)
Fair/bad/very bad	395 (40%)	457 (12%)	534 (10%)
Long-term health condition
Yes	659 (37%)	828 (15%)	1,005 (11%)
No	769 (41%)	804 (16%)	730 (9%)
Country of birth
Ireland or UK	1,305 (39%)	1,422 (16%)	1,540 (10%)
Outside of Ireland or UK	123 (35%)	210 (10%)	195 (10%)
Region
Dublin	449 (44%)	492 (16%)	494 (9%)
Rest of Leinster	351 (33%)	442 (15%)	474 (11%)
Munster	382 (40%)	425 (15%)	470 (11%)
Connaught/Ulster	246 (37%)	273 (14%)	297 (10%)
Civil status
Married/partnered	949 (37%)	880 (15%)	925 (10%)
Not married/partnered	479 (42%)	752 (15%)	810 (11%)
Employment
Working for pay/profit	728 (40%)	848 (16%)	947 (10%)
Not working for pay/profit	700 (38%)	784 (14%)	788 (10%)
Social class indicator
Nonmanual worker	574 (43%)	878 (16%)	990 (11%)
Manual worker	854 (37%)	754 (14%)	745 (9%)
Education
Degree or higher	545 (39%)	670 (18%)	740 (11%)
Less than degree	883 (39%)	962 (14%)	995 (10%)

Note: Data are weighted.

PHI, private health insurance; GP, general practitioner.

STATISTICAL ANALYSIS

The unadjusted prevalence of remote GP consultations in the population was described—both for the population as a whole and for several subgroups. Among those who had consulted a GP in the last 4 weeks, logistic regression analysis was used to assess the association between reporting that the most recent consultation took place via telephone/video and the explanatory variables in Table 1. The analysis uses sample weights and robust standard errors, and the results are presented with adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Individuals with missing data across the study variable were dropped from the analysis, leaving a final sample of 1,428 for Wave 7, 1,632 for Wave 8, and 1,735 for Wave 9. The analysis was carried out using STATA 17.0.

Results

Table 1 shows the number of survey respondents that had consulted the GP in the previous 4 weeks and the percentage of those that reported that their most recent consultation took place via telephone or video. There was a significant decrease in the percentage of consultations that took place remotely over the period of analysis, from 39% in 2020/2021 to 10% in 2022/2023. In all periods, a slightly higher proportion of females reported a remote consultation, while in general the likelihood of a remote consultation decreased with age. In the two later periods, a higher proportion of those with PHI reported a remote consultation compared with those without. Additionally, consistent across all periods, a lower proportion of manual workers compared with nonmanual workers reported that their most recent consultation took place remotely.

Turing to the adjusted analysis (Table 2), in the later periods, females were significantly more likely to report that their most recent consultation took place remotely, while older age groups (e.g., 50+) were significantly less likely to have had a remote consultation relative to younger age groups. No significant association was found between marital status, education, employment status, and the likelihood of a respondent’s most recent GP consultation being remote. Similarly, having a medical or GP visit card was not significantly associated with the likelihood of a remote consultation. However, in 2022/2023, those with PHI were significantly more likely to have reported a remote consultation than those without. In terms of health status, in 2022/2023 having a long-term health condition was associated with a higher likelihood of the individual reporting that their most recent consultation took place remotely.

Table 2.

Adjusted Odds Ratios and Associated Confidence Intervals Showing the Associations Between Independent Variables and the Probability of a Respondent Who Had Seen the General Practitioner in the 4 Weeks Preceding the Survey Reporting That Their Most Recent General Practitioner Consultation Took Place Remotely (via Telephone or Video Consultation)

	2020–2021 (n = 1,428)	2021–2022 (n = 1,632)	2022–2023 (n = 1,735)
Sex
Male	1.00	1.00	1.00
Female	1.04 [0.77, 1.39]	1.47^** [1.04, 2.09]	1.47^* [0.98, 2.21]
Age
15–29	1.00	1.00	1.00
30–49	1.50 [0.94, 2.39]	1.00 [0.58, 1.73]	0.92 [0.51, 1.65]
50–64	1.09 [0.65, 1.83]	0.97 [0.52, 1.78]	0.55^* [0.29, 1.05]
65+	0.80 [0.44, 1.43]	0.58^* [0.31, 1.09]	0.29^*** [0.13, 0.62]
Region
Dublin	1.00	1.00	1.00
Rest of Leinster	0.63^** [0.43, 0.92]	0.88 [0.55, 1.38]	1.12 [0.67, 1.88]
Munster	0.85 [0.59, 1.21]	0.90 [0.57, 1.38]	1.21 [0.75, 1.97]
Connaught/Ulster	0.79 [0.52, 1.21]	0.84 [0.52, 1.35]	1.11 [0.61, 2.04]
Country of birth
Ireland/UK	1.00	1.00	1.00
Outside Ireland/UK	0.68 [0.41, 1.11]	0.51^** [0.30, 0.89]	0.89 [0.48, 1.66]
Marital status
Not married/partnered	1.00	1.00	1.00
Married/partnered	0.82 [0.59, 1.15]	1.00 [0.76, 1.59]	1.06 [0.69, 1.63]
Education
Less than degree	1.00	1.00	1.00
Degree or higher	0.83 [0.59, 1.16]	1.08 [0.74, 1.56]	0.81 [0.53, 1.23]
Employment status
Working for payment/profit	1.00	1.00	1.00
Not working for payment/profit	1.26 [0.88, 1.81]	1.12 [0.74, 1.71]	1.30 [0.79, 2.12]
Card status
No card	1.00	1.00	1.00
Medical or GP visit card	1.09 [0.74, 1.59]	0.91 [0.59, 1.40]	1.02 [0.62, 1.67]
Insurance status
No PHI	1.00	1.00	1.00
PHI	0.94 [0.66, 1.33]	1.15 [0.76, 1.73]	1.76^** [1.13, 2.73]
Self-reported health
Fair/bad/very bad health	1.00	1.00	1.00
Good/very good health	0.85 [0.59, 1.22]	1.35 [0.86, 2.14]	1.00 [0.63, 1.58]
Long-term health condition
No LTHC	1.00	1.00	1.00
LTHC	0.77 [0.55, 1.06]	1.11 [0.76, 1.61]	1.53^* [0.98, 2.39]
Social class classification
Nonmanual	1.00	1.00	1.00
Manual	0.67^** [0.47, 0.96]	1.07 [0.74, 1.53]	0.70 [0.36, 1.39]

p < 0.1.

p < 0.05.

***

p < 0.01.

Discussion

The analysis found a significant decrease in the percentage of respondents reporting that their most recent GP consultation took place remotely. In later periods, being female, having PHI, and having a long-term health condition are positively associated with the probability of reporting a remote consultation, while being in an older age group is negatively associated.

A relationship between age, gender, and telemedicine utilization has been commonly found in the literature. In the United States, for example, one study found that females had a higher odds of a remote consultation relative to males, while the odds of a remote consultation decreased with age.⁷ Looking specifically at COVID-19-related care in New York City,⁹ patients aged ≥65 had higher odds of using in-person appointments compared with all other age groups. However, another study¹⁰ found that, at the outset of the pandemic, odds of any telehealth encounter were higher for those aged ≥65 (compared with a base of 18–44). This, coupled with the fact that the analysis in this study found that older age only became significantly associated with lower odds of telemedicine utilization in later time periods, may indicate that older age groups may have utilized telemedicine during the emergency phase of the pandemic, but transitioned back to in-person appointments when possible. Additionally, the positive and significant association between PHI and remote consultations found in the later periods is consistent with existing findings among the older population in Ireland.¹⁶

While there was a significant increase in the use of remote GP consultations during the COVID-19 pandemic in Ireland, this was not maintained in the period after the pandemic, with the rates observed in this analysis for 2022/2023 similar to those found in another study in the prepandemic period.²⁴ A recent review of telemedicine in general practice in Europe found somewhat diverging views about the future of telemedicine in general practice.²⁵ While some GPs anticipated that some consultations would continue to be conducted remotely after the COVID-19 pandemic, others expressed a preference for continuing with in-person care. There were a number of reasons for this including an inability to assess subtle symptoms remotely, increases in GP workloads through increased training needs, and concerns regarding the accessibility of remote consultations for some patient groups.²⁵

Several factors may contribute to disparities in the use of remote consultations across different groups. First, certain groups may place a higher value on the advantages of remote consultations. Women, for example, who are more likely to act as primary caregivers in families and carry out a disproportionate level of household tasks, may be more time-poor²⁶ and unable to leave caring responsibilities and may therefore place a higher value than men on the reduction or elimination of travel to and from GP clinics. Second, some groups may be more likely than others to present with symptoms that are more/less suited to a remote consultation. It may be the case that older patients are presenting with more complex symptoms that require an in-person appointment. The higher utilization of remote consultations among those with a long-term condition in the last period found in this analysis may reflect the use of remote consultations (in part) for those participating in the recently established chronic disease management program, where some of the review appointments can be held remotely. Third, certain groups may more acutely experience the disadvantages of remote consultations. Older people seem to value face-to-face interaction highly in their interactions with the health system, which may deter them from utilizing remote consultations.^6,27

An Irish study identified several difficulties experienced by users of remote consultations during the pandemic, including connectivity, video/sound quality, and difficulties with hardware (microphones, headphones, etc.),²⁷ and it is likely that these issues will disproportionately affect some groups, including those with poor internet access/quality and those less familiar with the relevant technologies. If developments in remote consultations and telehealth more generally are based on an approach emphasizing cost-saving at the expense of health gains, these issues may be exacerbated, further widening inequalities in access to health care and worsening patient experiences and outcomes.

Similar to another Irish study,¹⁶ this analysis found a positive and significant association between holding PHI and use of remote consultations. There are a number of potential reasons for this in the Irish context, including the increased provision of remote GP consultations by many of the main health insurers in Ireland.²⁸ In addition, given the positive association between household income and PHI coverage, both in Ireland and internationally,^29,30 it may be the case that PHI is acting as a proxy for household income, which previous analysis has been found to be associated with remote consultations use in general.³¹

LIMITATIONS

There are limitations to the current analysis. First, as the analysis only includes those that reported having a GP consultation in the previous 12 months, it does not include those that “lost out” on a GP consultation, especially in the height of the pandemic, due to not being able to transition from in-person to remote health care. Second, the question in the survey only asks about form taken by the most recent consultation, meaning some remote consultations are not included. However, this is unlikely to impact on the disparities in utilization found in this analysis. Third, several additional variables found elsewhere to be significantly associated with remote consultations were not available in the current study, including area-based variables such as deprivation and population density.^10,32,33 The limited number of variables in the current study also means that it is not possible to rule out the possibility that variables found to be significantly associated with the likelihood of having a remote consultation are acting as a proxy for some other factor.

Conclusions

Various Irish government documents have highlighted the potential for telehealth in the Irish health care system.³ This research, however, shows a significant drop in the use of remote consultations in general practice after the COVID-19 pandemic. While some of this drop is to be expected as the COVID-19 pandemic and associated restrictions lessened, it is somewhat surprising how rapid the fall has been and how low the rate of remote consultations in general practice is in Ireland relative to, for example, England where approximately 27% of GP appointments took place remotely in 2023.³⁴

To help ensure the integration of telehealth in the Irish health care system, there is a need for further research to identify the reason why there was such a significant decline in the use of remote consultations since the COVID-19 pandemic. Furthermore, there is a need to identify why some groups are less likely than others to avail of remote consultations. For example, are the lower rates observed among older people driven by preferences or by an inability to access or use the required technology—or by a combination of both factors. Only then will it be possible to address these inequalities and ensure equitable access to telemedicine services.

This study highlights the need to ensure that no one is left behind by the increased emphasis on and use of telemedicine and remote consultations into future. As such, the emphasis on patient choice and empowerment in the Digital Health Framework for Ireland ³⁵ is welcome. However, further investment to build trust in digital health care systems and to increase people’s capacity to engage with such services may be required. Further research may also be required on the appropriateness of remote consultations and telehealth more generally for particular types of appointments, as well as the benefits and costs of such consultations (both in terms of patient outcomes and in terms of time and financial costs to the health system). While government bodies may point to telehealth’s cost-saving potential, this does not always happen in practice.^36
–38 Finally, the Irish HSE Telehealth Roadmap ³ emphasizes the potential for telehealth to enable continuance of health care provision in events such as natural disasters, pandemics, and so on. If this strategy holds into the future, then investment in telehealth provision in public health care settings will be required to avoid disparities in accessing health care in the face of challenging events that limit staff and patient mobility.^3,39

Footnotes

Authors’ Contributions

Study concept and design: S.C. Analysis and interpretation of data: E.M.H. and S.C. Writing original draft: E.M.H. Writing—review and editing: S.C. and E.M.H.

Disclosure Statement

The authors declare they have no competing interests.

Funding Information

No specific funding was received for this study.

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