The acceptability, appropriateness, and equity of remote consultations in sexual and reproductive health services in England and Wales: a qualitative study

Technical Summary: Acceptability, Appropriateness, and Equity of Remote Consultations in SRHS

Problem Statement
Sexual and Reproductive Health Services (SRHS) in England and Wales have increasingly adopted remote consultation models (telephone, video, secure messaging) driven by the NHS 10-year plan, funding constraints, and the acceleration of digital tools during the COVID-19 pandemic. While remote consultations offer potential benefits regarding convenience, efficiency, and access for those in rural areas or with disabilities, there is limited evidence regarding their impact on health outcomes and health inequalities. Concerns persist regarding confidentiality, the inability to perform physical examinations, patient acceptability, and the risk of exacerbating digital exclusion. The study addresses the gap in understanding how these remote models affect equity, specifically examining whether they create barriers for marginalized populations such as those with low digital literacy, language barriers, or limited access to private spaces.

Methodology
This qualitative study, part of the broader CONNECT study (NIHR153151), utilized semi-structured in-depth interviews to explore the equity implications of remote SRHS consultations.

• Participants: The study included 54 service users (or potential users) and 35 professional stakeholders (clinicians, managers, commissioners).
• Sampling: Participants were purposively sampled across three diverse Case Study Areas (CSAs) to ensure variation in socio-demographics, geography (urban/rural), and service delivery models. Maximum variation sampling was used to include diverse age groups, ethnicities, disabilities, and socioeconomic statuses.
• Data Collection: Interviews were conducted between March 2024 and January 2025, either in-person, via telephone, or through video conferencing (Microsoft Teams/Zoom).
• Analysis: Data were transcribed, pseudonymized, and thematically analyzed using NVivo software. The analysis was guided by the Framework for Digital Health Equity, which extends existing health disparity frameworks to include digital determinants of health (technology access, digital literacy, community infrastructure). Findings were interpreted collaboratively with Public and Patient Involvement (PPI) groups.
• Ethics: The study received ethical approval from the NHS Research Ethics Committee (REC: 23/NS/0128).

Key Contributions
The paper contributes to the literature by applying the Digital Health Equity framework specifically to SRHS, moving beyond general practice to examine the unique sensitivities of sexual health. It shifts the analytical focus from individual capacity to the structural and social levels of the digital environment. The study provides empirical evidence on how remote consultations reshape care pathways, affect the clinician-patient relationship, and distribute benefits and burdens unevenly across different populations.

Results
The analysis identified two primary narrative themes:

1. Remote consultations transform the delivery of care:

   • Efficiency vs. Workload: Remote models streamlined pathways by prioritizing in-person visits for complex cases and allowing asymptomatic or simple cases (e.g., chlamydia) to be managed via Online Postal Self-Sampling (OPSS) or remote prescribing. However, this introduced new clinical workloads, such as coordinating medication posting, and was associated with reduced job satisfaction for some clinicians who felt isolated or perceived their remote work as less prestigious ("working in a call centre").
   • Interaction and Rapport: Building rapport was perceived as more challenging remotely. While some service users found the tone of voice on the phone comforting, others found video calls stressful due to the pressure of being on screen.
   • Care Pathways: The shift from walk-in to scheduled appointments improved flow management but extended the time to access care for some, creating a "long-winded" process compared to pre-pandemic walk-in models.
   • Confidentiality and Safeguarding: Clinicians expressed concern over their inability to verify that patients were alone during calls, raising risks for confidentiality breaches and complicating safeguarding screening (e.g., for domestic violence).

2. The challenges and benefits of remote consultation are not distributed evenly:

   • Unequal Access to Space: A lack of private, safe space was a critical barrier. Service users in shared housing, those with children, or those experiencing intimate partner violence struggled to find a distraction-free environment, potentially compromising safety and privacy. Conversely, remote access benefited those wishing to avoid the stigma of visiting a clinic in public.
   • Digital Exclusion and Literacy: Access was hindered by a lack of suitable devices, unreliable internet connectivity (particularly in rural areas), and digital literacy gaps. Assumptions that young people are digitally fluent were challenged; some found NHS websites outdated or lacked funds for pay-as-you-go data. Conversely, older adults were not universally excluded, though some preferred in-person care.
   • Intersectional Barriers: Language barriers, sensory impairments (deafness, visual impairment), and neurodivergence (autism, dyslexia) created specific hurdles. Clinicians sometimes incorrectly assumed remote consultations were unsuitable for non-native English speakers, while others found remote formats rushed or difficult for those with memory issues.
   • Stigma and Marginalization: Remote options provided anonymity for minoritized ethnic groups and trans individuals who feared harassment or misgendering in public clinics. However, for those without private spaces or digital access, these options were exclusionary.

Significance and Claims
The authors claim that remote consultations are not a "one-size-fits-all" solution. While they improve efficiency for some, they introduce significant challenges regarding interaction quality, equity, and confidentiality. The study concludes that the benefits and burdens of remote care are unevenly distributed, reflecting structural, social, and individual factors.

The paper argues that SRHS must ensure equitable access by offering choice between remote and in-person consultations. It emphasizes that a "digital-first" approach without addressing digital determinants of health risks widening health inequalities. The findings suggest that services must actively design pathways that accommodate diverse needs, including those with disabilities, language barriers, and limited private space, rather than assuming digital access is universal. Continued research and evaluation are necessary to understand how evolving service models impact equity for marginalized populations.