45 How digital innovation in primary care disrupts the clinical consultation

Remote consulting and digital triage have recently been adopted in response to the COVID-19 pandemic and are changing the nature of consultations in primary care. These new modes of consultation unsettle the interaction between patient and clinician which lies at the core of general practice. Drawing on Bakhtin's notion of language as dialogical we explore how these innovations open the consultation up to different voices and spatio-temporal arrangements. We used mixed methods to explore remote consulting and digital triage in three general practices. We undertook team ethnography over two separate weeks in each practice, complemented by go-along interviews with staff and narrative interviews with patients. We also reviewed patient records to map consultation activity over the previous two years. The findings demonstrate how digital triage and remote consulting disrupt the clinical consultation through spatio-temporal fragmentation coupled with the incorporation of multiple new voices. Before entering the consultation room, patients tell their problem(s) to receptionists and record them in online forms. Doctors review these accounts from patients (or receptionists), they liaise with colleagues about patients (in clinical meetings and triage rooms), send asynchronous text messages to patients (with or without the option to respond), and enter into synchronous conversation with patients via telephone (and sometimes face-to-face). This makes a 'single' consultation spatio-temporally dispersed, increasingly 'crowded', and ultimately more 'heteroglossic'. We have traced how digital triage and remote consulting create and disrupt dialogue by incorporating the voices of receptionists, clinicians, technology developers and policy-makers across online and physical spaces. By unpacking how patients and doctors create meaning in a changed communicative landscape, we identify sites for potential improvement.