Closing the gap: staff perspectives on the effectiveness of teleconsultation in pre-hospital emergency care - a qualitative study.

INTRODUCTION: Teleconsultation is increasingly used within pre-hospital emergency care to provide remote clinical support for paramedics and patients. Despite its growing integration into healthcare systems, there is limited empirical research exploring paramedics' lived experiences of teleconsultation and the factors shaping its effectiveness in practice. The aim of this study is to explore paramedics' perspectives on teleconsultation in pre-hospital care and to identify the mechanisms influencing its effectiveness. METHODS: A qualitative study was conducted using semi-structured interviews with 12 paramedics working in critical care and clinical advisory roles within a large NHS ambulance trust in England. The study was grounded in Bhaskarian transcendental realism, commonly referred to as critical realism in applied health research. Data were analysed using a critical realist thematic approach, combining reflexive thematic analysis with abductive and retroductive reasoning to identify underlying mechanisms. RESULTS: Three interrelated mechanisms were identified. First, a 'teleconsultation competence gap' reflected insufficient preparation for remote consultation within paramedic education and training. Second, 'environmental determinism' highlighted the influence of organisational culture, leadership and workload on practitioners' experiences. Third, an 'autonomy-governance balance' captured tensions between clinical autonomy and oversight, particularly where governance processes were perceived as punitive rather than supportive. These mechanisms operated differently across contexts, shaping both practitioner confidence in and engagement with teleconsultation. CONCLUSION: Teleconsultation in pre-hospital care is shaped by interacting educational, organisational and governance mechanisms. Addressing these collectively, through targeted training, supportive working environments and transparent governance, may enhance paramedic confidence, improve service effectiveness and support patient-centred care.