Background: To reduce contagion of COVID-19, in March 2020 UK general practices implemented predominantly remote consulting via telephone, video or online consultation platforms. Aim: To investigate the rapid implementation of remote consulting and explore impact over the initial months of the COVID-19 pandemic. Design and Setting: Mixed-methods study in 21 general practices in Bristol, North Somerset and South Gloucestershire. Methods: Quantitative: Longitudinal observational analysis comparing volume and type of consultations in April-July 2020 with April-July 2019. Negative binomial models were used to identify if changes differed amongst different groups of patients. Qualitative: 87 practice staff longitudinal interviews in four rounds investigated practices experience of the move to remote consulting, challenges faced and solutions. A thematic analysis utilised Normalisation Process Theory. Results: There was universal consensus that remote consulting was necessary. This drove a rapid change to 90% remote GP consulting (46% for nurses) by April 2020. Consultation rates reduced in April-July 2020 compared to 2019; GPs/nurses maintained a focus on older patients, shielding patients and patients with poor mental health. Telephone consulting was sufficient for many patient problems, video consulting was used more rarely, and was less essential as lockdown eased. SMS-messaging increased more than three-fold. GPs were concerned about increased clinical risk and some had difficulties setting thresholds for seeing patients face-to-face as lockdown eased. Conclusions: The shift to remote consulting was successful and a focus maintained on vulnerable patients. It was driven by the imperative to reduce contagion and may have risks; post-pandemic, the model will need adjustment.

Background: To reduce contagion of COVID-19, in March 2020 UK general practices implemented predominantly remote consulting via telephone, video or online consultation platforms.Aim: To investigate the rapid implementation of remote consulting and explore impact over the initial months of the COVID-19 pandemic.Design and Setting: Mixed-methods study in 21 general practices in Bristol, North Somerset and South Gloucestershire.Methods: Quantitative: Longitudinal observational analysis comparing volume and type of consultations in April-July 2020 with April-July 2019. Negative binomial models were used to identify if changes differed amongst different groups of patients. Qualitative: 87 practice staff longitudinal interviews in four rounds investigated practices experience of the move to remote consulting, challenges faced and solutions. A thematic analysis utilised Normalisation Process Theory.Results: There was universal consensus that remote consulting was necessary. This drove a rapid change to 90% remote GP consulting (46% for nurses) by April 2020. Consultation rates reduced in April-July 2020 compared to 2019; GPs/nurses maintained a focus on older patients, shielding patients and patients with poor mental health. Telephone consulting was sufficient for many patient problems, video consulting was used more rarely, and was less essential as lockdown eased. SMS-messaging increased more than three-fold. GPs were concerned about increased clinical risk and some had difficulties setting thresholds for seeing patients face-to-face as lockdown eased.Conclusions: The shift to remote consulting was successful and a focus maintained on vulnerable patients. It was driven by the imperative to reduce contagion and may have risks; post-pandemic, the model may need adjustment.

Background Health services in many countries are promoting digital-first models of access to general practice based on offering online, video, or telephone consultations before a face-to-face consultation. It is claimed that this will improve access for patients and moderate the workload of doctors. However, improved access could also potentially increase doctors’ workload. Objective The aim of this study was to explore whether and under what circumstances digital-first access to general practice is likely to decrease or increase general practice workload. Methods A process map to delineate primary care access pathways was developed and a model to estimate general practice workload constructed in Microsoft Excel (Microsoft Corp). The model was populated using estimates of key variables obtained from a systematic review of published studies. A MEDLINE search was conducted for studies published in English between January 1, 2000, and September 30, 2019. Included papers provided quantitative data about online, telephone, or video consultations for unselected patients requesting a general practice in-hours consultation for any problem. We excluded studies of general practitioners consulting specialists, consultations not conducted by doctors, and consultations conducted after hours, in secondary care, in specialist services, or for a specific health care problem. Data about the following variables were extracted from the included papers to form the model inputs: the proportion of consultations managed digitally, the proportion of digital consultations completed without a subsequent consultation, the proportion of subsequent consultations conducted by telephone rather than face-to-face, consultation duration, and the proportion of digital consultations that represent new demand. The outcome was general practice workload. The model was used to test the likely impact of different digital-first scenarios, based on the best available evidence and the plausible range of estimates from the published studies. The model allows others to test the impact on workload of varying assumptions about model inputs. Results Digital-first approaches are likely to increase general practice workload unless they are shorter, and a higher proportion of patients are managed without a subsequent consultation than observed in most published studies. In our base-case scenarios (based on the best available evidence), digital-first access models using online, telephone, or video consultations are likely to increase general practitioner workload by 25%, 3%, and 31%, respectively. An important determinant of workload is whether the availability of digital-first approaches changes the demand for general practice consultations, but there is little robust evidence to answer this question. Conclusions Digital-first approaches to primary care could increase general practice workload unless stringent conditions are met. Justification for these approaches should be based on evidence about the benefits in relation to the costs, rather than assumptions about reductions in workload. Given the potential increase in workload, which in due course could worsen problems of access, these initiatives should be implemented in a staged way alongside careful evaluation.

BackgroundThe WHO is calling for the integration of palliative care in all health care settings globally.MethodsA 3.5–year program was implemented in 12 government hospitals, three each in Kenya, Rwanda, Uganda and Zambia. A four–pillared approach of advocacy, staff training, service delivery strengthening and international and regional partnership working was utilized. A baseline assessment was undertaken to ascertain needs, and 27 indicators were agreed to guide and evaluate the intervention. Data were also collected through surveys, interviews and focus groups.ResultsPalliative care was integrated into all 12 hospital settings to various degrees through concurrent interventions of these four approaches. Overall, 218 advocacy activities were undertaken and 4153 community members attended awareness training. 781 staff were equipped with the skills and resources to cascade palliative care through their hospitals and into the community. Patients identified for palliative care increased by a factor of 2.7. All 12 hospitals had oral morphine available and consumption increased by a factor of 2.4 over two years. Twenty–two UK mentors contributed 750 volunteer days to support colleagues in each hospital transfer knowledge and skills.ConclusionsIntegration of palliative care within different government health services in Africa can be achieved through agreed interventions being delivered concurrently. These include advocacy at Ministry, Provincial and District level, intensive and wide–ranging training, clinical and support services supported by resources, including essential medicines, and an investment in partnerships between hospital, district and community.

Background: Continuity of care is a core principle of primary care and related to improved patient outcomes and reduced healthcare costs. Evidence suggests continuity of care is declining. Aim: (i) to confirm reports of declining continuity of care, (ii) to explore differences in decline according to practice characteristics, (iii) to examine associations between practice populations or appointment provision and changes in continuity of care. Design and Setting: Longitudinal study of aggregated practice-level data from repeated questions in GP-Patient surveys between 2012-2017 on having a preferred GP, seeing this GP always/often (usually), appointment system and practice population characteristics, linked to rural/urban location and deprivation. Method: Multilevel modelling; time (level-1) and practices (level-2). Results: 56.7% of patients had a preferred GP in 2012, declining by 9.4%-points (95%CI -9.6 to -9.2) by 2017. 66.4% of patients with a preferred GP saw this GP usually in 2012, which declined by 9.7%-points (95%CI -10.0 to -9.4) by 2017. This decline was visible in all types of practices, irrespective of baseline continuity, rural/urban location, or deprivation. At practice-level, an increase over time in the percentage of patients reporting good overall experience of making appointments was associated with an increase in both the percentage of patients having a preferred GP, and the percentage of patients being able to see that GP usually. Conclusion: Patients reported a steady decline in continuity of care over time, which should concern clinicians and policymakers. The ability of practices to offer patients a satisfactorily working appointment system could partly counteract this decline.