Protocol: Remote care as the ‘new normal’?  Multi-site case study in UK general practice

Abstract

Background: Following a pandemic-driven shift to remote service provision, UK general practices offer telephone, video or online consultation options alongside face-to-face. This study explores practices’ varied experiences over time as they seek to establish remote forms of accessing and delivering care. Methods: This protocol is for a mixed-methods multi-site case study with co-design and national stakeholder engagement. 11 general practices were selected for diversity in geographical location, size, demographics, ethos, and digital maturity. Each practice has a researcher-in-residence whose role is to become familiar with its context and activity, follow it longitudinally for two years using interviews, public-domain documents and ethnography, and support improvement efforts. Research team members meet regularly to compare and contrast across cases. Practice staff are invited to join online learning events. Patient representatives work locally within their practice patient involvement groups as well as joining an online patient learning set or linking via a non-digital buddy system. NHS Research Ethics Approval has been granted. Governance includes a diverse independent advisory group with lay chair. We also have policy in-reach (national stakeholders sit on our advisory group) and outreach (research team members sit on national policy working groups). Results (anticipated): We expect to produce rich narratives of contingent change over time, addressing cross-cutting themes including access, triage and capacity; digital and wider inequities; quality and safety of care (e.g. continuity, long-term condition management, timely diagnosis, complex needs); workforce and staff wellbeing (including non-clinical staff, students and trainees); technologies and digital infrastructure; patient perspectives; and sustainability (e.g. carbon footprint). Conclusion: By using case study methods focusing on depth and detail, we hope to explain why digital solutions that work well in one practice do not work at all in another. We plan to inform policy and service development through inter-sectoral network-building, stakeholder workshops and topic-focused policy briefings.

Remote care in UK general practice: baseline data on 11 case studies

“…Our early interviews did not pick up on much in the way of comments about what actually goes on in the consultation, nor many specific comments about quality and safety when managing long-term conditions, early indicators of serious conditions (which might be missed in the absence of an in-person encounter), and patients with communication challenges or complex needs). Previous research by ourselves and others suggests that remote care may compromise the therapeutic relationship and continuity of care, lead to more transactional forms of clinical interaction, fewer 'doorknob consultations', and delayed diagnosis of serious illness (see our protocol paper for literature review 2 ). These problems are likely to affect the patient population disproportionately and generate new kinds of inequity.…”

“…Full details of governance, NHS ethics approval and methods are reported separately 2 . Briefly, Remote by Default 2 is sponsored by the University of Oxford and overseen by an independent advisory group with a lay chair and patient representation.…”

“…The coronavirus disease 2019 (COVID-19) pandemic was (among other things) a unique opportunity for digital innovation in the healthcare sector 1 . As described in more detail in our protocol paper 2 , it triggered unprecedented changes in general practice. Remote digital access (e.g.…”

“…Notwithstanding commendable efforts to make digital services accessible and ensure that the needs of the digitally excluded are met 14,15 , the tendency of digitalisation of services to worsen socio-economic inequalities is well-described 2,16 . Digitally-supported service models are often depicted as more efficient than in-person alternatives, though evidence supporting this claim is sparse even in studies of carefully selected low-risk patients 2 .…”

“…Notwithstanding commendable efforts to make digital services accessible and ensure that the needs of the digitally excluded are met 14,15 , the tendency of digitalisation of services to worsen socio-economic inequalities is well-described 2,16 . Digitally-supported service models are often depicted as more efficient than in-person alternatives, though evidence supporting this claim is sparse even in studies of carefully selected low-risk patients 2 . One large study of telephone-first models in general practice showed an overall reduction in efficiency compared to standard access models, but there was wide variation between practices with some reporting benefits and others no change 17 .…”