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

Abstract

Background: Accessing and receiving care remotely (by telephone, video or online) became the default option during the coronavirus disease 2019 (COVID-19) pandemic, but in-person care has unique benefits in some circumstances. We are studying UK general practices as they try to balance remote and in-person care, with recurrent waves of COVID-19 and various post-pandemic backlogs. Methods: Mixed-methods (mostly qualitative) case study across 11 general practices. Researchers-in-residence have built relationships with practices and become familiar with their contexts and activities; they are following their progress for two years via staff and patient interviews, documents and ethnography, and supporting improvement efforts through co-design. In this paper, we report baseline data. Results: Reflecting our maximum-variety sampling strategy, the 11 practices vary in size, setting, ethos, staffing, population demographics and digital maturity, but share common contextual features—notably system-level stressors such as high workload and staff shortages, and UK’s technical and regulatory infrastructure. We have identified both commonalities and differences between practices in terms of how they: 1] manage the ‘digital front door’ (access and triage) and balance demand and capacity; 2] strive for high standards of quality and safety; 3] ensure digital inclusion and mitigate wider inequalities; 4] support and train their staff (clinical and non-clinical), students and trainees; 5] select, install, pilot and use technologies and the digital infrastructure which support them; and 6] involve patients in their improvement efforts. Conclusions: General practices’ responses to pandemic-induced disruptive innovation appear unique and situated. We anticipate that by focusing on depth and detail, this longitudinal study will throw light on why a solution that works well in one practice does not work at all in another. As the study unfolds, we will explore how practices achieve timely diagnosis of urgent or serious illness and manage continuity of care, long-term conditions and complex needs.

Modernising continuity: a new conceptual framework

“…Our ongoing ethnographic research in 11 general practices across the UK 5 suggests that achieving continuity, especially for the most disadvantaged and vulnerable, takes additional resource and creative action from both clinicians and support staff (Ladds E, Greenhalgh T, unpublished data, 2023). It may be tempting to conclude that general practice has become so complex and is under so much pressure that continuity has simply become too difficult to achieve.…”

“… 3 Multiple system-level pressures — including rising workload, under-resourcing and staffing, increased policy emphasis on rapid access and plurality of provision, and societal fragmentation resulting in high turnover of patients and staff (especially in deprived localities) — have contributed to a de-prioritisation of continuity within UK general practice. The emergence of multidisciplinary teams covering a wide range of roles 4 and the introduction and expansion of digital and remote modalities 5 have created both challenges and opportunities for the delivery of continuity. 6 …”

“…3 Multiple system-level pressuresincluding rising workload, under-resourcing and staffing, increased policy emphasis on rapid access and plurality of provision, and societal fragmentation resulting in high turnover of patients and staff (especially in deprived localities) -have contributed to a de-prioritisation of continuity within UK general practice. The emergence of multidisciplinary teams covering a wide range of roles 4 and the introduction and expansion of digital and remote modalities 5 have created both challenges and opportunities for the delivery of continuity. 6 A NEW FRAMEWORK Academic studies of continuity in primary care have tended to follow a conceptual framework introduced in 2003 by Haggerty et al, which distinguished between relational continuity (an ongoing interpersonal relationship between a patient and one or more practitioners), informational continuity (the use of past, recorded information to make current care appropriate for each individual), and managerial continuity (a consistent and coherent approach to the management of health or illness, often disseminated between practitioners and providers).…”

Training needs for staff providing remote services in general practice: a mixed-methods study

“…The sub-study reported here emerged from the ongoing Remote by Default 2 (RBD2) study whose protocol 5 and baseline findings 6 have been published. RBD2 has three main work packages.…”

Protocol: How can people with social care needs be supported through processes of digital care navigation to access remote primary care? A multi-site case study in UK general practice of remote care as the ‘new normal’.

“…Previous empirical work by the study team found that people in supporting roles had to extend that support to help patients navigate online access to healthcare ( Greenhalgh et al , 2022b ). Digital disparities, such as ownership of digital devices and access to the internet, were exacerbated by other difficulties in accessing remote care ( Rosen et al , 2022 ).…”