Background and rationale
The move to online primary health care services
The National Health Service (NHS) is under pressure due to the increasing demands of a growing and ageing population, technological progress and changing expectations among the public. Successive governments have viewed technology as part of a solution in addressing the pressures facing primary care, and policy for delivery of general practice has reflected this thinking.1
Recent years have seen a push towards the adoption of online services in primary care, ranging from booking appointments and ordering repeat prescriptions through to the use of alternatives to face-to-face consultation with a patient (e.g. e-mail, video). By 2022, the reach of such services had extended to 22 million users.2 Current NHS policy in England emphasises use of digital services in primary health care, and to date 28 million people have downloaded the NHS app, and 40 million people have acquired an NHS login.2 Drivers behind the move to online primary care provision include the assumption that online services lead to improved choice, convenience, and ease of access for users, improved triage systems and streamlining of service delivery.3
Context of this research: the COVID pandemic
In March 2020, the UK recognised the global health emergency of a pandemic associated with rapidly spreading COVID virus. In the UK, COVID led to widespread changes in society and within the healthcare system. From the perspective of this research, some relevant policy initiatives4 are summarised in Box 1. Overall, the pandemic was associated with increasing and substantial pressure for many staff in primary care, and for primary care within the healthcare system. The British Medical Association has estimated that numbers of full-time equivalent general practitioners (GPs) fell by nearly 6% between 2015 and 2021.5 Moreover, the telephone first consultation, which was available pre-pandemic and widely adopted during the COVID pandemic, initially generated a 33% increase in the mean number of GP contacts per patient per 28 days,6 and during the pandemic increased telephone consultations from 39% to 51%.7
General practice settings moved to using remote methods of consultation to enable safe delivery of care. The shift was dramatic, with a rapid change to 90% remote GP consulting (46% for nurses) by April 2020.11 The researchers in that study noted a universal consensus that remote consulting was necessary. Telephone consulting was sufficient for many patient problems, video consulting was used more rarely, and appeared less essential as lockdown eased. Short message service (SMS)-messaging increased more than threefold.11,12
Figures from 2022 for use of technology and online primary care services show an increasing use of NHS online services13 (increased from 44% of respondents reporting that they had ‘recently used’ such services, to 55% in the year to July 2022) – covering areas such as ordering repeat prescriptions online (26–31%), having an online consultation or appointment (18–22%), booking appointments online (19–21%) or accessing personal health records (7–17%). Geographical variation across England is evident in the application of online general practice services (GP services) by integrated care systems (ICS), with usage ranging from 46% of patients using an online GP service in the past 12 months to a maximum of 70% across 42 systems. Increases were evident in the proportion of patients reporting use of their GP practice’s website (from 36% in 2018 to 60% in 2022) with around 66% of respondents reporting the practice’s website being ‘easy to use’ in 2022.
Prior to the pandemic, research studies had established that for patients a face-to-face consultation is seen as the ‘gold standard’ and was the most used type of consultation.13 The rapid change occurring in general practice means that digital services are now more widely available to all patients, and they may be expected to use them, regardless of digital confidence, proficiency and ease of access to the required technology and connectivity. For some patients, this change in patterns of access has been beneficial, for others it has been more challenging.14
Moving to online provision – impacts and sequelae
The introduction of digital services and the move to a digital-first health service envisaged at the time this research was commissioned, raises important questions about digital access in the population. The research reported here has taken place in a changing policy environment – from the early days of a ‘digital-first’ vision for access to primary care services, through the ‘total triage’ model encouraged by NHS England during the COVID-19 pandemic to reduce footfall in general practices and to protect staff and patients, and, more recently, to a refined and nuanced vision of GP access, encompassing a range of modes of access, responding to the needs and ambitions of the NHS and of local patients and populations. In order for GP practices and patients to gain the potential benefits that technological innovation can bring to primary care,15 patients must be able to, and wish to, access and use online services. Digital inequalities tend to adversely affect certain groups of people. In this context, individuals from older age groups, non-white ethnicities, those in lower socioeconomic groups, those in poorer health and individuals in rural settings are recognised as vulnerable groups who may struggle to access digital services.16–19 As online delivery of primary care is a key priority for policy-makers,2,20–23 it is important to understand how barriers to uptake might be overcome and inequality avoided. In attempting to mitigate the potential for digital inequalities, the research literature suggests that meaningfully involving users, tailoring services and interventions to target groups’ contexts, delivering credible messages and having a clear understanding of how services using technology improve health are key elements in developing relevant interventions.24 One way to combat these potential inequalities is via digital facilitation (DF) – actively supporting patients and carers in using practice-based online services.
Value of online services
Financial investment in online health services is enormous. In the USA, for example, digital health doubled between 2019 and 2020, being seen as a ‘quarter trillion dollar opportunity’, and investment in online and digital health being described as ‘skyrocketing’ in recent years.25 The number of health apps available globally is rapidly increasing, and was estimated at around 318,000 by 2017.26 Such substantial investment and development activity highlights the need to estimate the value of such services to the population being served – does the investment yield significant returns in terms of health and well-being or patient experience of care, and is it cost-effective?
These are reasonable questions to ask, but challenging questions to answer. UK investment in online healthcare provision is comparable to that from other advanced economies, all of whom have moved to increasing online provision of health services; in 2021 it was estimated that around US$40 billion was invested in digital health globally with around US$5 billion being invested in Europe/Switzerland, and a further US$4 billion being invested in the UK alone.27 Capital investments within this sector support a variety of facilities and provision. These range from providing core infrastructure through to developing support for accessing services, and the development and delivery of necessary software to support online delivery of care to whole populations, or to those with specific health needs28,29 – such as the development of applications to provide support and care to people living with mental health conditions.29
At a national level the NHS in England has described a range of sequelae associated with increasing digital health provision – seen as important for the NHS in its ability to achieve strategic health and social care priorities, and with potential benefits for patients and carers, and the wider healthcare system (Box 2).30 Specifically, the introduction of a major NHS-funded programme aimed at widening digital healthcare participation amongst individuals with low digital health literacy was associated with substantial increases (59%) in confidence regarding use of online health information, substantial reductions (52%) in a sense of loneliness or isolation, a 21% reduction in visits to the GP for minor ailments, increased use (by around 20%) in booking GP appointments online and in ordering prescriptions online, and an apparent substantial saving in time through carrying out health transactions online.31 A recent evaluation of that programme estimated a return on investment of £6.40 for every £1.00 spent by the NHS on digital inclusion support.30 Earlier research32 calculated the social return on investment of digital inclusion for individuals and for workers. For individuals, getting online for general purposes was estimated to be worth £1064 a year due to increased confidence, less social isolation, financial savings and opportunities in employment and leisure. For workers, getting online was estimated to be worth £3568 a year due to opportunities for remote working and increased earnings opportunities. In England, digital transformation of health and social care services is seen as a top priority for the Department of Health and Social Care and National Health Service England (NHSE) with estimates of many billion GBP investment – for example, the anticipation of £2 billion of funding (against a commissioning budget of £153 billion)33 to support electronic patient records to be in all NHS trusts, and additional help for over 500,000 people to use digital tools to manage their long-term health conditions in their own homes.2 A fully integrated, digitally based health and social care system covering primary and secondary care sectors is seen as the goal to be achieved. The stakes are high to ensure implementation of a nationally co-ordinated plan ensuring that all individuals, including those most vulnerable in society, are given opportunity to benefit from these dramatic and costly changes.
Patients: inequality
Although there is a clear drive towards the development, promotion and use of online GP services, the impact for patients and for GP practices remains unclear. There is potential for NHS patients and primary care staff to benefit through reduced administrative burden for staff, better communication between patients and practices, expanded health knowledge for patients and improved access to care services.35 But there is also the danger that such initiatives create or exacerbate inequalities in access to healthcare information and services.36
Medically underserved and vulnerable populations are less likely, than other patient groups, to engage with online services.37 For example, indices of deprivation were one of the strongest determinants of non-use of patient portals among patients with chronic kidney disease attending renal clinics in the UK, with patients from postcode areas with the lowest levels of deprivation being 2.4 times more likely to register for portals than patients from postcodes with the highest level of deprivation in England and Wales, and 3.2 times more likely in Scotland.38 Underserved and vulnerable population groups span those captured by the PROGRESS Plus39 and NHSE40 criteria and include groups classified as vulnerable due to issues of race, ethnicity, culture or language; occupation; gender/sex; religion; education; socioeconomic status; social capital; age; disability; homelessness or migration status.
Engaging ‘harder to reach’ patients and reluctant users of online services may offer potential to reduce inequality of access, but also to improve patient health and potentially reduce GP and/or other NHS costs. Other sectors of health, commerce and business have developed initiatives to support clients in using online services, for example, Barclays ‘Digital Eagles’, where selected individuals acted as champions to encourage confidence and improve skills in use of digital services.41
Patients: digital literacy
The concept of digital literacy, first proposed in 1997,42 is highly relevant where the health of individuals and populations and the uptake of online health services are at stake. Rowlands has proposed a definition of digital health literacy as ‘the ability to seek, and understand, and appraise health information from electronic sources and apply the knowledge gained to preventing, addressing or solving a health problem’.43 Encompassing both technical skills and sociocultural domains, digital health literacy is recognised to vary widely across the population, to be measurable using standard instruments,44 and to be a key driver of the digital divide – the health inequality experienced by ‘populations able to benefit from access to and use of health information and services online and populations unable to take up such opportunities’.45 Low digital health literacy is associated with low health literacy, and with poorer health outcomes, an effect seen, especially amongst poorer, more vulnerable sections of the population.44 In planning their scoping review of digital health focused interventions, Hamilton and colleagues helpfully identify the need to address the digital health divide by targeting both the acquisition of necessary skills, especially in vulnerable individuals, and also to target health systems and healthcare practitioners and their need to be responsive to the digital health needs of the individuals and populations they serve.45 Finally, Kim and Xie44 note that interventions aimed at addressing poor health literacy should not just offer online health services tailored to individual’s health literacy levels, but ‘should include education about how to access online resources for health information and disease management, how to search for information effectively, and how to evaluate the quality of online health information’.
Challenges to staff engagement with online services
The digital competence of healthcare professionals and their acceptance of online service provision are also important for successful implementation of online patient services. Konttila et al.46 argue that healthcare professionals are more accepting of digital technologies when they perceive the technology as helpful for patients and supportive of the practice’s workflow, but that factors such as a lack of comfort or perceived issues of competence with using the technology can decrease acceptance and uptake. Healthcare professionals were found to be less accepting of digital technologies when they misunderstood the purpose of the technology, or found it difficult or uncomfortable to use, or when it was not seen as part of their principal work. Others47 have identified the potential loss of ‘valuable non-verbal communication’ in remote consultations as a specific concern. Israeli qualitative research48 identified the potential for better quality care resulting from integration of medical expertise – recognising the phenomenon of the patient, empowered with e-knowledge and challenging traditional boundaries of medical care. Konttila and colleagues’46 systematic review also found that healthcare professionals often experienced IT education for themselves as pointless, under-resourced, time-consuming and with poorly understood benefits. However, supportive organisations and managers were found to facilitate support for staff education and acceptance of digital technologies. It thus appears that support for practice staff in using and supporting patients in using digital health technologies is crucial, and must be carried out in a sensitive and constructive manner.
System: inverted investment
Concern has been expressed at the limited investment by healthcare planners and governments in addressing gaps identified around the uptake and use of services and innovations underpinning effective medical care. In system terms, NHS online services may be judged as potentially ‘effective’ and therefore potentially subject to implementation delays and delays in uptake.49 In addition, the decision to introduce digital care on a widespread scale came before consideration of how that rollout might be achieved. This inverted approach to supporting implementation is exemplified by the introduction of toolkits to support practices delivering online consultations sometime after, and not alongside or before, the relevant policy and funding statements.50
Challenges to patient engagement with online services
The reasons for the lower engagement of some sections of the population with digital and online health services are complex and include factors that limit access to technologies as well as factors affecting motivations to use the technologies. Specific barriers to engagement with online services for these groups include a lack of experience with using the internet,37,51 lower health literacy37,52 and a lack of trust towards the information being provided through online interfaces.37,53 Issues relating to ‘usability’ can also impede older users from accessing information through patient portals. For example, when older users lost required access codes after registering on patient portals, they became discouraged in their use of the service.37 Research in Scotland has identified technical and practical considerations (poor connection, ‘frozen’ images, poor sound quality, slow broadband) in adopting IT innovations,54,55 including amongst rural populations, who may have limited access to good quality broadband services. In research undertaken in homeless populations,56 qualitative research findings have highlighted the importance of addressing practical and technological barriers as well as supporting communication and choice for mode of consultation. In their reviews of the literature, Irizarry et al.52 and others23 have concluded that the ability of patients to access online health services is strongly influenced by combinations of personal factors such as health literacy, health status, age, ethnicity, education level and whether individuals have caring responsibilities.57 Likewise, in a systematic review of qualitative studies examining the factors affecting patient recruitment to digital health interventions, O’Connor et al.58 concluded that greater investment is required to improve computer literacy to ensure that technologies are accessible and affordable. Cognisant of these issues, we have been involved in research examining the unintended consequences of providing some online services in primary care,59,60 and investigating patient use and experience of online booking in general practice.
Supporting the move to online services
For the purposes of this research, our focus is on services accessed via a primary care practice website (e.g. booking appointments, access to records) and via online platforms provided by general practices. From 1 November 2022, patients were due to have online access to new entries in their personal medical records,61 although this initiative has been delayed in implementation at the time of writing.
Digital facilitation
In this research, we address ‘digital facilitation’, a unique term defined as ‘that range of processes, procedures and personnel which seeks to support NHS patients in their uptake and use of online services’. The specific focus of this study relates to those processes, procedures and personnel provided by or on behalf of GP practices to support access by their registered patients, and carers of those patients, to NHS online primary care services. Support in accessing and using services is required at all stages, from supporting registration with practices, downloading and using the NHS app, and supporting patients in navigating NHS online provision and accessing the wide range of health resources and information of relevance to NHS patients.
At the inception of this project we were connected to Lea Valley Health Federation (9 GP practices, 86,000 patients), who took early steps to support patients to use digital services by employing a local digital facilitator officer to support patients’ and staff engagement with their online services.62 In Lea Valley, implementation was driven by a ‘Primary Care Demand and Capacity Audit’.63 The appointment of a digital facilitator was undertaken with the ambition of engaging patients and staff who might otherwise not engage, for personal or economic reasons or because they might lack the digital skills, with online GP services. Appointment of such an individual represents one approach to supporting and facilitating patient and user access. There is, however, no existing evidence as to the nature and scope, effectiveness, or cost impact of appointing such an individual. Other routes to achieve those aims, such as using volunteers to provide support or referring patients to community programme, may be of potential value, but the nature and extent of innovative approaches offered by practices are currently unknown.
Although research on the use of DF is relatively limited to date, there is evidence to support its use and its ability to reduce inequalities in access to digital resources amongst ‘harder to reach’ and vulnerable groups. One approach to facilitation identified by O’Connor et al. involved the use of ‘direct engagement’, including ‘consultations with health professionals, employers, personal recommendations from family or friends or being spoken to by research or management staff’.58 Personal recommendations from family or peers, or the endorsement of digital resources by practice staff were found to increase enrolment in digital health technologies. This is further supported by evidence from systematic reviews which find that patients more generally, including comparatively less well-served populations, are more likely to engage with digital health resources when they have the encouragement of friends or family members.51,64,65 Evidence also suggests that people with lower education levels and older people require more support than other patient groups in order to use digital health applications. We have not identified any evaluations of such engagement approaches in practice, although we have identified that poor understanding of service provision may be a barrier to service uptake,66 and that staff have expressed concerns regarding adverse workload implications which might ensue. There is also evidence showing that introducing the NHS App was associated with improved digital access during its pilot testing phase with 64% (out of 3192) of users of the App reporting that they had previously not used online services to access GP services.67 Feedback from practice staff during the pilot testing of the NHS App identified that some practice staff wanted additional training and support in order to effectively communicate with patients about the app.
Other interventions designed to target direct engagement with digital technologies have been identified, for example, the use of staff ‘champions’ for GP online services,68 as well as specific interventions to improve people’s online health literacy.69 Cowie et al. evaluated the implementation of an online tool providing advice to support self-management and the opportunity to digitally consult with a GP, concluding that the presence of a champion within the practice was a significant factor in ensuring successful integration of the tool.68 Amongst some patients, who had no previous computer experience, training on computer and internet use, development of effective search skills and interpretation of online information was associated with greater health information seeking and interpretation skills, and with increased self-management.
It is thus important to understand the extent to which digital facilitators or other approaches to DF are being used, how they are being used, what impact they are having on uptake of online services, and how such uptake may be impacting patient health and access to healthcare information and services, GP practices and the wider NHS.
Aims, objectives and study structure
The overarching aims for the research study were to:
- Identify, characterise and explore the potential benefits and challenges associated with different models of DF currently in use in general practice which are aimed at improving patient access to online services in general practice in England.
- Use the resulting intelligence to design a framework for future evaluations of the effectiveness and cost effectiveness of such interventions.
- Explore how patients with mental health conditions experience DF and to gauge their need for this support.
To address these aims, we have conducted a series of interlinked research work packages (WPs) (Figure 1). The objectives of the WPs were to:
FIGURE 1 Flow diagram of study showing work stage flow. (Figure not reproduced here; see the original article.)
- review published literature to understand and characterise the range, effectiveness and cost effectiveness of models of DF for improving access to online services within health and other sectors, and to develop a typology of DF (WP1)
- undertake a practice staff survey to investigate the range of DF services currently offered in a sample of English primary care practices and relating this to patient experience of care in those practices as measured by the national General Practice Patient Survey (GPPS) (WP2A)
- undertake a patient survey to investigate patient views of DF in a sample of English primary care practices and relating this to different modes of DF identified in the practice survey and to explore how patient factors predict awareness and uptake of DF (WP2B)
- conduct a qualitative exploration seeking to understand in-depth and from the perspective of practice staff, patients and other stakeholders the potential benefits and challenges associated with different models of DF (WP3).
Synthesise learning from these elements and develop a framework for future evaluations of effectiveness and cost effectiveness of models of DF (WP4).
During the course of the project, we successfully responded to a NIHR commissioning brief to apply for further project funding to extend the scope of the project to perform additional work focusing on patients living with mental health conditions. In doing so, a further objective was added to the project:
- Explore the experiences of patients living with mental health conditions by (1) augmenting our existing patient survey with a boost sample of patients with mental health conditions (added to WP2B) and (2) conducting additional qualitative interviews with patients with mental health conditions (added to WP3). In both cases, findings will be integrated with those from the original patient survey and patient interviews.
Outcome
The ultimate outcome of the project is a summary of the current status of DF as presently implemented within primary care. This includes what is known about the likely effectiveness, cost and equity of access implications of the approaches identified, and an indication of the prevalence of various approaches in four regions of England (East of England and North London; South-West; West Midlands;). We have provided recommendations for future development and implementation of promising approaches to DF, and a framework for future evaluations to assess the effectiveness, cost effectiveness and impact on inequalities of access to the online services, of relevant facilitation approaches within primary care settings.
Theoretical framework
We have used Weiss’s theory-based evaluation as our theoretical framework to understand how, and in what ways, different models of DF bring benefits and challenges to general practice.70 Weiss distinguishes between ‘programme theory’, which specifies the mechanism of change, and ‘implementation theory’, which describes how the intervention is carried out.
We have done this by drawing on the findings of the evidence synthesis, surveys and case studies to develop the ‘programme theory’ and ‘the implementation theory’.
To develop the ‘programme theory’ we used a realist approach to describe provision of DF. A realist approach asks ‘What works for whom, in what circumstances, in what respects, and how?’71
We explored this in terms of:
- context (e.g. characteristics of the general practice, the target patient population, the policy framework, and the IT infrastructure)
- the theory and assumptions underlying the intervention (how and why DF might lead to benefits)
- the flow of activities that comprise the intervention (the key processes that occur when patients make use of DF)
- intended benefits/outcomes (those deemed important to patients and practitioners).
The ‘implementation theory’ explored moderating factors which influence the extent to which the process and outcomes were achieved, such as factors acting as barriers and facilitators to practices offering DF or to different groups of patients using them.
Patient and public involvement and engagement
This research is underpinned by recognition that patient and public involvement and engagement (PPIE) is an integral part of research practice. Patients’ voices should be reflected and addressed in the design and delivery of health research in order to ensure that research outputs are meaningful and relevant to them. As a research team we have followed the UK standards framework for public involvement in research including: inclusive opportunities, working together, support and learning, governance, communications and impact.72
From the outset we have worked with patients to shape the scope and objectives of this research and continued to work collaboratively with patients throughout the research. Patients and carers have been active partners and included at all stages of the research process, including in setting the research agenda and analysing data.73 The approach to involvement, the impact on the research and reflections on how it worked are included throughout the report.