We strongly encourage decision-makers to study the key findings set out in Take-home messages section. We use those take-home messages to structure some key implications.
Our findings on the impact of remote and digital services on patients have a number of important implications for national government in relation to promoting digital inclusion and capacity planning for general practice; for national and local training bodies regarding the new skills staff need; and for primary care commissioners to secure the support needed for vulnerable patients to use digital services. Because patients vary in their ability to use remote and digital services, all services must have a range of services offered through different modalities (including in-person), a way of ascertaining patients’ capabilities and preferences, and sufficient time, capacity and resources to provide a flexible service. Because low-income patients may have limited connectivity and data packages, remote and digital services should be designed to be readily accessible via entry-level and even outdated technologies. Because patients with multiple kinds of disadvantage (especially those living in deprived settings with complex health and social care needs) tend to be unable to benefit from digitalised services, in-person services may be a strategic priority in some ‘Deep End’ settings. Because human intermediation helps some but not all patients who are unable to access digitalised services unaided, and because it is costly and in limited supply, ‘digital navigators’ should be resourced but we should recognise that they are, at best, a partial solution to digital inequities.
Our findings on the challenges to quality in remote and digital general practice (over and above those to patient access) have the following implications. Because digitalisation (usually introduced with the aim of increasing efficiency) may generate unintended inefficiencies which can be potentially ironed out by careful attention to optimising tasks and processes, the ongoing work of embedding and optimisation needs to be prioritised and resourced. We return to this point below. Because remote encounters (especially text-based asynchronous ones) cannot provide the same level of human presence as a traditional in-person consultation, sufficient in-person appointment slots should be available to patients whose clinical or social needs require such presence. Because the high standard of patient safety that is currently achieved in general practice depends on staff initiative and creativity (e.g. ‘workarounds’), staff should be supported and encouraged to take action as needed.
An additional element of quality is the safety implications of remote and digital care with implications of study findings for decision-makers in RCGP and Royal College of Nursing (RCN) in relation to both undergraduate and post-graduate clinical curricula and for training practice support staff who have a safety critical role in assessing and booking patients. There are also implications for national decision-makers working on incentives in the GP contract for quality, safety and continuity and for ICB level digital primary care leads in supporting the design and implementation of safe digital services. Because rare safety incidents tend to be traced back to high workload, interruptions and stress among support staff, providing a calm, low-stress working environment and minimising interruptions is safety-critical. Because clinical factors in safety incidents include poor choice of modality, poor rapport-building, limited assessment and poor use of algorithms, clinicians should be specifically trained to use and sharpen their skills in the remote environment (including use of the telephone). Because there is now a strong and consistent evidence base on the kind of problems that make for unsafe remote consultations, all practice staff should know the main clinical conditions and trajectories that should be given an in-person appointment. Because continuity is (often though not always) a key component of quality, and because it is harder to achieve in a digitalised service, incentives and resources should be allocated to ensuring that continuity is provided to patients who need it. As digitalisation and distributed work become the norm in many practices, it is important to ensure that there is a shared and documented knowledge of patients’ clinical needs, capabilities, vulnerabilities and what is at stake for them. Because long-term condition management includes components that cannot be safely undertaken remotely, and because information gathered on remote platforms may not give an accurate or complete picture of patients’ health status, some in-person capacity must be provided for long-term condition monitoring. With a growing body of research on remote consultations, the time is right to convene a national expert group to optimise digital assessment and triage pathways and update guidance on quality and safety in remote services.
The implications in relation to staff relate both to national bodies charged with training curricula (i.e. NHS England, RCGP, General Medical Council, RCN and others) and to local decision-makers in relation designing digital services in ways that optimising staff well-being and minimise technostress. For trainee GPs and practice nurses, the core curriculum needs to include remote consultation skills such as communication and rapport building in digital consultations and safeguarding assessment. Because learning how to provide remote and digital services is as much about shared information spaces and workflows and ‘system knowledge’ as it is about knowing how to operate particular technologies, on-the-job and team training is essential. Because training needs are many and often unmet currently, and because both support staff and clinical trainees often describe themselves as undertrained and underconfident, additional incentives and resources need to be provided for staff training. The NHS in England and Scotland could consider scaling the model used by health boards in Wales, whereby practices are granted funding to provide practice-wide, all-staff learning days, enabling multidisciplinary teams to train together.
Because many staff are part-time or newly appointed, training courses which are flexible and modular are essential to ensure that all staff can access them. Because staff at different grades and levels of experience have different roles and training needs, all key roles should be linked to explicit competencies and training arranged accordingly. Outline competencies for clinical and support staff are given in Appendix 1, Table 4. The Department of Health and Social Care and NHS England could consider trialling a national training programme for reception staff, for example adapted from the 3-year training provided for clinic assistants in the Netherlands.130 Finally, because digitalisation increases pressure on support staff (with burnout occurring not uncommonly), and because effective and safe services depend on harmonious teamwork, urgent attention should be paid to recruiting, valuing, retaining and supporting staff of all grades.
We suggest the following implications for supporting the innovation and routinisation process in general practice. Because technologies are not plug-and-play (digitalisation requires extensive redesign), because primary care services are currently under severe strain, and because technologies that are not optimised into workflows can generate inefficiencies, ringfenced investment is urgently needed in ICB digital primary care budgets for digital transformation in general practice – not just to purchase technologies but to help practices assimilate, embed and sustain them.
Furthermore, because practices are at different stages of digital maturity, support should be tailored accordingly. Practices serving multiply disadvantaged communities who have chosen to prioritise in-person services (‘strategically traditional’) need affirmation and support for this traditional model plus resources to ensure that basic digital tools and infrastructure (especially the telephone) are dependable and optimised. Practices lacking the material, technical, financial and human preconditions for digital innovation (‘digitally hesitant’) may need significant support to get to the stage where they can identify, introduce, routinise and evaluate digital innovations. Practices which are already introducing digital innovations but in a somewhat unsystematic way (‘digitally reactive’) may need help to achieve a more co-ordinated and strategic approach. In England, there is a clear role for Integrated Care System Digital First teams and PCN digital care leads to support practices to implement all the above effectively. The need for this support to practices is recognised in NHS England’s Delivery Plan for Recovering Access to Primary Care, but there is a risk practices may not be adequately resourced to support a digitally enabled, whole practice team approach to improving access and triage for patients.
Practices that have reached the ability to take such an approach (‘digitally strategic’) should be supported to identify, obtain, trial and routinise the technologies they need to achieve their vision and meet the needs of their population. Digitally advanced and innovative (‘trailblazer’) practices may inspire and support other practices but since they often serve a predominantly digitally enabled population, they should not be used as a blueprint. Policy-makers should not confuse the ‘technology-light’ digitally strategic practice (which is cautious about certain technologies and pathways for good reasons) with the digitally hesitant practice and should be careful not to stigmatise the practice which chooses strategic de-digitalisation. Because larger practices tend to have more slack resources and higher absorptive capacity (e.g. in-house technologies and know-how, horizon-scanning capability), additional support may be needed for smaller practices, which (in general but not invariably) tend to be less digitally advanced.
Implications around technologies and infrastructure include the following. Because novel technologies are only part of the digital transformation challenge and because the context for innovation is currently suboptimal, policy-makers should look beyond new technologies and seek to optimise the preconditions for innovation within practices and externally to them. For example, because standardised and top-down procurement arrangements can stifle innovation, these should be made more flexible and negotiable. Because the range of available technologies is vast and confusing, guidance and mentorship should be available to practices seeking to identify and select technologies. Because new technologies will not work if introduced into practices that lack the capacity to assimilate, embed, adapt and evaluate them, funding is urgently needed to strengthen the material, human and technological infrastructure for remote and digital general practice. And because the picture is dynamic, and especially because the ‘AI revolution’ is generating novel technologies with the promise of transforming services, it is even more urgent to ensure that practices have a basic level of infrastructure and in-house knowledge and capability, and that they are supported in an ongoing way to meet the future.
In sum, there is a need to ensure that a proportion of the £3.4B currently earmarked for digital infrastructure in the NHS131 is allocated to infrastructural strengthening in general practice, including developing the installed base, attending to regulatory levers and incentives, and significantly boosting the capability and confidence of staff. In sum, there is a need to ensure that a proportion of the £3.4B currently earmarked for digital infrastructure and improving productivity in the NHS131 is allocated to infrastructural strengthening in general practice, including developing the installed base, attending to regulatory levers and incentives, and significantly boosting the capability and confidence of staff. Crucially, national strategies for digital transformation need to shift focus from the development and implementation of particular technologies towards supporting ongoing system-wide improvement, maintenance and integration. Distributed control over different elements of infrastructure demands concerted and collective approaches to improvement, and the mobilisation of existing resources and expertise. This is likely to be mostly about incremental development, building on existing infrastructure, rather than large-scale, big-bang rapid transformation – and hence needs attention over the longer term.