Our findings have gone a long way to answer the original research questions posed in the RBD2 study and have generated some important new questions on key topics. We consider some of those below (these topic suggestions are not intended to be comprehensive).
Informing and communicating with patients
The RBD2 study revealed widespread confusion among patients in relation to the options for seeking and receiving health care from their GP surgery. System knowledge in particular was limited – most patients lacked awareness of current services offered by their practice; many had no idea how to navigate these services or what other services or routes they might be channelled to. We worked with a design company to generate materials and resources (both digital and paper based, and in different ethnic languages) to begin to address this need. But we believe there is a continuing need for better signposting and information to help patients navigate the complexities of the digital NHS. Signage in many NHS organisations is clear and consistent (every emergency department in the country, e.g. has the same signs, in the same font, same colours, with the same meaning). There is a piece of design work to be done to bring a similar level of clarity and consistency to the ‘signage’ of digital services. This work should include advice on how to select an appropriate modality and actions to take if conditions deteriorate.
Theory-driven ways to mitigate digital inequities in the most disadvantaged
We believe that one of the most important outputs from this study has been a significant contribution to the theoretical literature on digital inequity. Dakin et al.’s work on digital candidacy introduces the novel concept of the digital facsimile – the idea that the patient seeking access to care now needs to create an accurate, complete and persuasive version of themselves on the electronic record.63 In contrast to traditional candidacy theory, in which the negotiation of a person’s candidacy for care occurs synchronously and directly with a human being (e.g. a receptionist or triage nurse), the negotiation of candidacy in the digital world involves ‘gaming’ an algorithm and crafting pull-down menus and other digital tools to generate the facsimile which a human (or conceivably, a technology) will subsequently assess for eligibility. While the idea of digital candidacy and the digital facsimile are appealing, we did not actually study these facsimiles directly. There is scope for further research to examine the material and rhetorical properties of such facsimiles and explore why those submitted by disadvantaged patients may result in them being deprioritised or routed inappropriately.
Rybczynska-Bunt et al.’s work on fractured reflexivity is also theoretically novel and ripe for further empirical application, especially in relation to the finding that people with multiple axes of disadvantage are at very high risk of digital exclusion.66 Scambler has depicted fractured reflexivity has been depicted as a neglected social determinant of health.65 Extending Archer’s original typology, he describes some fractured reflexives as characterised by ‘disconnected fatalism’, which includes a tendency to engage in habits and behaviours that are injurious to health and to underuse health and social services. In our published paper, we have applied these ideas to a sample of multiply disadvantaged patients (including social disadvantage, drug use and neurocognitive impairments) who were participants in our RBD2 study. Our analysis illustrated how maladaptive behaviours (such as impulsively putting the phone down or getting into altercations with receptionists) emerge in such patients. In general, this group did not benefit much from digital navigator support. This work could be extended by developing interventions (perhaps using a codesign approach) to better meet the needs of these complex patients.
We have begun to show how an intersectionality approach might bring together multiple intersecting axes of disadvantage in the study of digital inequities – for example, in considering how to provide for people who are elderly, poor, with limited English, low health literacy, low system literacy, digitally ill-equipped and unskilled, and with past experience of perceived racism and discrimination.19 Intersectionality theory, which originated in critical race theory and feminism, takes as its starting point that these multiple axes combine in any one individual to produce a single, unique identity.132 Husain has begun to show how the use of composite case narratives and personas (i.e. fictional profiles that represent key user segments and are designed to humanise the technology design process133) could capture these complexities in a way that allows provider organisations to reflect and re[design] services around their needs.71 However, the literature suggests that personas can also have a negative effect of reinforcing and activating stereotypes and – worse – ensuring that these stereotypes become ‘baked in’ to the design of digital technologies and services.134 There is scope for a programme of research into how to optimise the codesign and sensitive use of personas in shaping patient-centred health services, perhaps with a particular focus on ethnic and racial minorities.134 There is scope for a programme of research into how to optimise the co-design and sensitive use of personas in shaping patient-centred health services, perhaps with a particular focus on ethnic and racial minorities.
System-wide partnerships for digital innovation in primary care
The longitudinal and collaborative components of the RBD2 study highlighted the importance of building and harnessing inter-organisational and inter-sectoral partnerships in order to facilitate the implementation and use of technology and to address infrastructural constraints. It is important to consider how national policy can facilitate trusted partnerships and knowledge transfer pathways, including investment into formal and centrally co-ordinated activities alongside informal and locally driven initiatives and networks. There is a substantial literature on the role of intersectoral partnerships in driving forward large-scale innovation in the healthcare sector, most of which emphasises the role of the private sector.56,135–137 A smaller literature, to which the RBD2 team are contributing, warns against commercially focused ‘utopian’ visions and instead emphasises the crucial role of the state in creating a digital economy that is primarily oriented to delivering universal healthcare and digital services to all as a human right and a public good.128 A recent review concluded that ‘the dynamics of translation, which results in new technologies, are complex, transdisciplinary, inter-institutional, systemic, and non-linear’.136 While it is already known (and confirmed by this study) that such networks are important in the innovation process, we know remarkably little about how such networks should best be designed and facilitated for the specific challenge of strengthening the infrastructure of primary care and promoting digital innovation.128 A recent review concluded that ‘the dynamics of translation, which results in new technologies, are complex, transdisciplinary, inter-institutional, systemic, and non-linear’.136 While it is already known (and confirmed by this study) that such networks are important in the innovation process, we know remarkably little about how such networks should best be designed and facilitated for the specific challenge of strengthening the infrastructure of primary care and promoting digital innovation. A programme of research on this topic would be timely.
After the teleconsultation
A key finding from this study was that workflows need to change to maximise the potential of remote and digital technologies. The patient with a possible urinary tract infection, following a telephone consultation and urine test, needs to pick up a prescription for antibiotics. The patient who has had a telephone consultation for asthma monitoring may be identified as needing input on inhaler technique – something that could be provided by an educational video. A patient with chronic chest disease with an acute exacerbation may be invited to monitor their oxygen levels at home and send in the readings. The parent who has had a telephone consultation for a febrile child needs safety-netting instructions in case the child deteriorates.
In all these situations, something – a prescription, a link to an online video, a set of biomarker readings, a set of instructions – is being sent to or from the patient after the teleconsultation. There is limited research on what happens to these various links and artefacts, or why (in some cases) patients fail to take them up as expected or find them helpful. Optimising the workflows and transfer of materials for these post-teleconsultation follow-on activities, and exploring inequities in their uptake and use, is an under-researched aspect of remote general practice services. Both quantitative studies (to ascertain patterns of use) and qualitative ones (to seek explanations for variation in these patterns) are needed. More broadly, more thought needs to go into optimising ‘post-consultation infrastructure’ for transfer of data and supporting follow-up, and into identifying and addressing inequities in the post-consultation phase.
Workforce support
Another key finding in the RBD2 study was that both clinical and administrative staff experienced job dissatisfaction, worsened well-being and a sense of misalignment with professional identity and values. We extended Gill’s original theory of workplace suffering85 with sociotechnical theories to produce a novel theory of technostress, and are currently exploring how staff who are stressed and burnt out from the demands of digitalisation have difficulty forming the positive workplace relationships on which effective multidisciplinary teamwork depends (paper in preparation). There is an important set of research questions to be addressed around how best to reduce technostress and workplace suffering. Related to this, published and upcoming work highlights the value of relational approaches to work in general practice, particularly during periods of crisis, change and innovation, and the need to improve relational co-ordination among practice staff. To understand how to improve relational competencies in GP teams, we need to better understand the preconditions for developing relational workplaces, how they can be embedded, and what can trigger their erosion.
Green agenda
An aspect of remote care which we had intended to explore was its role in contributing to the ‘green agenda’ of reducing the carbon footprint of the NHS. There is an expanding and hopeful literature on this topic,127,138–140 but almost no evidence from a primary care setting. In the RBD2 study, we asked practice staff about the green agenda, but we did not identify any examples of this agenda driving (or even explicitly influencing) digitalisation strategy in general practice. Since patients tend to live near their GP surgery, published estimates of energy savings are likely to be an overestimate. A focused research study could examine in more detail whether a major shift away from in-person care could make a significant contribution to the carbon footprint of the NHS – and also what the trade-offs of such an achievement (e.g. in terms of possible double-handling or increased prescriptions or investigations) might be. As the drive for digitalisation and use of AI progresses in primary care, and the NHS more widely, there will inevitably be questions about the environmental impact of such technologies, not only in terms of carbon emissions but also impact on communities and resources (e.g. water use). Research in this field could examine how and where best to focus digitalisation efforts in primary care while at the same time achieving a net zero health service.141
Remote links between general practice and other providers
Based on reviewers’ comments on an earlier draft of this paper, we agree that another priority area for future research should be how to optimise remote and digital links between general practice and other providers, including (but not limited to) secondary care, community mental health services, nursing and care homes, hospices, social services, hostels and prisons. The RBD2 study was not designed to explore any of these links in detail but they are of course essential to an effective and safe local health and care system.