This report presents the work carried out across the four WPs of the Di-Facto project, including the additional work specifically undertaken with patients living with mental health conditions. The key results have been brought together and synthesised in Chapter 6. Here we suggest the key implications of the work for policy, practice and research. We also reflect on the contribution of PPIE throughout the research process, and on issues relating to equality, diversity and inclusion. Digital facilitation is a concept that the research team defined when developing this study. As such it does not yet have a widely accepted meaning, nor will it necessarily be recognised as a coherent concept by those not exposed to this research. However, the research has demonstrated the need for, and the potential value of, DF.
Implications for policy
The current policy direction for Primary Care in the UK highlights the continued implementation and use of digital services. If this change in service configuration is to happen, then there is a clear role for DF in providing relevant support. However, our research has shown that there is a disconnect between the perceptions and expectations of some key national and regional stakeholders and what DF efforts are actually occurring at practice level, where the reality is messier and often falling short of expectations. This disconnect needs to be recognised, as do the reasons why these expectations are not met. Our work provides some relevant insight, including the observations that many practices would like to support patients in their use digital service, but do not have the resources to do so. To realise the NHS vision of increasing use of general practice digital services, targeted investment looks certain to be required in terms of staff time and training.
In order for DF to happen effectively, there needs to be clarity provided around the responsibility for its delivery. Currently, responsibility is often assumed to be the role of ‘others’, and thus little action follows. Those ‘others’ are primarily the reception and administrative staff in individual general practices, who rarely have training or skills in DF. Responsibility for DF in the future may lie with several parties across health systems, rather than being the remit of an individual part of the health system. In addition, developing a specific facilitator role might benefit from involvement of a range of individuals such as community link workers, social prescribers alongside other, already recognised staff such as practice based administrators, IT, or other support staff roles such as Digital and Transformation Lead Roles reimbursable via the Additional Roles Reimbursement Scheme.186 Some DF may well fall outside the health sector entirely, recognising the benefits of digital enablement at a societal level. An example of such societal investment in the USA has been linked to potential benefits in terms of health equity.187 Educating patients on the benefits of digital services, and how to use them effectively, could well be performed at a national level. However, the variation in which digital services are implemented across England means that detailed, targeted, support for individual patients will be hard to achieve. This difficulty is reflected in current NHS patient facing materials, such as the ‘How to access your GP practice’ video,188 which makes multiple mentions of digital tools but provides only generic information about how these might work. We know from our research that the reality is each general practice offering a different range of tools. Where consistent digital tools are available at a national level (e.g. the NHS App, or the NHS website) there is the potential to provide specific patient support for these tools. Such support could include promotion activities, as well as user support that is either passive (e.g. ‘how to’ guides, such as the user directions for use of the NHS App provided on the national NHS website189,190) or reactive (e.g. support helpline). While the evaluation of this material fell outside the scope of our research, we note that the material provided is often generic and lacking specific details, reflecting the fact that different practices may utilise different functionality within the NHS App, and that often the specific tools used (e.g. for online consultations) will affect the appearance of those services within the app. How a tool functions is also user dependent and in reality will be influenced by the characteristics of the individual staff member and the individual patient using it, within a specific general practice.
Responsibility for providing support for patients to use specific platforms, commonly falls to general practice staff. However, this risks an inconsistent and inefficient approach whereby potentially thousands of practices are individually developing support for any given platform. There is a case to be made that the platform providers could be encouraged, or mandated, to provide patient facing support either directly to patients or to general practices to help them support their patients. Some platform providers do have passive guidance available that could be made available to patients, but these do not appear to be widely used.191 Ultimately, general practices will be the point of first contact for many patients and so some responsibility for supporting patients will always fall to general practice staff. ICSs are being championed as having a ‘vital role to play in developing a more coherent approach to digital transformation in primary care’.192 The extent to which ICSs will achieve this remains to be seen. Furthermore, DF activities inevitably face needs that vary across different groups in the population. We have found that GP practices are aware in principle of different needs for different groups, but we have found little evidence of targeted facilitation in practice for particular groups. In this context, we suggest there may be a role for national support to the provision of DF in primary care aimed at, for example, the less digitally literate in the population or those hindered by particular disabilities.
Our research has shown that DF is often more effective when the parties involved see worth in the digital tools that are being supported. Other research shows that doctors’ willingness to recommend digital tools depends on their own attitudes and beliefs around digital services.193,194 There is a policy need to articulate to service users and staff the motivation for, purpose and potential benefits of, various online tools. Prior to the COVID pandemic, use of certain online tools by general practices was linked to remuneration or was mandated within the GP contract.195 While this results in the provision of digital services, it does not necessarily lead to the effective use of them. During the COVID pandemic, the need for digital services was acknowledged by most healthcare providers and patients. However, as the restrictions associated with COVID have receded, the benefits of, and need for, all digital services are not universally agreed upon by providers or patients. There is anecdotal evidence emerging, along with some more formal sources of evidence, that the availability of online consultations may lead to rising patient demand.196–199
It is not possible to consider DF entirely in isolation from the digital tools being implemented. Digital tools that are easier to use, easier to access and whose purpose is easier to understand will, by definition, require less DF. NHS policy could focus on improving the usability of different digital tools, and ensuring that the development of digital platforms is undertaken considering both the functionality from a clinical point of view, as well as the patient users’ perspectives.199,200 The necessary rush to implement digital services is now passed. There is time for considered reflection on the impact of digital services, particularly on groups that cannot access them, or do not wish to.
Implications for practice
Our research indicates the potential for DF to help patients and practices make the most of various digital tools and platforms used in general practice. However, to capitalise on this potential will require substantial investment, in and by, general practices. Practices wishing to engage in effective DF will also have to ensure there is clear understanding of the responsibility for delivery. Since commonly the day-to-day responsibility for delivering DF falls to receptionists and administrative staff, care needs to be taken to ensure the staff are equipped to deliver this support and that assumptions are not made about which staff members can and cannot deliver the support based on age or gender stereotypes. Practice leadership and management will need to take responsibility for the overall DF strategy and will need to carefully monitor that what is being delivered does reflect expectations. Similarly, other research has found that adopting digital innovation is complex and will be improved by building consensus between stakeholders and developing dedicated implementation teams.201,202
Our research also highlighted that patients are often supported in the use of online services by friends and family. While this overcomes barriers and enables patients to access online services, it may lead to challenges around patient confidentiality. Digital channels also make it more challenging for staff to ascertain if responses have come directly from a patient or from a carer or family member. Practices should be aware of this and ensure policies to ensure patient confidentiality are in place for use of digital services as they have been historically used for a third party joining a face-to-face consultation.
Practices may need to recognise that DF can take many forms, active and passive, proactive and reactive. It is likely to be important that all types of facilitation are conducted within a practice, though the balance of efforts may need to change depending on the needs of the registered population. Until more evidence emerges about DF, practices would be best served by focusing on understanding and responding to the needs of their specific patient population. This may include paying particular attention to vulnerable populations within their practice who may have specific needs which require more tailored help and support. Vulnerable populations are the least likely to be considered when services are designed which can severely impact on their ability to access and interact with primary care services.
Practices need to recognise that increasing awareness of, and sign up to, digital services do not inevitably lead to increased use. Monitoring continued use of services is at least as important as monitoring initial registration. Whatever form DF takes, it is important that part of this support involves making the purpose and benefits of using digital tools clear to patients and to practice staff. Relatedly, it might be that practices need to make the expectations of digital services use clear to patients. A shared agenda between practices and patients is likely to be important in ensuring effective facilitation, with both parties understanding the reasons for using digital services.
When implementing digital services, practices should ensure that they choose platforms and tools that are as patient-centred and easy to use as possible. In doing so, the need for facilitation will be minimised allowing efforts to be focused on those that need it most. Using digital services that function well together and collectively present a coherent service to patients is likely to be an effective facilitation approach in its own right. Alongside presenting a coherent package of services, there will likely need to be a recognition that digital services will not work for all patients all of the time, and that they may not work in all circumstances, and that some patients may never be able or willing to use them. Traditional, non-digital access to care will inevitably need to remain an option regardless of how developed and applied DF becomes.
Implications for research
The research deficit in this area is large, and the potential for useful research great. The primary care system is under pressure from increasing service demand, especially in the aftermath of the pandemic,192,203 and changing, for example, following the introduction of new professional roles and opportunities in primary care under the new reimbursement for additional roles scheme.186 In these circumstances, the research recommendations highlighted in bold here would usefully be the subject of a priority setting exercise by relevant research funding bodies.
Future research on digital facilitation
We found only limited associations between the DF efforts described by practices and either the patient awareness and use of online services in those practices or the perception of DF efforts by patients. This is not surprising given the observations from the ethnographic case studies that facilitation efforts were often reactive rather than proactive, and that efforts to perform effective DF were hampered by lack of resources. Future research might therefore further explore the association between awareness by (potential) users of digital primary care and actual use of those same services, especially within the context of the introduction of specific efforts to support the awareness and use of such services.
In Evaluation framework we have laid out a framework for a future evaluation of DF in primary care, and while we set out some of the key facets that such an intervention might encompass, we do not specify exactly what form such an intervention might take. Our intention with the Di-Facto project was to explore DF that was already underway, with the potential of identifying good practice which could be either developed further as an intervention for testing or shared more widely for immediate implementation. However, we did not find an example of what might be considered ‘text book’ DF, and certainly nothing that would form a complete, practical intervention package. Any intervention development could build on our research, but given the findings around the need for digital technologies to be a ‘good fit’, it would be essential to co-develop any intervention both with patients, and with general practice staff who would be delivering it to ensure a responsive and adaptive approach.
Related to the development of DF interventions is the development of patient facing digital tools. Currently, these tools are generally developed by commercial providers, but research into what facets of digital platforms make them easier to use and understand by patients is warranted. The context in which these digital tools are presented to patients, usually a general practice website, also warrants consideration. A study in Scotland showed that 77% of practice websites featured information that exceeded the recommended 9–14 reading age for online content, while 81% scored below the recommended Flesch Reading Ease score for ‘plain English’.204 Research into optimising the presentation of practice websites for patient engagement may lead to increased usage of digital tools and reduce the need for DF.
While it is clear that DF is likely to need to be tailored to different patient groups, there is currently a lack of evidence about what this should look like. Future research is needed to address this gap along with identifying which patient groups are most in need of DF. DF and the use of digital services have the potential to both introduce new and extend existing health inequalities, while addressing others (e.g. in groups who experience stigma).205 Any future research on DF also needs to ensure that associated digital exclusion of certain groups, including, but not limited to, older patients, is investigated.206 In addition to the observation that older patients were much less likely to be digitally confident, we have also found that people with long-term health problems, whose first language is not English, who are retired, or not in work/education had lower digital confidence. Care needs to be taken to remember that these findings represent an average picture, and any targeted support should not automatically stereotype patients into being digitally able or not. We found limited evidence that people living with mental health problems were particularly in need of DF, though they had varying views on the use of digital services. The newly developed framework for digital health equity may help to minimise any negative impacts on certain patient groups.207
Finally, we would recommend that any research into DF monitors sustained use of online services, rather than the current focus on initial sign-up. Such sustained use will be required if the perceived benefits of digital service use are to be realised.
Research conduct
Taken at face value and in isolation, the findings from the practice survey might have implied that proactive, effective, DF was being carried out at scale across the country. However, comparisons of the practice survey responses with patient responses, and with the ethnographic observations, suggested a rather different picture. This has major implications for the isolated use of organisational-level surveys to examine how services are being delivered. Only by using a mixed-methods approach and synthesising the evidence from different research methods as we have done here, can a reliable and full picture be gained.
In studies of health service delivery as it is happening in everyday practice, it is important to examine a wide range of service providers to obtain findings that will be generalisable to the wider population. In conducting this study, we made efforts to include practices that were not ‘research active’ in order to make our results as generalisable as possible. However, the NIHR CRN, which was set up to support the delivery of NIHR funded research, has a strong focus on ‘research active’ practices. We found that CRNs were not set up to approach non-research active practices, and along with capacity issues, this posed a challenge to the delivery of the research. We would recommend a widening of the CRN remit to encourage contact with all general practices, especially for the conduct of health services research.
Equality, diversity and inclusion
Participant representation
Several steps have been taken in this research to ensure that the participants were representative of the wider population. Given the scope of this research, the population of interest is all users of GP services in England. The areas of the country where our research was conducted were selected to cover a diverse population, including a mix of city, urban and rural areas, a range of deprivation levels, and areas with high numbers of ethnic minorities.
Within WP2 we used a random sample of practices across our research area to ensure our findings were generalisable. Despite efforts to engage with all practices, the eventual practice survey respondent sample was somewhat less likely to include practices serving more deprived populations but was reasonably representative in terms of the age profile, and proportion from ethnic minorities, of the registered population.
The responders to the WP2B patient survey were skewed towards those of older age (over 65). However, this is reflective of the differential use of primary care services by older patients, and may denote improved representativeness of the sample relative to the people that exert most demand for primary care services.208 Only 8% of responders described themselves as having a non-white ethnicity, which is below the national average (18%). This may in part reflect the age profile of responders but is still less than ideal. The respondent209 sample included participants with a wide range of working statuses as well good representation of carers and parents. There was also good representation of people with long-term physical and mental health conditions, with the latter group particularly focused on in the mental health boost sample. There were 358 patients who were deaf or had a hearing impediment, but only a small number describing themselves as blind, or partially sighted, a potentially important group for this study. Crucially, the patient survey was accessible in both paper and online formats to enable patients unable to engage with digital platforms to participate. We worked with our PAG to ensure the survey materials were accessible to as many potential responders as possible, although unfortunately resources did not allow for translations or large print versions. The steps taken to target more deprived populations in the patient survey resulted in an even spread of responders across the range of practice deprivation scores.
The analysis of GPPS data included data from across the country to maximise generalisability. Furthermore, due to the very large sample size of the GPPS survey, it was possible to examine awareness and use of online services in relatively small groups, something that would not have been possible with primary data collection. The GPPS is offered for patients to complete online, or over the phone, in 14 languages other than English as well as British Sign Language. However, given the paper version of the GPPS questionnaire is only available in English, and the strong relationship between response mode (paper/online) and digital confidence in our patient survey, it is likely that responders to the GPPS may be biased towards more digitally confident patients particularly among ethnic minorities.
Within WP3 the participating practices were purposefully sampled to include those serving populations with a range of deprivation levels, and varying proportions of both ethnic minority and older (aged over 65) patients. Practice staff participating in interviews covered a range of ages, and more than half were female, which probably reflects the gender balance in the staff roles included. Similarly, patient interview participants covered a range of ages, and again more than half were female. Around a third of patient participants described themselves as having a non-white ethnicity, all but one of whom described themselves as Asian.
The research team and wider involvement
There was no formal monitoring of the characteristics of the research team, as this was deemed inappropriate on the basis of potential disclosure. However, the research team included researchers and co-applicants across a range of ages, with a mix of genders and ethnicities. By the nature of being employed, none of the research team was over the age of 65 (a key population in this research). There was an even split of genders across the co-investigator team. The remaining research team was predominantly female. The team included researchers with a very wide range of experience and expertise, from undergraduate student interns to newly qualified post-doctoral researchers, more senior researchers, and the principal investigator with 35 years of experience.
Various development opportunities were provided to more junior members of the research team. Junior team members have presented work from the project at conferences and will continue to do so over the months following the end of the project as we continue to disseminate the findings. Furthermore, junior members of the team are taking leadership positions in many of the planned publications arising from this work. Informal training has been provided to those team members undertaking statistical analysis, and formal training was provided for conducting ethnographic fieldwork.
As with the research team, we did not formally monitor diversity within the PAG. However, its membership was predominantly white and had members aged over 50. While this is broadly representative of service users in one of our research areas (Southwest England), more could potentially have been done to make the PAG composition more representative of the broader areas covered. We took care to expand this group to inform the work focused on patients living with mental health, reflecting the importance of including relevant patients in the advice received.
Patient and public involvement and engagement
Patient and public involvement and engagement has been fully integrated within this project from the inception to completion. Due to the integrated nature of the PPIE we have reported the influence of integrated PPIE in each chapter of the report rather than describing it separately here. The project has benefited from a patient co-applicant, and a dedicated PPIE co-ordinator throughout the project. The PAG has been involved in every WP. In particular, three members of the PAG have been involved in each of the synthesis workshops in WP4 ensuring that the patient voice was at the heart of bringing the different research strands together.
Conclusion
Digital facilitation, while not a widely recognised concept, is important in the context of the move to an NHS with enhanced digital opportunities and enhanced digital access, and general practice staff are spending time and effort to provide it in general practices in England. It is viewed to have value and potential to increase the uptake of online services. DF can take many forms, though much of that is reactive and passive. As such there is clear scope to develop a more proactive approach to facilitation that actively engages patients. There is currently a disconnect between the expectations and perceptions of what DF is happening and its potential effectiveness, and the reality seen in everyday practice. This is related to a lack of clarity over the responsibility for delivering DF and resulting pressures on the time of general practice staff teams. Patients, practice staff members and national policy makers often perceive that the responsibility lies elsewhere. The establishment of clear lines of responsibility, and the development of digital tools and platforms that work well for patients and practice staff, will both be needed, alongside investment in staff time and training, if DF is to deliver on its promise.