Qualitative exploration (work package 3): findings

As outlined in the previous chapter, the qualitative exploration comprised focused ethnographic case studies in general practices, an interview study with stakeholders and an interview study with patients who have a mental health condition. The data and findings are considered as an integrated whole, not as individual components. No critical incidents occurred during the data collection phase in this work package.

Description of the case study sites

Eight practices were recruited representing a broad variation across locations, ethnic diversity, practice size, the proportion of patients aged ≥ 65 years and level of deprivation (Table 14). Reasons for declining participation included COVID pressures, staffing challenges and site relocations.

Participating practices were located in four geographical areas and five were classed as large practices, one as medium and two as small. Two were in rural areas, one in semi-rural and five in urban areas. Percentage of ethnic minority patients ranged from 1.2% to 85.7%. Deprivation scores ranged from 1 to 10, with two practices classed as being in an area of high deprivation according to their IMD score. The percentage of patients aged ≥ 65 years ranged from 7.3% to 33.8%. Types of DF ranged from ad hoc provision of support when needed to designing platforms targeted to specific patient groups. See practice summaries for details (see additional files www.fundingawards.nihr.ac.uk/award/NIHR128268; accessed 3 April 2024).

There were few examples identified of documentation relevant to policies and procedures for DF. New staff members were generally shown what to do rather than having any documentation as a reference guide. Across the case study practices there was just one meeting that was considered relevant to DF, and this was in the context of a patient participation group. It appeared that DF was not something that was routinely considered by general practice teams.

Researchers conducted fieldwork in practices from September 2021 to July 2022 and were in each practice for 2–6 weeks. Two researchers (BT, CB) collected data from three practices each, and one researcher from two practices (SS).

Description of case study interview participants

Practice staff

The majority of staff participants were female. We interviewed 36 staff from a range of roles and age groups (Table 15).

Interview lengths ranged from 8 minutes to 1 hour. Interviews were conducted in person, via video conferencing or telephone.

Patients

Patients had a variety of self-reported experiences of using GP online services ranging from not at all to being frequent users. They had varied experiences with DF. We interviewed 33 patients across 8 practices, 7 were carers (Table 16).

Interview lengths ranged from 14 minutes to 50 minutes. We achieved a maximally variable sample in relation to patient population demographics.

Description of participants with a mental health condition

We recruited 10 patients with a mental health condition, falling short of the intended 15 patients. These were from five of the eight case studies practices. We had intended to recruit three to four case study practices to this additional study element.

Only one participant was male (Table 17). All but one patient had a diagnosis of anxiety and/or depression and eight were White British.

Description of stakeholder interview participants

Nineteen stakeholders participated in interviews between October 2021 and May 2022. Interviewees, including males and females, held one of the following roles, although many were also GPs and/or members of advisory groups relating to digital primary care (see Box 6).

To maintain confidentiality, we provided only limited information about roles. Interview lengths ranged from 22 to 62 minutes. Interviews were conducted via video conferencing and one by telephone.

Types of digital facilitation

Using the data from the focused ethnographic case studies, we outline the types of DF that we observed. The types of DF could be proactive, reactive, or a mixture of both.

Proactive forms of DF involved prior identification of the need for DF and a planned response to this perceived need. Reactive forms of DF involved responding to a real time need for DF without any planning. Sometimes DF had reactive and proactive aspects. The COVID pandemic was an important context for this as it had led to rapid change that necessitated both proactive planning as digital services were introduced and reactive responses to the changes faced by patients. The types of DF were not mutually exclusive, and more than one type of DF was used in each practice.

We identified six types of DF across the eight practices:

• DF focused solely on an individual digital platform
• patient facing DF being the responsibility of administrative staff
• DF via passive paperwork
• DF via workarounds
• family/social network led DF
• ‘tablet computer in the drawer’ DF.

Digital facilitation focused solely on individual digital platforms

Proactive, reactive

This occurred where DF was focused on helping the patient population to use an individual digital platform at the general practice, for example, the online consultation platform. This type of DF was focused solely on assisting the patient population to take up and use the platform and does not go beyond that into supporting their use of online services in general. Here an example is given as observed by a researcher in the field.

Overheard call advising patient to use eConsult. Sent link by text. Or they could call at 8 am in the morning. Conversation with staff member after revealed the reason they sent the link by text is because sometimes it’s easier for the patient, and another thing is that they think it’s better to give them something than nothing – it satisfies the patient.

Patient and carer facing digital facilitation as the responsibility of administrative staff

Reactive

This describes the situation in practices where providing patients with DF was deemed to be the responsibility of the administrative staff, particularly reception staff. This DF was provided on an 'as needed’ basis. Assisting patients in this way was seen as an ongoing administrative responsibility. Whether and how this kind of DF was delivered was very dependent on the attitudes of administrative staff towards digital services and their confidence in using these. Here is an example of older staff members on the administrative team being less confident in DF relative to younger staff.

we’re a bit older now, our work force downstairs, but we have the youngsters who are really good, you know, you’d say, ‘Oh, can you sort this out?’

Digital facilitation via passive ‘paperwork’

Proactive

This type of DF was focused on awareness. General practices would place posters on the wall in the waiting room or put information on the practice website. Some left recorded messages on the general practice telephone lines for patients to listen to. Bulk text messages were used to inform patients about the availability of a particular digital service. In one example practice staff posted leaflets through the letterboxes of patients’ homes. This was a practice where the patient population lived in close proximity to the practice. In the example below, a staff member describes using text messages and posters to invite interest from patients in digital services.

So, it’s just the main thing of telling them, you know, setting up, I’ve set up some templates that you just send patients an easy text message, let them know that this is going on. Putting up posters so they can read it in their own time and, you know, a lot of the time it does get their attention and they’ll, they will come to the desk and they will ask more details.

Digital facilitation via workarounds

Reactive

This was the application of DF to assist where patients were having particular issues with specific digital services across the spectrum of services available. This was something observed as being associated with the NHS App. For example, proxy access for parents and carers was difficult to use and led to staff formulating temporary ‘workarounds’ to enable patients to access services there and then. This reflected in part the NHS App being run and controlled centrally by NHS England but proxy access being the responsibility of the general practice.

Patient came in face-to-face as they had issues with patient access app access. They can see their child’s (8 yrs old) account on the app but not their own and need to order their medication. The receptionist unconfidently tried a couple of things to resolve the problem that did not work. Then the receptionist tried unlinking and re-linking the patient’s account. Patient said they could now see their account but that they (the parent) were under the proxy access of their child, rather than the child being under the parent.

Family/social network led digital facilitation

Proactive, reactive

This kind of DF was provided to patients by family members, friends or carers. Carers were usually informal family carers. We observed some patients preferring to be supported in their use of digital services by family members, sometimes for cultural reasons because they routinely would seek family support for activity in their day-to-day lives. This was sometimes the case where the patient spoke English as a second language, or not at all. Grandchildren and children were mentioned as being supportive of parents and grandparents who needed to use digital services. General practice staff saw this as an acceptable way to ensure access to digital services for patients.

In the example below, a member of practice staff refers to adult children supporting older patients to use services by providing their mobile telephone number. This raises questions for the health service about confidentiality for patients where family members can access their health information as informal proxies.

And we have done in the past where we’ve had an elder member of the family who can’t fill in but it’s been the son’s mobile number and the son’s received it, he’s been with them and he’s completed the form.

‘Tablet computer in the drawer’ digital facilitation

Proactive

We encountered practices that had, pre pandemic, actively supported patients to take up digital services, by using tablets in the waiting room to sign them up, or by running sessions to help patients. These initiatives had been put on hold for various reasons:

• the rapid introduction of digital services in 2020 meant that the pre-2020 need for support was seen to have passed;
• ongoing concerns about infection control limiting what could be done;
• no clear reason, with plans outlined or intended but not acted upon.

In the example given here a member of practice staff talks about what the practice has considered doing, but not gone ahead with.

… perhaps we run a technology evening, so we could get somebody from the college down the road, that’s doing IT and get them to talk to the older generations … he or she could do a presentation on how to use technology … And that’s something that the PCN and I were going to look at …

The types presented here are based on empirical data from the focused ethnographic case studies and they provide depth alongside the complementary quantitative approaches that are used in the wider study. Stakeholders taking part in the interview study described models of DF that were in place in general practices prior to the COVID pandemic. These were often programmes delivered by external organisations. We were not able to identify practices doing this type of DF at the time we recruited to this study.

Themes

We identified six themes, categorised into two groups; scene-setting themes that consider the background context within which digital services sit in general practice, and themes relating directly to DF.

Scene-setting themes

We identified three ‘scene-setting themes’, as being integral to our understanding of the potential benefits and challenges of DF. These were ‘COVID’, ‘the value and purpose of digital services in general practice’ and ‘conflation of access with digital routes to an appointment or contact’.

COVID

The delivery of digital services in general practice was impacted by changes brought about by the COVID pandemic.

Uptake of digital services by individual general practices and patients was low before the COVID pandemic169 and many practices were at the point of considering or planning the implementation of digital services. This was disrupted when uptake of digital services by general practices increased rapidly because of the COVID pandemic.

This was particularly the case at the height of the pandemic when face-to-face appointments were limited to avoid physical proximity. One practice described only offering a face-to-face appointment when:

There is a medical need for a face-to-face appointment

Another described the scenario caused by multiple lockdowns and changing government guidance:

Crisis, solution, crisis, solution … the advantage for that method of it working is you have rapid change. But it’s not always without consequence.

The COVID pandemic was observed as a ‘catalyst’ for change by leading to the introduction of digital services within general practices, but general practices were not necessarily equipped for this change:

And then it, it was almost like we were just moving slowly towards, you know, some remote working and getting laptops and eConsults [mentioned as discussing training for eConsult]. And then all of a sudden, the pandemic just accelerated all of that through, through the need to manage it that way.

Where general practices had set up initiatives pre pandemic to support patients in using digital services these were paused due to COVID. Examples included asking patients to bring in their devices to obtain support or running advertising campaigns for video consultation use.

so [before the pandemic] the IT guys, in reception for, sort of, a couple of hours in the morning, a couple of hours in the afternoon, helping people if they were struggling to get online. Even if you’re … ‘Bring your device with you if it’s a, a laptop or a tablet, or, or even your phone. Bring it in, we’ll help you. They’ll sort it out.’ Again, a lot of that all stopped because of lockdown.

The rapid implementation of digital services was felt by those involved in organising services at a high level, with one stakeholder remarking that the COVID pandemic:

punched a hole in our timeline.

On the ground, experiences at this time were mixed. There were perceived benefits to this rapid change, with digital services being time saving, or fitting in with their lives better. The patient in the following example felt positive about the change:

I think that has helped to improve things. Because I think that’s encouraged people down the route of finding other ways other than just walking into a GP practice to access medical services. And I, I personally thought, when, sort of, telephone calls and WhatsApp calls took off with doctors, I thought it was great. Cause I’m a busy person.

However, there was acknowledgement that the introduction of digital services was associated with difficulties for some. Patients felt digital services could reduce their ability to express themselves clearly or they felt rushed. Both staff and patients in older age groups were reported as struggling the most with the introduction of digital services. Some staff, particularly older GPs, and some stakeholders, expressed dissatisfaction with the move to digital services.

In this example a staff member describes the unfamiliarity of digital services:

And then language, not being able to read or what it says, where to touch and where to do these things.

Any requirement by staff and patients for support in using digital services had not necessarily been considered and resource limitations meant general practice did not have time to make strategic plans for supporting patients.

After the initial changes to the use of digital services that were required because of the COVID pandemic and need to deliver care at a distance, there were reflections on what would happen next:

But what is actually happening is that we’re, we’re channelling the work down the routes of maximum efficiency whilst trying to keep staff and patients safe at the time of the pandemic. But even outside of the pandemic it’s, it’s balancing the benefits of online services, to face-to-face, and some of them we need both, like the booking of an appointment for instance.

While general practices regarded changes made as permanent, patients questioned whether services could return to the pre-pandemic approach. Acceleration of digital services was not uniform, with some services stalling, such as online appointment booking, as a result of the COVID pandemic when it was put on pause by NHSE, and others such as obtaining a repeat prescription online becoming more popular.

Value and purpose of digital services

We identified context relating to the value and purpose of digital services within general practice and the subsequent impact on the need for DF.

Rationale for digital services

Beyond the changes made in response to the pandemic, the rationale for using digital services in the first place was not always clear. There was a noted contrast between the views of stakeholders who were hugely engaged in the concept of digital services, and some staff and patients who struggled to understand the rationale for their introduction:

So, there are a number of different ways in which actually technology can be incredibly empowering and enabling for people with impairments and people of all ages.

I can’t be bothered going through all that sort of thing and then to be told at the end that no one can see her for a couple of days, you know. I like to know exactly what I am with it.

There was a lack of shared understanding about what digital services should achieve and who was responsible for them. Stakeholders viewed digital services as a tool to manage patient demand on practices. Patients reported the view that the drive to use digital services was an attempt to reduce the burden on GP practices, while conversely staff reported that digital systems have created an uncapped demand, making general practice too available.

All participant groups reflected on the move from paper to digital in wider society as context for the changes happening in general practice. Stakeholders described the need for patients to build digital literacy and confidence across a lot of systems, not just health, and that it is not the responsibility of health care to address this:

So, they know that it’s an issue but there’s a big question mark about actually whose responsibility it is to really take this forward, hold this, make sure that digital inclusion is a core part of policies and programs and strategies. So, we are making, you know, we’re taking that message to the UK government.

On a practical level, CCGs were described by staff and stakeholders as being influential as to what services the practices would offer; they were responsible for determining which digital service or product was used and issued local directives for example, targets for use of particular digital services.

It was perceived by staff and stakeholders that there was no formal guidance or support from government to encourage the use of digital services by practices and patients. Two of the practice managers interviewed felt that the GP contract should have greater specificity about digital provision:

And at the same time practices have just got to buy into it and get it done. How you do that, I don’t know. I mean, I know they’ve tried to incentivise financially in practices. You know, NHS Digital have in terms of access to records and stuff like that. So, to me, they should just make it a contractual requirement that you, you know, you, you, you’ve got to do these online services.

Good digital services

Staff and stakeholders acknowledged the importance of services ‘working’ for patients:

So, I think the, the task here onwards is to try and make the digital access acceptable for practices from a workload point of view, acceptable for patients from a convenience point of view but, obviously, still retaining all the benefits of that, that it can offer.

This was not the reality as the reported experiences were mixed; some patients reported difficulties with new digital approaches and others embraced them. This example outlines a positive view:

I mean, it’s just so much easier to have it. As somebody that does use their phone, has apps, it’s so easy to hit the app, load it up, book an appointment. It’s done in ten seconds.

Contrasted by a negative view from a patient whose first language was a spoken language and therefore would not translate easily into text. In the example the patient talks about digital platforms being translated into non-English languages:

Some people … because what it is with our languages, people don’t, it’s not written. Some languages are just spoken. So, if it was written, they probably wouldn’t understand anyway. And it’s just spoken. So, you’ll, you’ll need like a voiceover. But how many languages would you have a voiceover for? So, it’s going to be really, really difficult.

For staff and patients, named digital platforms are the point of reference, for example, ‘the eConsult’, ‘the NHS App’. Some practices did have written documents with policies/guidance on digital service use but often staff did not know that these existed or assumed more guidance existed than did, or guidance was seldom updated so often became out of date.

At practice level there was not necessarily a shared vision about what ‘good’ digital services looked like. The online repeat prescription ordering service was widely acknowledged as beneficial by both patients and staff and was routinely given as an exemplar of a good digital service illustrating that some digital services were a ‘good fit’:

Male member of staff thinks prescription requests done by e-mail are easier for the patients and the reply to say it has been done feels more personal (even though it is a template message).

Digital services are difficult to deliver if patients do not want what is being offered and some practice staff perceived this to be the main barrier to use of digital services:

I think, I think getting them online, like, isn’t necessarily a problem. I think it’s more whether they want to is more of a problem, like, cause we do, we do, I mean, I think, feel like every other phone call is, ‘You can go online and do eConsults’, or, we’re pushing online all the time.

It appeared that a patient’s past experience of the NHS could influence their perceptions of using digital services in primary care, in either a positive or negative way. Previous experiences of using digital systems and communication outside of primary care also appeared to influence patients’ perceptions:

I like technology and I’m up to date with a, a telephone, or a mobile phone that allows me to do everything, that it, it appears that is required of me through online services. [ … ] I have found everything to be very simplistic but also in a very human way.

On the whole, practices had reflected on the changes they had made to digital services and what this meant for different patient groups but had not yet considered how patients might start using online services and what support would be needed to enable this. Staff and stakeholders emphasised that the movement from paper to digital would take time and the experience for patients and staff can be complex and time and resource intensive.

Conflation of access with digital routes to an appointment/contact

Digital services are viewed by patients as a route to access the practice. Any kind of remote access, including the telephone, is regarded under the digital umbrella. Despite the research project being clearly focused on digital services, stakeholders and practice staff referred to telephone triage and increased use of the telephone for consultations and they were a key part of the recent changes to service delivery in general practice:

I think actually some of that [increased reliance on digital services] is just as much about telephone, frankly even more about telephone than about digital.

This reflected the crossover between the two when certain digital platforms were used, for example, those that required an online contact to be followed up by a telephone call from the general practice, or that used a mixture of approaches as outlined in this example:

With their online access they can order their medication so that is an online service because they can either phone and speak to somebody or they can text a message to somebody at the [system] and they call them back and speak to them, or they go online and order their medications.

For patients, digital services are often viewed and treated purely as a gateway to access the general practice.

The patient priority is to successfully navigate the system to achieve access. For many, access is the key concept, not digital:

I wouldn’t even start to try and book an online appointment with my GP. Because if I did that, I would probably be offered something in four to five weeks’ time. And my only choice, if I want to see a doctor, urgent or not, is to phone up at 8.30 on the morning and fight with everybody else for an appointment on the phone, for a that-day appointment. So yeah, that, that facility is rubbish, to be honest. And it’s symptomatic of a much bigger problem that GP services have, to my mind.

Overall, patients seem open to different consultation modes, with their priority being to be seen as quickly as possible in whichever way that access was achieved. Digital services were seen to increase accessibility of appointments for patients who were travelling, away for work or those where working commitments made traditional appointment booking methods difficult. In these situations, digital services overcome obstacles in attending healthcare appointments for some patients:

It’s much easier to just look at the screen and put an answer on there than actually physically talk to people. [ … ] it just saves time going down there. That’s all, really. It’s just convenient.

Where general practices used a digital gateway for access this creates problems for those who are unable to use it, with those able to use it being able to get to the front of the queue for access:

Spoke to Patient Care Advisor about eConsult recommendations. She said that the only appointments available in the next 48 hrs are for eConsults. The patients can only have them if they complete an eConsult. She told the patient to complete one and that she would look out for their eConsult so that she could then give them an appointment for the next day. Otherwise they would have to phone back the next day and wait in line or wait over a month for a pre-bookable appointment.

The onus is on patients to adopt digital services and understand their use if they wish to be able to access their health care.

Digital facilitation themes

We identified three themes relating directly to DF. These were comprised of subthemes: ‘the operationalisation of digital facilitation – making digital facilitation happen’, ‘usability of digital services in practice and the consequent need for digital facilitation’ and ‘assumptions and stereotypes’.

The operationalisation of digital facilitation – making digital facilitation happen

Digital facilitation as a concept

For the purposes of this research study, we developed and applied a definition for DF: The range of processes, procedures and personnel which seeks to support NHS patients (or their carers) in their uptake and use of online services.

When explained to staff, patient and stakeholder participants, DF is perceived to be conceptually valuable and regarded in the positive. However, it is not used or understood as a term in practice:

I, I don’t understand what that means, I don’t think other people would, not everyone … I wouldn’t understand what that means? … I don’t want to pigeonhole anyone, but if you said it to my mum, she would have no idea what you’re talking about … Yeah, I don’t, I just don’t, yeah, like, the, like, patient care and digital facilitation don’t sound like they go together, do they

It is regarded as difficult to have a working definition or usable term for something (DF) that is movable and relative to a person’s circumstance. We observed that it was difficult for participants to ‘grasp’ it as a concept, being mixed up with the digital services themselves.

Sometimes exemplars are used by stakeholders and general practice staff to illustrate the concept of DF, and these link to specific digital platforms (e.g. using iPads to support registration with the NHS App) or organisations (Barclays Bank and their Eagles programme to support people in accessing the internet). Stakeholders felt this was helpful in communicating examples of DF to the public:

And Barclays have done some great work on this with their Digital Eagles … work I don’t know if you’ve come across. But it’s definitely worth looking at. So during the pandemic Barclays Bank, they’ve got something called Digital Eagles. And we did get them doing some work with patients. And they would, like, get them, sort of, sorted out with iPads and … this is obviously when loads of people had nothing to do during the pandemic.

While the different participant groups (stakeholder, staff and patients) varied in their understanding and experience of DF, they were united in understanding it as a way to achieve the perceived end point; that being the successful use of digital services to access health care. It is not seen as anything more complex than this. Stakeholders felt that DF would improve access, and subsequently improve health care:

I suppose, so, you know, if you’ve gotta, gotta wait on a telephone for, for 25 minutes on a morning then actually we need to redirect them to the website and they need to be using online services, you know, that will then will free up the time of the wait for those who don’t want to use that system and need to speak to somebody.

The interpretation of DF as a means to achieve successful use of digital services to access health care assumes that digital services are desirable and positive. In this example the staff member refers to patients being asked to have belief in ‘eConsults’:

Yeah I’ve told them that they can use it yeah I have told them that they can use it and, and, and the benefits of using eConsults, they don’t always believe me.

Engaging with the concept of DF requires some cognitive dissonance between what it is perceived that digital services can deliver (the positive elements) and the challenges and reality of how they work in day-to-day general practice.

Responsibility for delivery of digital facilitation

There was lack of clarity on the responsibility for delivering DF. There is a ‘bystander effect’ with patients, different staff groups and stakeholders assuming responsibility for DF to lie elsewhere.

Some participating stakeholders and also some patients expressed that the responsibility for DF should lie with the general practice, including reception staff, administrators and clinical staff:

for me I think it should be the GP practice’s responsibility to show their patients how to use their service ‘cause it is in their best interests. The more people they get using the automated services theoretically, the less, again, through on the phone every day.

General practice staff believe that patients bear some responsibility for being able to access their own health care and that support can be sought from friends and families:

a lot of people will get help from family members.

Within the general practice team, clinical staff were observed to pass responsibility for delivering DF onto reception staff and administrators:

… Online medication request system as well that patients can use, I’m not entirely familiar with but often I have perhaps direct patients to our admin staff or our receptionists if they needed to get set up with that. […] I guess use of online services that would be more for admin or reception staff.

Patients stated that the responsibility for providing DF lay with the wider health system and regional or government level organisations as well as being a societal issue (described in ‘value and purpose of digital services’ theme). This may relate to how DF was viewed by patients, as being a means to use digital services so that they can achieve access:

It’s difficult, isn’t it? I, I don’t see the role of the practice to be educating us in, in how to adopt technology. I think it’s just too much. I think the remit of the NHS is so wide.

There was an additional view from some patients that they themselves had some responsibility for trying to use digital services if they wanted to achieve access:

I think it’s like going to school again, isn’t it? You’ve got to practice and do it and learn it and, and remember. And, yes, yes, absolutely, you’ve gotta be a bit disciplined and do it.

See Figure 16 for a visual representation of how different groups view responsibility for delivering DF.

FIGURE 16 Perception of responsibility for delivering DF in different groups. (Figure not reproduced here; see the original article.)

What is consistent across staff, patients and stakeholders is that, in practical terms, the responsibility for any facilitation in relation to digital access currently falls to reception staff.

Logistics of digital facilitation

There are day-to-day logistics underpinning the delivery of DF. Regardless of how DF is delivered and at what level there was awareness amongst participants that well-developed approaches to DF require organisation, planning, time, financial input and training resources:

Then it has to come from the NHS and government as well at the same time. Well, what provision have you put into place? Or what funding have you put into place that we can give time to patients say, this is how to do it.

At present, DF is largely occurring in an ad hoc fashion, without external support and with a lack of training or systematic approaches. As a result, organising DF is beyond the capability of most general practices.

The usability of digital services in practice and the consequent need for digital facilitation

Barriers and enablers created by individual digital platforms and the need for digital facilitation

There is a variation between digital platforms with some being easier to use than others for both patients and staff. Initial registration for the specific digital platforms created a barrier to digital services for patients before they had even managed to use them, creating a need for DF. Certain platforms require complex registration processes such as usernames, passwords and e-mail links. Complex registration processes lead patients to seek support from staff:

Because I kept doing it and it wasn’t accepting it and it wasn’t registering. And it was frustrating because I couldn’t do. And I was there forever, and my battery was dying, and I’m thinking, ‘I need to get this done but I can’t do it.’

Patients also seek support when navigating the use of digital platforms, and staff are aware that certain platforms are likely to cause more need for DF than others:

I do think the patients need educating on it, and I do think the eConsult itself is, is clunky, because I’ve looked at it from a patient perspective on our eConsults, and it, you just get caught in a mine field of information

There were digital platforms that were easier to use and did not create a need for DF. As mentioned earlier, some digital services (e.g. online repeat prescriptions) are a ‘good fit’ and tend not to be associated with a need for DF beyond any initial registration. This suggests that the choice of and purpose of the digital platform impact how much DF is required, and therefore the amount of DF that the general practice will need to deliver:

As long as I follow the instructions they’re, they’re quite easy.

In other cases, where digital systems were designed and operated from outside of the general practice, as is the case for the NHS App, general practice staff felt unable to offer support to patients in their use of these platforms even though it concerned their use of digital services:

So, it’s a bit difficult because the NHS App is a third party app there is obviously only so much we can do our end which you can do.

Where these interoperability issues occurred, it could bring the patients’ digital journey to a halt.

Negative impact of mixing digital services and platforms: a fractured digital landscape

It can be challenging for patients and staff to navigate the range of different platforms and services used within a single practice. There could be multiple platforms all working in different ways and for different purposes and sometimes general practices used them interchangeably, as demonstrated in this example:

Or, like, on the phone, I’ve advised people how they can … so if you can’t manage the text message, I’ve talked people through how to go online and do an eConsult and upload the photographs that way.

While for some patients there are issues of digital skills and digital access, even for patients who were digitally literate this could cause issues with their access to digital services.

Some general practices attempted to manage changes to how the digital platforms were accessed limiting their use to certain times of day, or turning them on and off without warning and changing the digital platforms available, but without communicating this to patients or offering patient education:

The advisors explained that when the practice shuts down eConsult, it just shows an error message to patients, not anything like ‘eConsult will be available again tomorrow morning at 8 am’, so lots of patients ring up saying that their eConsult isn’t working. The care advisors said it would be good to add a message to the blurb at the start of the practice’s telephone call too when they’ve taken down eConsult.

General practice staff had to contend with incompatible systems, old computers and remembering which platform was used for which purpose. This was the context in which they were supporting patients to use digital services.

Accessibility for different groups

Individual circumstances matter when it comes to having a need for DF to use digital services; especially to those vulnerable groups such as the homeless, those with learning disabilities, those with hearing or sight impairment, those experiencing an acute state of illness and those in lower socioeconomic groups. In this example, a patient talked about the costs associated with using digital services:

They’ve got to watch their data, you know, and if they’re not on Wi-Fi they can use a lot of data, especially homeless people, you know, who haven’t got access to Wi-Fi perhaps, and they, they all generally afford about a tenner a month for the phone. But the data for that online, they might not do it.

There are some groups where circumstances influence their need for DF. For example, those with no access to technology or internet, those living in rural areas with poor internet connection, those with poor literacy, those with no third-party support, those with poor manual dexterity and those who do not speak English or speak it as a second language.

And again, with language barriers as well, because they don’t really understand what’s being asked of them and what they need to do.

General practices took steps to accommodate these patients in relation to their use of digital services as part of their attempts to provide DF. What was unclear was whether this was enough, given the complexity of adapting services for patients with very different needs:

Also, we are advertising, if people are unable to read stuff on the website or struggling with the online, that we can actually print larger print or we can make it accessible for anyone. And also, we can translate it. I think our website actually has got a option to translate in different language the page.

Individual circumstances applied not only to patients but also to staff. Digital confidence in staff could be observed through how staff interacted with patients and in this example a staff member expressed uncertainty about their skills:

I think I’ve just sent you a link – I hope anyway.

Age was perceived to have an impact on both staff and patients’ digital knowledge, understanding, experience and confidence. Patients and staff understood that for older patients, use of online service was partly a feature of having access and ability to use them but also an issue of trust in the use of online services, particularly for personal transactions. For example, patients drew parallels in the use of online banking services, which some were not comfortable with:

For banking, for ordering prescriptions, but I’m beginning to … oh, also filing my tax return … But I’m beginning to use it less and less … Security issues, basically, and the fact that people like Google are just so powerful and so invasive nowadays.

Digital facilitation was required to be about more than practical digital skills for these patients and served a social function.

While there is a shared vision that all digital services should be designed to eventually work with ease for all groups of patients without extra efforts and support, at present, there is little consideration for how marginalised and vulnerable groups can be supported to use these services:

And then everybody’s talking about digital inclusion now. So, loads of people are talking about it. But how many people actually understand what it really means

It is not clear if patients who are not able to contact their practice are the ones in greatest need of DF and least able to navigate the digital processes involved, which makes planning for DF difficult.

Assumptions and stereotypes

We observed embedded attitudes about who needs DF. Assumptions were made about who may or may not be able to use digital services, and these are not necessarily grounded in evidence. There is a risk of stereotyping patients.

Patients and practice staff often categorise themselves or others around their digital abilities, for example, staff referring to patients as ‘tech savvy’ or ‘technophobes’ reflecting societal perceptions about who does or does not use digital services:

Yeah, I, I would say, so. I mean, we use it constantly, so we use Teams at work, Outlook, as well sort of Excel. I’m an, an accountant so I use finance systems and things like that at work as well. So, yeah, I guess compared to a lot of people who might not use the computer much at all, then, yeah, I’m reasonably tech savvy.

There were cases of ‘othering’ with assumptions made about who needs help, or that there was little value in offering DF to help certain groups, this was particularly the case for assumptions made about age where younger people were deemed more competent and confident in using digital services than older people:

Yeah. It’s getting better, and obviously it depends on the demographics of the patient, because, you know, obviously the elderly and, and ones that aren’t so computer-literate, you know, can’t do it or aren’t interested in doing it.

The youngsters, once they get, the younger people, once they tend to get up on it, there’s no real issues.

When assumptions are made about patients with certain characteristics, for example, of a certain age, having a disability, low literacy or education level, those living what are deemed to be precarious lifestyles etc. it inevitably affects the range of choice of services offered or indeed supported, and this sometimes means that staff may not offer access to digital services at all.

We observed an assumption being made that those unable to use digital services would have some form of ‘proxy access’ either in the form of a family helper or carer who can support their online access. Reliance by practices on this form of input potentially excludes patients where family or carer support is not available:

She feels that different skills are needed for using online technology so if a person is not IT literate, they will ask them to get a family member or grandchildren involved to help them.

Assumptions extend to staff and this impacts on who within the general practice team are expected to provide DF. Younger staff are often asked to deliver DF because of the assumption that they ‘understand’ digital services better, despite receiving the same training, if any.

… if anyone else needs IT help, it’s usually, ‘[youngest staff member name], can you help this …’ sort of like, ‘… patient out with this?’ sort of thing, and it’s usually me.

As outlined in the previous theme, it was the case that staff who are confident with digital services offered more support to patients, indicating that confidence is important rather than competence.

Patients with mental health conditions

The themes identified in the mental health interviews were closely aligned to most of the findings in the main sample. As with the main sample, patients conflated digital with access, referring to experiences in using the telephone to contact the practice alongside their reflections on digital services.

In contrast with the main sample, patients shared their experiences of how their condition impacted on their contact with the general practice. Many of the participants reported a cycle of infrequent GP visits during periods where their condition is well controlled, and frequent use of the general practice during periods of instability:

Yeah, I think it’s because I see the GP a lot … more than normal people … So sometimes I can see the GP for three, four days. I call today, I call tomorrow, I call the day after

This impacted on their use of digital services and their need for DF. As frequent attenders, they were familiar with the practice’s digital services therefore did not require DF. As in the main sample, services were a good fit for patients and this meant they did not require DF.

There were participants who reported struggling with digital services and they were generally less familiar with technology and more likely to rely on family and friends, rather than the practice, for support:

I can’t say I have, really, but as I say, I’ve not been with this doctors’ that long, and I, obviously everything’s online, isn’t it … so if I do have any difficulty, [daughter’s name], will sort it out for me.

This mirrored the situation for patients in the main sample where family support was used by patients.

There were experiences of using digital services that were specific to patients living with a mental health condition. There were patients who experienced digital services to be advantageous in relation to their condition by allowing them to avoid using the telephone:

Well, the advantages, I suppose, is it can be quick and convenient. And for some, for my personal reasons with my anxiety, I can get stressed knowing … I have to ring, you know, and ring round and try and sort things out, whereas if, if I can just use the app, and, you know, on my own phone in my own home … and I can do it, that, that works for me.

Examples given included reduction in the anxiety caused by queuing on the telephone, or not having to telephone first thing in the morning when medication for their mental health condition made getting up difficult. Patients noted that because the telephone could cause anxiety, this meant that seeking DF if needed would be likely to be difficult as this would have to be via the only other access route, the telephone.

Some of the patients found digital services less acceptable because of a lack of trust in digital services or because using them caused increased anxiety. This was not attributed to a lack of DF or the nature of the services themselves:

It doesn’t help at all if you have to look at a screen … It, it makes you more anxious, and the only thing I can think of is actually talking to somebody on the telephone.

On the whole, achieving access was the most important factor to these patients, with DF secondary to this, if needed at all.

Discussion

Summary of key findings

We identified different types of facilitation occurring in practices, and these were often reactive and in response to individual patient need. Context was important, with the value and purpose of digital services not always well understood by either patients or staff, and with access to an appointment often conflated with digital routes to an appointment or service. COVID had influenced how services were delivered with an increase in digital platforms used by practices.

Digital facilitation was seen as valuable but was poorly conceptualised within general practice. It was unclear where the responsibility for DF lay and there was a tendency to assume it was the responsibility of someone else. Well-developed DF requires support, resources and training and these were not available.

The usability of digital services influenced whether DF was needed. Where multiple digital platforms were used, this required support for patients to understand which to use and how to use them. General practices often made changes without informing patients and patients did not know what would be available to them.

We observed assumptions being made by both patients and practice staff about who could use digital services and who could not, including stereotypes about age that were applied to both staff and patients. When it came to who needed DF, individual circumstances mattered, with needs being movable in line with personal circumstances. Vulnerable populations were particularly in need but were also least likely to be considered when services are designed.

Deviations from the original proposal

We expanded from three to four geographical areas.

This allowed us to recruit a practice in an area of high deprivation and with a varied population profile relative to our other practices. This in turn ensured our sample was maximally variable.

We sampled practices according to their experience of and/or delivery of DF using different approaches. We had anticipated at the design stage of the study that we would be able to identify discrete approaches to DF, based on what we knew to be happening in general practice, and from the literature review. By the time we were recruiting general practices, the COVID pandemic had changed how GP services were delivered. To counter this, we ensured that we were fully appraised of DF activity at the point of recruitment rather than relying on the practice survey data or prior reports. We were alert to the possibility of changes due to the COVID pandemic while we conducted fieldwork.

Strengths and limitations

We were able to recruit a varied sample of general practices during the COVID pandemic and conduct ethnographic fieldwork as intended over the period from September 2021 to July 2022. During this time there were various levels of lockdown and restrictions which the team successfully negotiated to ensure the fieldwork was completed. We were conducting the fieldwork at a key time for general practice, with the COVID pandemic leading to an increased use of digital services. This allowed us to capture how practices responded to an increased need for DF in real time, and our sample included populations with high numbers of patients in ethnic minority groups, and in areas of high deprivation. We recruited a broad range of 19 key stakeholders at a time when those in professional roles were under extreme pressure.

The COVID pandemic has impacted the ways in which general practices were operating and in their relationships with their patients. There was little patient footfall in the practices’ premises, and this changed the nature of the non-participant observation, which was focused on staff. Because fewer patients were attending the practice in person, the main recruitment tool to access patients was a letter sent via the practices. In some practices, initial responses were very limited which resulted in second mail outs being necessary. However, we did recruit and interview a wide range of patients with varied characteristics.

Recognition of the need for and subsequent funding of the additional interviews was a strength in ensuring inclusion of this under researched group. However, in line with the broader challenges associated with conducting research in this area, recruitment of practices and patients for the study of patients with mental health conditions was challenging. We aimed to recruit the case study practices to this additional interview study but two declined for capacity reasons and a further declined due to sensitivities about the patient group. In the practices that were recruited, workforce capacity was an issue which delayed mail outs.

We were able to recruit patients in groups that are vulnerable to digital inequalities, which included individuals from older age groups, those in minority ethnic groups, those in poorer health, and individuals in rural settings. Several participants intersected these characteristics. We were not successful in recruiting patients who were in marginalised groups. This reflected the additional and substantial challenges in recruiting general practices and patients during the pandemic.

The response rate to the invitations to take part in an interview was lower amongst individuals living with a mental health condition than for the main study; and the majority of participants in this group were female and aged in their 40s. This may reflect the timing, with some invites sent over the summer period. However, it may also be due, in part, to the stigma associated with having a mental health condition, or a lack of recognition amongst some patients of their diagnosis. Even some participants that took part in interviews did not consider themselves to be ‘diagnosed’ with a condition but instead felt they had ‘a touch of anxiety’, or ‘a bit of low mood’. This suggests difficulties with the labelling of a mental health diagnosis for some patients. The approach may not have been appropriate for this cohort of patients and another strategy may have been more successful. The findings should be viewed in this light.

In conclusion, the qualitative exploration allowed an in-depth analysis of how DF is realised in general practices in England. It highlights areas that could be targeted in developing DF as a concept and in applying it to the delivery of care to patients.