The RBD2 study picked up the story of remote and digital care in UK general practice following a period of disruptive innovation (the rapid introduction of remote services as a pandemic response) and followed that story from September 2021 to December 2023. Empirically, this was an opportunity to look at variation in the continued assimilation, embedding, adaptation and (in some cases) abandonment of remote and digital technologies, in a diverse sample of 12 practices, as they moved to the ‘new normal’ of hybrid provision, and to capture the experience of patients and staff. Theoretically, it was an opportunity to develop and extend theory on important elements of primary health care in the digital age, including digital inequity, continuity, safety, competence, workforce well-being, team relations and the wider context (including infrastructure and the market for digital technologies).
We have produced important take-home messages on the patient experience, the challenges of quality care (including equity, safety, continuity, effectiveness and efficiency) in contemporary general practice, and the training and well-being needs of staff. Of particular note is our finding that while all patients deserve the option of remote and digital care where appropriate (hence, such services need to be designed to be accessible from basic ‘entry level’ digital technologies and by people with limited digital and health literacy), patients with multiple axes of disadvantage (e.g. complex health and social care needs) may have severe and intractable difficulties accessing services. For complex reasons, such patients can repeatedly find the practice’s ‘digital front door’ closed in their face – a problem for which there are no easy solutions. We have offered a deeper theorisation of the challenges of digital inequity and proposed a rethink of empirical solutions.
We have also produced a unique and rich ethnography of the process of embedding and adapting remote and digital services in the busy and dynamic setting of UK general practice. Our findings that this embedding process is labour-intensive and ongoing, that staff are currently undertrained and underconfident to deliver a digital-by-default service, and that infrastructure is weak (sometimes precariously so) have mission-critical implications for the funding of digital transformation of general practice. We believe that a proportion of recently announced resources for digital transformation of the NHS131 must be urgently allocated not just to purchasing new technologies but to strengthening the installed base of general practice, retaining and training staff, and the work of continually adapting and transforming work processes and pathways to maximise the value of existing and new technologies. We believe that a proportion of recently announced resources for digital transformation of the NHS131 must be urgently allocated not just to purchasing new technologies but also to strengthening the installed base of general practice, retaining and training staff, and the work of continually adapting and transforming work processes and pathways to maximise the value of existing and new technologies. The picture is dynamic and the looming opportunities and threats of the AI revolution make the need for this investment all the more imperative.
The study raised challenges in how to involve patients and the lay public, since a fully in-person PPI group was impractical in a UK-wide study, but an online PPI group would necessarily be skewed towards the digitally enabled. The combination of a ‘buddying’ scheme in which PPI group members linked with less digitally enabled friends or relatives and the recruitment of a lay panel from a hostel for socially disadvantaged people with complex needs produced some much-needed balance to our PPI input. The second patient panel was particularly helpful in helping us to analyse data on digitally excluded patients and producing credible composite narratives that reflected the experiences of, for example, homeless, struggling and drug-addicted patients trying to access care.
We were fortunate to partner with a policy think tank, The Nuffield Trust, whose members are co-applicants (RR) on the grant and coauthors (RR, Nina Hemmings) on our outputs. Nuffield Trust’s long experience working at the policy interface enabled us to reach a national policy audience and remain engaged with them and other stakeholders throughout and beyond the funding period.
On the basis of our findings, and cognisant of other research in this space, we offered six priority areas for future research: first, further studies (e.g. from the design perspective) of how to improve information and signposting for patients attempting to navigate remote and digital services; second, continuing theory-driven research on the needs of the multiply disadvantaged and digitally excluded patient; third, research into how to develop and evaluate system-wide partnerships for developing the complex knowledge and transformation impetus for primary care digital transformation; fourth, studies of the nature of patients’ needs (in terms of investigations, medication, follow-up monitoring and safety-netting) after a remote consultation and how these needs might be met; fifth, studies informed by theories of workplace well-being and team dynamics of how best to train and support the workforce; and finally, focused studies of how remote and digital general practice might better interface with the ‘green agenda’ in health care.