Supporting patients to use online services in General practice – what does the research say?

It can sometimes feel that working in general practice is a job of two halves. The first, is the clinical side. This is what we train for, pass our exams in and what we expected when we took our jobs. We have guidelines, we have “best practice”, we have expert opinion. We have an evidence base that helps inform the patient care we can deliver. 

The other half is all the non-clinical stuff – the finance, the management, the targets. No one teaches us how to do this, and we learn on the job or from those around us. What do we do when these two overlap? 

Increasingly there is a push to deliver care via digital services to patients. This happened during the covid pandemic as a consequence of social distancing and shielding but then became part of everyday demand management. As policy makers have sought to deal with the mismatch between workforce and demand, digital has become synonymous with access. But what is the evidence base in this area, and how can we use it to help ensure digital works for us and our patients? 

This case study published in March’s BJGP was carried out in England, and is a focused ethnographic study involving observation and interviews. It was carried out across 8 practices with a varied patient demographic. While some interviews with individual patients and staff members were carried out, researchers also observed interactions between staff and patients that helped inform their results. Observations during clinical interactions were not included. The authors’ analysis identified three themes that ‘set the scene’ for digital facilitation:

• COVID-19 context;
• the type of digital facilitation; and
• the perceived value and purpose of digital services.

The observations and results strike me as both blindingly obvious yet largely ignored during system discussions around the digital agenda. See how many of the researchers observations chime with you and your practice:

• Digital facilitation was delivered in an ad hoc fashion, rather than there being a co-ordinated approach that staff and patients were clear on. 
• There was no clear responsibility for digital facilitation. 
• There were often several online systems in place – online records, apps, text messaging systems – this could lead to confusion for all. 
• Practice staff understood that some patient groups would need additional support, but how this could be delivered wasn’t always clear. 
• The digital landscape for patients and practices was patchy. 
• Assumptions and stereotypes were present regarding staff and patients, with younger practice staff expected to deliver more of the digital facilitation, despite their being no evidence of age-related training or experience. Older patients were assumed to be less able to access online services, while younger patients were expected to face no barriers. 

The biggest lightbulb moment is the observation that reception staff were the main group that delivered digital facilitation. This was almost always in the context of the patient asking for something different – a different type of appointment, to see a certain clinician. It was framed as a “second best” and an alternative to their preferred and initial request, rather than being promoted independently of the original reason for contact. Conflating online services with “access” was commonly observed.  Most reception staff had no particular training or expertise in how to integrate the digital offer into patient contacts. Regardless, it was common for clinical staff to direct patients to reception or administrative colleagues for support with digital issues. 

The comparison with how digital devices are used in other countries is also fascinating – 2% of consultations in the UK are via video, a figure that is in keeping with other Northern European countries. Yet 51% of UK patients order repeat prescriptions online, and 25% of consultations in Denmark are via email. Repeat prescribing was spoken of as a success story in the case study, but the uptake of other services was variable. 

While this doesn’t give us a golden model to follow in our own practices, there are some interesting learning points here about having a clear plan and lines of responsibility around using digital tools to support patients and clinicians if we choose to. I’d encourage you to have a read of the whole paper, which contains more useful reflections than I’ve seen for some time on the ongoing challenges and possible solutions to this brave new world. Perhaps the final word should go to this excellent paragraph from the paper, which really sums it all up:

For the NHS to reach its ambition of greater use of online approaches in primary care there should be a more considered and coordinated approach to supporting patients. Successful digital facilitation will require funding, infrastructure, and staff training that is not currently consistently available. There should be acknowledgement from those at policy and commissioner level that merely procuring a service does not equate with successful use of that service by patients.