Digital Facilitation to Support Patient Access to Web-Based Primary Care Services: Scoping Literature Review

Understanding access to general practice through the lens of candidacy: a critical review of the literature

BACKGROUND

Dominant conceptualisations of access to health care are limited, framed in terms of speed and supply. The Candidacy Framework offers a more comprehensive approach, identifying diverse influences on how access is accomplished.

AIM

To characterise how the Candidacy Framework can explain access to general practice - an increasingly fraught area of public debate and policy.

DESIGN AND SETTING

Qualitative review guided by the principles of critical interpretive synthesis.

METHOD

We conducted a literature review using an author-led approach, involving iterative analytically guided searches. Articles were eligible for inclusion if they related to the context of general practice, without geographical or time limitations. Key themes relating to access to general practice were extracted and synthesised using the Candidacy Framework.

RESULTS

A total of 229 articles were included in the final synthesis. The seven features identified in the original Candidacy Framework are highly salient to general practice. Using the lens of candidacy demonstrates that access to general practice is subject to multiple influences that are highly dynamic, contingent, and subject to constant negotiation. These influences are socioeconomically and institutionally patterned, creating risks to access for some groups. This analysis enables understanding of the barriers to access that may exist, even though general practice in the UK is free at the point of care, but also demonstrates that a Candidacy Framework specific to this setting is needed.

CONCLUSION

The Candidacy Framework has considerable value as a way of understanding access to general practice, offering new insights for policy and practice. The original framework would benefit from further customisation for the distinctive setting of general practice.

Current experience and future potential of facilitating access to digital NHS primary care services in England: the Di-Facto mixed-methods study

Background

Current National Health Service policy in England encourages enhanced digital access in primary care service provision. In this study, we investigate 'digital facilitation' - that range of processes, procedures and personnel which seeks to support National Health Service primary care patients in their uptake and use of online services.

Objectives

Identify, characterise and explore the potential benefits and challenges associated with different models of digital facilitation currently in use in general practice which are aimed at improving patient access to online services in general practice in England. Use the resulting intelligence to design a framework for future evaluations of the effectiveness and cost effectiveness of such interventions. Explore how patients with mental health conditions experience digital facilitation and gauge their need for this support.

Design

Observational mixed-methods study (literature review, surveys, ethnographic observation and interviews); formal synthesis of findings.

Setting

General practice in four regions of England.

Participants

Practice survey: 156 staff. Patient survey: 3051 patients. Mental health survey: 756 patients. General practitioner patient survey: 3 million responders. Ethnographic case-studies: 8 practices; interviews with 36 staff, 33 patients and 10 patients with a mental health condition. Stakeholder interviews: 19 participants.

Intervention

Digital facilitation as undertaken in general practice.

Main outcome measures

Patient and practice staff reported use of, and views of, digital facilitation.

Data sources

Surveys, qualitative research; national General Practitioner Patient Survey (2019-22).

Review methods

Scoping-review methodology applied to academic and grey literature published 2015-20.

Results

While we did find examples of digital facilitation in routine practice, these often involved using passive or reactive modes of support. The context of COVID, and the necessary acceleration (at that time) of the move to a digital-first model of primary care, shaped the way digital facilitation was delivered. There was lack of clarity over where the responsibility for facilitation efforts lay; it was viewed as the responsibility of 'others'. Patients living with mental health conditions had similar needs and experiences regarding digital facilitation to other patients.

Limitations

The context of the COVID pandemic placed limitations on the project. Fewer practices responded to the practice survey than anticipated; reconfiguration of general practices to support COVID measures was a key consideration during non-participant observation with social distancing and other measures still in place during fieldwork.

Conclusions

Digital facilitation, while not a widely recognised concept, is important in supporting the move to a National Health Service with enhanced digital opportunities and enhanced digital access. General practice staff are allocating resources to provide such efforts in general practices in England. The establishment of clear lines of responsibility, the development of digital tools and platforms that work for patients and practice staff, and investment in staff time and training are needed if digital facilitation is to support the intended digital revolution.

Future work

We did not find one single dominant or preferred model of digital facilitation which might reasonably be considered to form the basis of an intervention to be tested. Rather, there is a need to co-develop such an intervention with patients, general practice staff and relevant policy experts. We outline a framework for a future evaluation of such an intervention.

Study registration

This study is registered as ResearchRegistry6523 (www.researchregistry.com/browse-the-registry#home/?view_2_search=Di-Facto&view_2_page=1) and PROSPERO CRD42020189019 (www.crd.york.ac.uk/prospero/display_record.php?RecordID=189019).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128268) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 32. See the NIHR Funding and Awards website for further award information.

Exploring How Patients Are Supported to Use Online Services in Primary Care in England Through "Digital Facilitation": Survey Study

BACKGROUND

Health service policy in many jurisdictions is driving greater investment into digital primary care services. While some patients and practices may benefit, there are concerns that not all are able or wish to access primary care services online. "Digital facilitation" is the "range of processes, procedures, and personnel seeking to support patients in their uptake and use of online services" and may address such concerns.

OBJECTIVE

As part of a multimethod research program, we undertook surveys of practice staff and patients to gain insight into the support being offered by practices and explore patients' experiences of this support.

METHODS

General practices from 4 regions of England were sent a questionnaire exploring the modes of digital facilitation offered, the personnel involved in its delivery, and views on the motivations and drivers for providing support. Moreover, 12,822 patients registered with 62 general practices (predominantly those providing practice survey responses) were sent a questionnaire exploring their experiences of any support offered by their practice to use online services.

RESULTS

Almost one-third of practices (156/500, 31.2%) responded to the practice survey, with most reporting using passive modes of digital facilitation (eg, display, leaflets, and SMS text messages) and few using active modes (eg, offering tablets or computers or using practice champions). However, 90.9% (130/143) reported providing ad hoc support. Practices agreed that it was the responsibility of both the practice (105/144, 72.9%) and the wider National Health Service (118/143, 82.5%) to support patients in using online services and that providing such support benefited the practice (126/144, 87.5%) and their patients (132/144, 91.7%). Nearly a quarter of the patients (3051/12,822, 23.8%) responded to the patient survey, with few (522/3051, 17.11% or less) reporting awareness of any modes of digital facilitation apart from text messages and emails (1205/3051, 39.5%) and only 13.36% (392/2935) reporting receiving support to use online services. Adjusted logistic regression analyses showed that older patients had a lower likelihood of 4 outcomes: being aware of, or of using, digital facilitation efforts, or being told about or being helped to use online services (all P<.05), particularly with regard to being helped to use online services (adjusted odds ratio for patients aged 85 years versus those aged 55-64 years: 0.08, 95% CI 0.02-0.36). However, ethnic minority participants or those for whom their first language was not English had positive associations with these outcomes.

CONCLUSIONS

General practices recognize that patients would benefit from support to access online services. However, the support provided is often passive or ad hoc, and patients were seldom aware of digital facilitation efforts that their practice provided. There is potential to increase engagement with online primary care services by providing more support for all patients, particularly to provide targeted support for older patients.

The Use of Online Consultation Systems and Patient Experience of Primary Care: Cross-Sectional Analysis Using the General Practice Patient Survey

BACKGROUND

NHS England encourages the use of online consultation (OC) systems alongside traditional access methods for patients to contact their general practice online and for practices to manage workflow. Access is a key driver of patients' primary care experience. The use of online technology and patient experience vary by sociodemographic characteristics.

OBJECTIVE

This study aims to assess the association between OC system use and patient experience of primary care in English general practice and how that varies by OC system model and practice sociodemographic characteristics (rurality, deprivation, age, and ethnicity).

METHODS

We categorized practices as "low-use" or "high-use" according to the volume of patient-initiated contacts made via the OC system. We considered practices using one of 2 OC systems with distinct designs and implementation models-shorter "free text" input with an embedded single workflow OC system (FT practices) and longer "mixed text" input with variation in implemented workflow OC system (MT practices). We used 2022 General Practice Patient Survey data to capture 4 dimensions of patient experience-overall experience, experience of making an appointment, continuity of care, and use of self-care before making an appointment. We used logistic regression at the practice level to explore the association between OC system use and patient experience, including interaction terms to assess sociodemographic variation.

RESULTS

We included 287,194 responses from 2423 MT and 170 FT practices. The proportions of patients reporting positive experiences at MT and FT practices were similar or better than practices nationally, except at high-use MT practices. At high-use MT practices, patients were 19.8% (odds ratio [OR] 0.802, 95% CI 0.782-0.823) less likely to report a good overall experience; 24.5% (OR 0.755, 95% CI 0.738-0.773) less likely to report a good experience of making an appointment; and 18.9% (OR 0.811, 95% CI 0.792-0.83) less likely to see their preferred general practitioner; but 27.8% (OR 1.278, 95% CI 1.249-1.308) more likely to use self-care, compared with low-use MT practices. Opposite trends were seen at FT practices. Sociodemographic inequalities in patient experience were generally lower at high-use than low-use practices; for example, gaps in overall experience between practices with the most and fewest White patients decreased by 2.7 percentage points at MT practices and 6.4 percentage points at FT practices. Trends suggested greater improvements in experience for traditionally underserved groups-patients from urban and deprived areas, younger patients, and non-White patients.

CONCLUSIONS

An OC system with shorter free text input and an integrated single workflow can enhance patient experience and reduce sociodemographic inequalities. Variation in patient experience between practices with different sociodemographic characteristics and OC systems underscores the importance of tailored design and implementation. Generalizing results across different OC systems is difficult due to variations in how they are integrated into practice workflows and communicated to patients.

Investigating Patient Use and Experience of Online Appointment Booking in Primary Care: Mixed Methods Study

BACKGROUND

Online appointment booking is a commonly used tool in several industries. There is limited evidence about the benefits and challenges of using online appointment booking in health care settings. Potential benefits include convenience and the ability to track appointments, although some groups of patients may find it harder to engage with online appointment booking. We sought to understand how patients in England used and experienced online appointment booking.

OBJECTIVE

This study aims to describe and compare the characteristics of patients in relation to their use of online appointment booking in general practice and investigate patients' views regarding online appointment booking arrangements.

METHODS

This was a mixed methods study set in English general practice comprising a retrospective analysis of the General Practice Patient Survey (GPPS) and semistructured interviews with patients. Data used in the retrospective analysis comprised responses to the 2018 and 2019 GPPS analyzed using mixed-effects logistic regression. Semistructured interviews with purposively sampled patients from 11 general practices in England explored experiences of and views on online appointment booking. Framework analysis was used to allow for comparison with the findings of the retrospective analysis.

RESULTS

The retrospective analysis included 1,327,693 GPPS responders (2018-2019 combined). We conducted 43 interviews with patients with a variety of experiences and awareness of online appointment booking; of these 43 patients, 6 (14%) were from ethnic minority groups. In the retrospective analysis, more patients were aware that online appointment booking was available (581,224/1,288,341, 45.11%) than had experience using it (203,184/1,301,694, 15.61%). There were deprivation gradients for awareness and use and a substantial decline in both awareness and use in patients aged >75 years. For interview participants, age and life stage were factors influencing experiences and perceptions, working patients valued convenience, and older patients preferred to use the telephone. Patients with long-term conditions were more aware of (odds ratio [OR] 1.43, 95% CI 1.41-1.44) and more likely to use (OR 1.65, 95% CI 1.63-1.67) online appointment booking. Interview participants with long-term conditions described online appointment booking as useful for routine nonurgent appointments. Patients in deprived areas were clustered in practices with low awareness and use of online appointment booking among GPPS respondents (OR for use 0.65, 95% CI 0.64-0.67). Other key findings included the influence of the availability of appointments online and differences in the registration process for accessing online booking.

CONCLUSIONS

Whether and how patients engage with online appointment booking is influenced by the practice with which they are registered, whether they live with long-term conditions, and their deprivation status. These factors should be considered in designing and implementing online appointment booking and have implications for patient engagement with the wider range of online services offered in general practice.

What helps patients access web-based services in primary care? Free-text analysis of patient responses to the Di-Facto questionnaire

BACKGROUND

The National Health Service (NHS) and general practice are increasingly adopting digital services. These services can impact both positively and negatively upon patient experiences, and access to digital services is not equal amongst all groups. Within a wider project examining digital facilitation (the Di-Facto study) our team conducted a patient survey amongst English primary care practices aiming to investigate patient views of what supports uptake and use of web-based services. This paper reports on the analysis of the free-text responses from the patient survey.

METHODS

The Di-Facto patient survey was distributed to practices in eight clinical commissioning groups (CCGs) in England between 2021-2022. We examined free-text responses to two questions relating to access to primary care web-based and support for web-based services. We used qualitative reflexive thematic analysis based on a six-stage process to analyse responses.

RESULTS

Of the 3051 patients who responded to the Di-Facto survey, 2246 provided a free-text response. We present our findings in two major themes: systems and structures and their impact on use of web-based services, and 'what works for me', a description of how respondents described what worked, or did not work in terms of their interactions with web-based services. Respondents described how the technology, such as poor practice website design, confusion over multiple digital apps, data security and concerns about eConsultation offerings impacted on use of web-based services. Respondents described practice level barriers, such as a lack of or inconsistent provision, which prevented optimal use of web-based services. Respondents described personal and technical barriers that impacted on their use of digital services, and described which web-based services worked well for them. Respondents felt that web-based services were not a replacement for face-to-face interactions with a doctor.

CONCLUSIONS

This analysis of free-text responses from a large patient survey highlights the system, practice, and person level barriers and facilitators to use of digital services in primary care. With an increasing push towards digital solutions in NHS primary care, practices should consider the design, rollout and communication of their web-based services to support patient access.

Supporting patients with a mental health diagnosis to use online services in primary care. A qualitative interview study

Objective

The increase in reliance on online services for general practice has the potential to increase inequalities within some populations. Patients with a mental health condition are one such group. Digital facilitation is defined as a range of processes, procedures, and people, which seek to support NHS patients in using online services. This study aimed to examine the views and experiences of digital facilitation in primary care amongst patients living with a mental health condition.

Methods

Semi-structured interviews were conducted with patients living with a mental health condition, recruited from general practices across England participating in the Di-Facto study. Thematic analysis was conducted on interview transcripts.

Results

Interviews were conducted with ten participants with a mental health condition, recruited from five general practices. Three themes were identified: (1) familiarity with online services; (2) experiences of those using online services; (3) the need for digital facilitation. The need for digital facilitation was identified in the registration for online services, and in trusting online services.

Conclusions

Online services offer convenience for patients, but registration for the use of such services remains a potential area of difficulty. Participants had difficulties with registering for online services and had concerns about trust in using them. Support offered by general practices in using online services needs to be varied and adaptable to meet the needs of individual patients.

Strengths, Weaknesses, Opportunities, and Threats Analysis of the Use of Digital Health Technologies in Primary Health Care in the Sub-Saharan African Region: Qualitative Study

BACKGROUND

Digital health technologies (DHTs) have become increasingly commonplace as a means of delivering primary care. While DHTs have been postulated to reduce inequalities, increase access, and strengthen health systems, how the implementation of DHTs has been realized in the sub-Saharan Africa (SSA) health care environment remains inadequately explored.

OBJECTIVE

This study aims to capture the multidisciplinary experiences of primary care professionals using DHTs to explore the strengths and weaknesses, as well as opportunities and threats, regarding the implementation and use of DHTs in SSA primary care settings.

METHODS

A combination of qualitative approaches was adopted (ie, focus groups and semistructured interviews). Participants were recruited through the African Forum for Primary Care and researchers' contact networks using convenience sampling and included if having experience with digital technologies in primary health care in SSA. Focus and interviews were conducted, respectively, in November 2021 and January-March 2022. Topic guides were used to cover relevant topics in the interviews, using the strengths, weaknesses, opportunities, and threats framework. Transcripts were compiled verbatim and systematically reviewed by 2 independent reviewers using framework analysis to identify emerging themes. The COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist was used to ensure the study met the recommended standards of qualitative data reporting.

RESULTS

A total of 33 participants participated in the study (n=13 and n=23 in the interviews and in focus groups, respectively; n=3 participants participated in both). The strengths of using DHTs ranged from improving access to care, supporting the continuity of care, and increasing care satisfaction and trust to greater collaboration, enabling safer decision-making, and hastening progress toward universal health coverage. Weaknesses included poor digital literacy, health inequalities, lack of human resources, inadequate training, lack of basic infrastructure and equipment, and poor coordination when implementing DHTs. DHTs were perceived as an opportunity to improve patient digital literacy, increase equity, promote more patient-centric design in upcoming DHTs, streamline expenditure, and provide a means to learn international best practices. Threats identified include the lack of buy-in from both patients and providers, insufficient human resources and local capacity, inadequate governmental support, overly restrictive regulations, and a lack of focus on cybersecurity and data protection.

CONCLUSIONS

The research highlights the complex challenges of implementing DHTs in the SSA context as a fast-moving health delivery modality, as well as the need for multistakeholder involvement. Future research should explore the nuances of these findings across different technologies and settings in the SSA region and implications on health and health care equity, capitalizing on mixed-methods research, including the use of real-world quantitative data to understand patient health needs. The promise of digital health will only be realized when informed by studies that incorporate patient perspective at every stage of the research cycle.