Digital first primary care for those with multiple long-term conditions: The views of patients, carers and health professionals

Background and rationale General practices across England are facing the pressure of rising patient demand alongside an increase in the complexity of the care required by patients, an increase in work transferred to GPs from secondary care, and challenges in recruiting and retaining GPs. Greater use of digital technologies by primary care has been advocated as a way of mitigating some of these challenges and improve efficiency in primary care. Digital First Primary Care is one aspect of this. Digital First Primary Care is when a patient's first contact for the arrangement of a GP consultation is via digital mechanisms, rather than face-to-face. The use of Digital First Primary Care has been increasing in recent years and the COVID-19 pandemic (2020 to present) has expedited this immensely, with NHS England advising all general practices to book appointments online and hold remote consultations, for example, via telephone or video. Several studies have examined the use of digital approaches in primary care in recent years, mainly focused on understanding the types of platforms used and how, the impact of this on the general practice and the views of practice staff about using digital approaches. Digital First services have, to date, been used mainly for patients with urgent problems, typically for 'on the day' appointments. There is a paucity of evidence about how well they can address more complex patients' needs, such as those of people living with multiple long-term conditions. This rapid evaluation will examine the views of patients living with multiple long-term conditions, their carers and health professionals about Digital First Primary Care. We use the definition from the National Institute for Health and Care Excellence which defines multimorbidity as 'the presence of two or more long-term health conditions, which can include: • Defined physical and mental health conditions such as diabetes or schizophrenia • Ongoing conditions such as learning disability • Symptom complexes such as frailty or chronic pain • Sensory impairment such as sight or hearing loss • Alcohol and substance misuse (NICE, 2016).' This will also include consideration of how any co-morbidities a patient with multiple long-term conditions has may influence their use and experience of Digital First Primary Care. Lessons learned from this evaluation are intended to be transferable to patients living with a range of long-term health conditions and may provide useful learning for the delivery of digital health care services more generally. Aims In view of the gaps in evidence identified through initial scoping work, this rapid evaluation will seek to answer questions concerned with understanding the impact of Digital First services in primary care. In particular, the evaluation will explore how Digital First Primary Care is experienced by patients with long term conditions, their carers and primary health professionals. Evaluation questions To address this overall aim, the study seeks to answer the following evaluation questions: • Question 1: What is the experience of Digital First Primary Care for patients with multiple long-term conditions, their carers and health professionals, both before and during the COVID-19 pandemic? • Question 2: What is the impact of Digital First Primary Care on the nature of consultations for carers/patients with multiple long-term conditions and health professionals, which includes aspects such as the health professional(s) spoken to, timeliness of care, and continuity of care? • Question 3: What, if any, are the advantages or disadvantages of Digital First Primary Care for patients with multiple long-term conditions, and their carers? • Question 4: What lessons can be learnt from patients', carers', and staffs' views for future service delivery for patients with multiple long-term conditions in primary care? Are there individual groups within the community where there is particular learning for future service provision? Design and methods This evaluation comprises three distinct work packages (WP): • WP1: Locating the study within the wider context, engaging with literature, as well as co-designing the study approach and research questions with service users. • WP2: Interviews with patients/carers of those living with multiple long-term conditions who have experienced Digital First Primary Care and health professionals. • WP3: Analysis of data, generation of themes, and testing findings with service users. • WP4: Synthesis, reporting and dissemination. Dissemination and outputs It is anticipated that the findings of this evaluation project will be disseminated in several ways, including: • A final report submitted to the National Institute for Health Research, Health Services and Delivery Research Programme (NIHR HS&DR) to be published in the NIHR Journals Library. • A range of slide packs to share findings with key audiences including primary care clinicians, practice managers, commissioners, policy makers, and patients/carers. • Web-based resources such as a link to the full report, blogs (written independently and/or in collaboration with NHS/NHS-related organisations) to highlight key findings to non-experts as well as more specialist audiences. Given the focus on patient and carer experience, there will be a particular focus on dissemination to patients, carers and associated representative organisations, and the research team will work closely with BRACE partner, National Voices, and their membership community to do this. • Videos or podcasts of research team members and others (e.g. members of the BRACE patient and public involvement (PPI) and health and care panel) reflecting on the evaluation and its conclusions. These will be made accessible to a range of audiences (e.g. we will use subtitles for videos). • Publication of articles in primary care professional press such as Pulse, Health Service Journal, or GP Online. • Publication of papers in high quality, peer-reviewed, academic journals. • Oral and/or poster conference presentations at the British Journal of General Practice (BJGP) conference, the Society for Academic Primary Care (SAPC) conference and Health Services Research UK annual conference (which could be co-presented with the PPI reviewers for this project). The team will also seek to present the work at other conferences attended by patients and patient groups. • Disseminating findings through BRACE networks, drawing on the expertise and assistance of PPI collaborators, health and care panel (particularly members with communication/ journalism expertise and those with primary care knowledge) and steering group members who are involved with the project and the BRACE Centre. WGuidance will be sought from Richard Kirby (NHS Chief Executive), Charlotte Augst (Chief Executive of National Voices) who are both BRACE co-investigators, and the BRACE Steering Group to understand how best to communicate findings with NHS managers, staff, patients and carers. Study timeline The study will take place over 6 months, assuming timely access to case study sites and securing the necessary ethical approvals. The start date for this work is to be confirmed. Funding This project is funded through the Health Services and Delivery Research evaluation team funded by the National Institute for Health Research (BRACE Project no. 16/138/31).