Remote-by-Default Care in the COVID-19 Pandemic: addressing the micro, meso-, and macro-level challenges of a radical new service model

COVID-19 research
COVID-19
The ‘Remote by Default’ Covid-19 project, funded through the ESRC, examined digital communications between patients and primary care practices. Led by Professor Trisha Greenhalgh from the University of Oxford, it also included researchers from the Nuffield Trust. The project sought to: develop tools to help clinicians assess people effectively by phone or video; support the change process through action research; and strengthen the supporting infrastructure for digital innovation in the NHS.
Dr Sarah Rybczynska-Bunt and Professor Richard Byng led the Plymouth site which focused on the impact of remote by default on inequalities. Investigation of the scale-up of ‘remote-by-default’ working, where patients could no longer automatically access face-to-face appointments, as a result of COVID-19 in Plymouth, helped identify positive and negative impacts on individuals living in poverty or with complex needs. We also worked closely with the ‘Deep End group of practices and Devon CCG.

Study discoveries

We developed and tested a Planning and Evaluating Remote Consultation Services (PERCS) framework. The framework is now used across Britain, supporting GP practices to deliver remote consultations. It has also helped make decisions about remote consulting in secondary care settings (i.e. after referrals).
The full paper on PERCS is now available on line. The findings, below, are taken from this policy document.
The digital switch-over during Covid-19
Some GP practices managed the switch to remote consultations better than others. The level of success related to the:
size of the practice
  • the population need
  • digital preparedness and infrastructure
  • the digital and communications skills of the staff involved
The benefits and trade-offs of remote consulting
Remote consultations can provide a convenient way to access health care. For staff, they can help to see patients in an efficient and timely manner and are ideal for some conditions and some aspects of disease monitoring. However, remote consultations can also be problematic. They can: 
  • reduce access to care for some patients and vulnerable groups
  • take longer than in-person consultations
  • increase investigations and referrals to other services
  • lead to missed or delayed diagnoses due to loss of information from visual clues
  • missed signs of a safeguarding risk
Remote triaging
Where remote triage works well, it steers people to the right professional and appointment type for their need and can avoid the need for a full consultation. Unfortunately, too often, triage arrangements are confusing and difficult for patients, and inefficient for practices, with many duplicated appointments. 
Managing the new mix of remote and face-to-face appointments
This can be stressful for reception staff, particularly when available appointments and triage rules conflict with patients’ expectations and preferred type of appointment.
Factors that influence preferences for face-to-face appointments
Some patients still value personal elements of face-to-face care in relation to both relational continuity and confidentiality (particularly for those without access to private space) 
Others prefer in-person consultations because they are unable to use digital services. But this can clash with capacity constraints, causing tension between patients and practice staff.
Many clinicians report finding it harder to build relationships, trust and a holistic understanding of patients through remote encounters, which are seen as more transactional than face-to-face car.
Co-design work
We worked with a design science who facilitated a patient workshop and two practice workshops to understand the access issues and develop ideas about how to improve access to primary care. Design science developed a range of ideas including a smart door interface that connects with your online and telephone services if the practice is closed and can be used by outreach services. 
Publications
Greenhalgh, T., Ladds, E., Hughes, G.  et al. (2022)  Why do GPs rarely do video consultations? qualitative study in UK general practice. British Journal of General Practice (72(728), ppe351-e360 DOI: https://doi.org/10.3399/BJGP.2021.0658 
Rosen R, Wieringa S, Greenhalgh T, Leone C, Rybczynska-Bunt S, Hughes G, Moore L, Shaw S, Wherton J & Byng R (2022) 'Clinical risk in remote consultations in general practice: findings from in-Covid-19 pandemic qualitative research' BJGP Open , DOI Open access
Greenhalgh T, Ladds E, Hughes G, Moore L, Wherton J, Shaw SE, Papoutsi C, Wieringa S, Rosen R & Rushforth A (2022) 'Why do GPs rarely do video consultations? qualitative study in UK general practice' British Journal of General Practice 72, (718) e351-e360 , DOI
Greenhalgh T, Rosen R, Shaw SE, Byng R, Faulkner S, Finlay T, Grundy E, Husain L, Hughes G & Leone C (2021) 'Planning and Evaluating Remote Consultation Services: A New Conceptual Framework Incorporating Complexity and Practical Ethics' Frontiers in Digital Health 3, , DOI Open access

Podcasts and blogs

Read our blog: Is primary care open for business?

Centre for Health Technology

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